Choledochocholedochostomy conversion to hepaticojejunostomy due to biliary obstruction in liver transplantation.

Choledochocholedochostomy with tutor (CC-T) or without (CC) is the technique of choice for biliary reconstruction in orthotopic liver transplantation (OLT), however, its rate of complications is high and does not decrease significantly over the years. Biliary obstruction is the most frequent complication and surgical treatment frequently involves conversion to hepaticojejunostomy (H-J). Out of 412 patients (448 OLTs) analyzed retrospectively, 74 (18%) presented biliary complications and 25 (6%) required conversion to H-J because of biliary obstruction, generally due to anastomotic stenosis (17 patients, 68%). Sixteen out of the 25 presented after the first 3 months, and in two patients, stenosis was secondary to arterial thrombosis. Anastomotic stenosis was more frequent in the CC group than in the CC-T group (9.9% versus 2.6%, p < 0.05). Sixteen patients (64%) underwent percutaneous dilatations, but the response was only transitory. There were no postoperative deaths. At the follow-up, three (12%) of the 17 surviving patients presented episodes of cholangitis which required percutaneous dilatations (1), revision of the H-J (1), or conversion to hepaticojejunoduodenostomy (1). Mean survival of patients with H-J was 70.9%, and the actuarial survival rate was 68% at 5 years. This does not differ from the actuarial survival in our series of transplanted patients (65%). CC or CC-T (in selected cases) is an adequate biliary reconstruction for OLT, in spite of the fact that a small number of patients will require conversion to H-J. H-J is an excellent technique of rescue in cases of biliary obstruction that are not possible to resolve by percutaneous dilatations.

Complicaciones de la cirugía de las hernias / Complications in hernia surgery

La reparación de una hernia inguinal es el procedimiento quirúrgico más frecuente realizado por los cirujanos generales y, quizás, el que mayor número de opciones técnicas presenta. Aunque en los últimos años se ha conseguido reducir la incidencia de complicaciones y en especial de la recidiva herniaria, no existe en la actualidad una técnica que haya logrado imponerse como tratamiento ideal. Por ello, es fundamental para prevenir las complicaciones un conocimiento claro de la fisiología y anatomía de la región inguinal, de los factores de riesgo del paciente y especialmente un dominio de la técnica quirúrgica que se va a realizar. Dentro de las complicaciones locales los seromas tienen una incidencia del 5 por ciento. En nuestra serie la tasa fue del 6 por ciento en las hernias primarias y del 8,7 por ciento en las terciarias .La infección de la herida operatoria fue del 1,3 por ciento, si bien parece que la infección en la vía laparoscópica es menor que en la vía convencional. La incidencia de hematomas, que se sitúa en las publicaciones en torno al 5 por ciento, fue del 2,7 por ciento en nuestra serie, sin que hayamos podido encontrar otras complicaciones de las que se describen en los textos. Las neuralgias, como las describe Chevrel, han estado presentes en el 2,1 por ciento de los casos con una duración superior a las 6 semanas, desapareciendo posteriormente con tratamiento. Las lesiones viscerales son infrecuentes, y en nuestra serie únicamente la lesión vesical estuvo presente en 2 casos (0,2 por ciento).Las orquitis isquémica y de atrofia testicular son descritas como complicaciones testiculares. La orquitis se encontró en el 4,6 por ciento de los pacientes y sólo hubo un caso de atrofia testicular. La complicación más frecuente a largo plazo es la recidiva, que dependiendo de la técnica quirúrgica realizada, se sitúa entre el 3 y el 23 por ciento en las técnicas sin prótesis y entre el 0 y el 10 por ciento cuando se utiliza malla. En nuestra serie estos últimos tienen una tasa del 0,1 por ciento. La incidencia de la recidiva en las correcciones laparoscópicas se sitúa en torno al 2 por ciento, dependiendo de la experiencia del equipo quirúrgico reintervenir a la paciente (AU)

[The efficacy of antiretroviral treatment in patients with human immunodeficiency virus infection. A study of 807 patients]. / Eficacia del tratamiento antirretroviral en pacientes con infección por el virus de la inmunodeficiencia humana. Estudio de 807 pacientes.

