Usefulness of PIVKA-II for monitoring after liver transplantation in patients with hepatocellular carcinoma.

The high morbidity and mortality of hepatocellular carcinoma (HCC) has encouraged the search for new biomarkers to be used alongside alpha-foetoprotein (AFP) and imaging tests. The aim of this study was to evaluate the clinical contribution of protein induced by vitamin K absence or antagonist-II (PIVKA-II) for HCC monitoring after liver transplantation (LT) and compare it with AFP, a routinely used tumour marker. A total of 46 HCC patients (Milan criteria) were enrolled in this study. Serum levels of PIVKA-II and AFP were measured before and after transplantation. Clinical features were determined for all the patients that were included. Significant correlations were found between PIVKA-II expression levels and some clinicopathological features, such as tumour size and number of pre-transplant transarterial chemoembolizations (TACEs). Serum levels of PIVKA-II and AFP decreased significantly after LT and increased in patients with tumour recurrence. Serum PIVKA-II levels may play an important role in predicting disease severity. Furthermore, monitoring PIVKA-II levels in HCC transplant recipients reflects the tumor early recurrence after transplantation and could be used, complementing AFP and imaging tests, as a novel biomarker of this pathology.

Hematic Antegrade Repriming Reduces Emboli on Cardiopulmonary Bypass: A Randomized Controlled Trial.

Particulate and gaseous microemboli (GME) are side effects of cardiac surgery that interfere with postoperative recovery by causing endothelial dysfunction and vascular blockages. GME sources during surgery are multiple, and cardiopulmonary bypass (CPB) is contributory to this embolic load. Hematic antegrade repriming (HAR) is a novel procedure that combines the benefits of repriming techniques with additional measures, by following a standardized procedure to provide a reproducible hemodilution of 300 ml. To clarify the safety of HAR in terms of embolic load delivery, a prospective and controlled study was conducted, by applying Doppler probes to the extracorporeal circuit, to determine the number and volume of GME released during CPB. A sample of 115 patients (n = 115) was considered for assessment. Both groups were managed under strict normothermia, and similar clinical conditions and protocols, receiving the same open and minimized circuit. Significant differences in GME volume delivery (control group [CG] = 0.28 ml vs. HAR = 0.08 ml; p = 0.004) and high embolic volume exposure (>1 ml) were found between the groups (CG = 30.36% vs. HAR = 4.26%; p = 0.001). The application of HAR did not represent an additional embolic risk and provided a four-fold reduction in the embolic volume delivered to the patient (coefficient, 0.24; 95% CI, 0.08-0.72; p = 0.01), which appears to enhance GME clearance of the oxygenator before CPB initiation.

Hematic Antegrade Repriming: A Reproducible Method to Decrease the Cardiopulmonary Bypass Insult.

The current practice of cardiopulmonary bypass (CPB) requires a preoperative priming of the circuit that is frequently performed with crystalloid solutions. Crystalloid priming avoids massive embolism but is unable to eliminate all microbubbles contained in the circuit. In addition, it causes a sudden hemodilution which is correlated with transfusion requirements and an increased risk of cognitive impairment. Several repriming techniques using autologous blood, collectively termed retrograde autologous priming (RAP), have been demonstrated to reduce the hemodilutional impact of CPB. However, the current heterogeneity in the practice of RAP limits its evidence and benefits. Here, we describe hematic antegrade repriming as an easy and reliable method that could be applied with any circuit in the market to decrease transfusion requirements, emboli, and inflammatory responses, reducing costs and the impact of CPB on postoperative recovery.

Are We Ready for Bariatric Surgery in a Liver Transplant Program? A Meta-Analysis.

BACKGROUND: Obesity-related non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are two main causes of end-stage liver disease requiring a liver transplantation. Studies exploring bariatric surgery in the liver transplantation setting have increased in recent years; however, a systematic analysis of the topic is lacking to date. This meta-analysis was conducted to explore the perioperative and long-term outcomes of bariatric surgery in obese patients undergoing liver transplantation. METHODS: Electronic databases were systematically searched for studies reporting bariatric surgery in patients undergoing liver transplantation. The primary outcomes were postoperative complications and mortality. We also extracted data about excess weight loss, body mass index, and improvement of comorbidities after bariatric surgery. RESULTS: A total of 96 patients from 8 articles were included. Bariatric surgery-related morbidity and mortality rates were 37% (95% CI 0.27-0.47) and 0.6% (95% CI 0.02-0.13), respectively. Body mass index at 24 months was 31.02 (95% CI 25.96-36.09) with a percentage excess weight loss at 12 and 24 months of 44.08 (95% CI 27.90-60.26) and 49.2 (95% CI 31.89-66.66), respectively. After bariatric surgery, rates of improvement of arterial hypertension and diabetes mellitus were 61% (95% CI 0.45-0.75) and 45% (95% CI 0.25-0.66), respectively. In most patients, bariatric surgery was performed after liver transplant and the most frequent technique was sleeve gastrectomy. CONCLUSIONS: Bariatric surgery can be performed safely in the setting of liver transplantation resulting in improvement of obesity-related comorbidities. The optimal timing and technique require further studies.

Sección medular cervical sin repercusión neurológica por herida anterior con arma blanca / Stab wound of the spinal cord from in front with no neurologic deficit

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Cómo perciben los