BACKGROUND: The natural history of HIV infection and its related diseases has changed after the introduction of new potent antiretroviral therapies (HAART). We have performed this study to analyse in our hospital the natural history of HIV infection in relation to the therapeutics advances. PATIENTS AND METHODS: We have exhaustively revised the clinic records of all the 807 adult HIV-infected patients followed at the HUC from January 1985 to December 1999. RESULTS: The incidence of most opportunistic diseases, new AIDS cases, hospital admissions and deaths decreased as from 1997. Patients who started antiretroviral therapy with HAART had lower incidence of AIDS, hospital admissions and deaths than patients with other therapy modalities. Survival of patients placed on HAART was better than that of patients who received different therapy modalities (p < 0.001), independently on the intensity of immunosuppression and AIDS diagnosis. Multivariate analysis showed that HAART therapy was the best protector factor, decreasing the risk of progression to death (p < 0.001). CONCLUSIONS: HAART therapy leads an important improvement of survival of HIV infected patients, independently an the intensity of immunosuppression and slows HIV progression, decreasing the number of new AIDS cases, hospital admissions and deaths.

Steroid withdrawal is safe and beneficial in stable cyclosporine-treated liver transplant patients.

BACKGROUND: In the immunosuppression of orthotopic liver transplant recipients, steroids are used despite their unspecific action and long-term side effects. Few studies have been carried out on steroid withdrawal and many aspects remain to be elucidated. METHODS: A prospective study was performed to analyse the effect of steroid withdrawal on 86 patients with stable graft function, more than 1 year after orthotopic liver transplant. Thirty patients had chronic hepatitis in the graft. Seventy-two continued with cyclosporine (CsA) and 14 with CsA-azathioprine (AZA) therapy. The follow-up was 23.2 +/- 8.1 months (range 12-52 months). A paired t-test was used for statistical analysis. RESULTS: No acute or chronic rejection occurred, and steroids were not reinstituted. There were no changes in serum transaminase levels, but bilirubin levels decreased (p < 0.01). At the end of the follow-up, we found improvements in blood pressure in hypertensive patients (systolic 156.1 +/- 8.4 mmHg vs. 139.4 +/- 8.7 mmHg, p < 0.001); body weight (72 +/- 13.5 kg vs. 70.8 +/- 13 kg, p < 0.05); serum cholesterol (211.3 +/- 42 mg/dl vs. 191.6 +/- 43.5 mg/dl, p < 0.001) and bone mineral density in lumbar spine (0.823 +/- 0.13 g/cm2 vs. 0.893 +/- 0.135 g/cm2, p < 0.001). Four of ten diabetic patients were no longer insulin-dependent and insulin requirements decreased in the remaining six. No significant biochemical changes were found in patients with hepatitis in the graft, and we found an improvement in inflammatory activity in the nine biopsied patients. CONCLUSIONS: Steroid withdrawal with CsA monotherapy is feasible, safe and beneficial in patients who have stable liver graft function 1 year after orthotopic liver transplant. We consider that AZA therapy is not necessary unless drastic reduction of CsA levels is required because of renal dysfunction.

Liver transplantation with a twenty-four hour delay and an initial low dose of cyclosporine.

BACKGROUND/AIMS: Cyclosporine A based immunosuppression protocols have improved the results of liver transplantation. However, there is no general agreement concerning the most appropriate initial dose of cyclosporine or the precise moment we should start its administration. MATERIALS AND METHODS: Two cyclosporine A administration procedures in liver transplantation were analyzed by means of a prospective study using 91 consecutive patients and dividing them into two groups: Group A: 50 consecutive transplants in which cyclosporine was started since the surgery at 4 mg/kg/day, and Group B: the following 41 consecutive transplants in which cyclosporine was started 24 hours after transplantation at 2 mg/kg/day. RESULTS: Cyclosporine levels were higher in Group A in the first month (without significant differences). There were differences in the need for hemodialysis (14% vs 0%, p < 0.01), in the length of time (h) on mechanical ventilation (147.5 +/- 36 vs 48.7 +/- 15.7, p < 0.05) and in the time (d) spent in intensive care (10.5 +/- 1.6 vs 6.5 +/- 0.8, p < 0.05). There were no differences in the incidence of acute rejection, arterial blood pressure, septic and neurological complications, or in the actuarial survival rate for patients and grafts at 36 months. CONCLUSIONS: Delayed administration of cyclosporine simplifies the treatment of patients in the first 24 hours, it has several beneficial features and does not appear to be associated with a high acute rejection rate. On the basis of these results, our group has adopted delayed and low-dosage cyclosporine procedure.

Reuse of liver grafts after early death of the first recipient.

Three cases are reported of reuse of a transplanted liver graft after early death of the first recipient due to cerebral hemorrhage. The good condition of the donors; the excellent biochemical evolution of the graft in the first recipients; total ABO compatibility and donor-recipient crossmatch; the absence of positivity to hepatitis B virus (HBV), hepatitis C virus (HCV), and bacteriologic cultures; and early death made reuse possible. The shortage of donors in relation to patients on the waiting list and the poor clinical condition of the second recipients made it necessary to adopt the decision to reuse the graft in an attempt to save their lives. The evolution of the patients and the reused grafts was satisfactory, and there were no complications that could be attributed to the fact that the graft had been transplanted before.

Diaphragmatic or transdiaphragmatic thoracic involvement in hepatic hydatid disease: surgical trends and classification.

We performed a retrospective study of 19 patients who had been operated on for hepatic hydatid disease with diaphragmatic or transdiaphragmatic (D-TD) thoracic involvement chosen from a total of 444 patients who underwent operations for hepatic hydatid disease. In all cases D-TD involvement was confirmed by ultrasonography, CT, or MRI scan. We propose a new classification (grades 1-5) based on the degree of development of D-TD involvement. Before 1984 exposure was obtained by thoracophrenolaparotomy (nine cases) and later by right subcostal incision. Only four patients required atypical pulmonary resection. In 13 cases the diaphragm was repaired, and all 24 hepatic cysts were treated with total (16 cases) or partial (8 cases) cystopericystectomy. There was no operative mortality, and the most serious morbidity consisted of a biliary fistula and a biliobronchial fistula. For treatment of these patients we recommended right subcostal incision and total or near-total cystopericystectomy as a first choice of surgical technique.

[Liver transplantation using grafts from donors over 65]. / Trasplante hepático utilizando injertos de donantes de más de 65 años.

OBJECTIVE: Donors age 50 years was an exclusion criteria in past decades. The increase of patients in the waiting list has determined the acceptance of older donors (over 65 years old). We analyze our results in liver transplantation using donors over 65 years. PATIENTS: From 1986 to may 1994, we performed 381 OLT. In five cases (1.3%) the OLT was performed using donors over 65 years of age (66, 67, 68, 70 and 71). The selection criteria for donors and recipients were similar to the other transplanted patients. Immunosuppression included cyclosporine or FK-506, prednisone and azathioprine. RESULTS: There were no primary graft failures and preservation damage, biochemical and clinical evolution were not different to the procedures using younger donors. Three grafts presented non-corticoresistant acute rejection. After a follow-up of 11.6 mo (range 4-37 mo) only one graft was lost (Kaposi's sarcoma in the liver). Four grafts and four patients are in excellent biochemical and clinical condition. CONCLUSIONS: Donor age should not be an exclusion criteria. Grafts from older donors (over 65 years old) may be considered safe and will permit to increase the number of OLT.

Assessing explanatory style: the content analysis of verbatim explanations and the Attributional Style Questionnaire.

We compare two methods of assessing explanatory style--the content analysis of verbatim explanations (CAVE) and the Attributional Style Questionnaire (ASQ). The CAVE technique is a method that allows the researcher to analyze any naturally occurring verbatim materials for explanatory style. This technique permits the measurement of various populations that are unwilling or unable to take the ASQ. We administered the ASQ and Beck Depression Inventory (BDI) to 169 undergraduates and content analyzed the written causes on the ASQ for explanatory style by the CAVE technique. The CAVE technique correlated 0.71 with the ASQ (P less than 0.0001, n = 159) and -0.36 with BDI (P less than 0.0001, n = 159). The ASQ correlated -0.51 with the BDI (P less than 0.0001, n = 160). Both the CAVE technique and the ASQ seem to be valid devices for assessing explanatory style.

Patologia Bucal Quirurgica. Incidencia Anatomopatologica en Sucre años 1975 - 1984 / Pathologic bucal surghery incident anamopatologica in the city of Sucre years 1975-1984

En los últimos diez años (1975 - 1984), se revisado 10.648 exámenes anatomopatológicos, de biópsias y piezas operatorias, en los distintos Servicios de Anatomía Patológia de la ciudad de Sucre, habiéndose encontrado 217 casos de Patologia Bucal Quirugica, lo que significa el 2,22 por ciento correspondiendo a su promedio de 21,7 casos por año. Respecto a la edad, dentro de los 217 casos, el grupo de edad que ha sido mas afectado, es de, los 21-30 años, con 35 casos (16,12 por ciento). siguiendole la década de los 51-60, con 32 casos ( 14,64 por ciento). Prácticamente todas las edades son afestadas por enfermedades de la boca. El sexo femenino hi sido ligeramente más comprometido po las alteraciones de la cavidad bucal, con 115 (53,00), en relación al sexo masculino con 102 (47 por ciento). Deste un punto de vista estadístico general, se ha podido apreciar que ocupan el,primer lugar los tumores malignos, con 64 casos (29.49 por ciento), siguiendoles en orden de frecuencia los procesos inflamatorios agudos y cronicos de diversa naturaleza con 58 observaciones (26,72 por ciento), y en tercer lugar, se encuentran los procesos neoplásicos benignos y el mucocele de las glándulas salivales con 33 casos (15,20 por ciento)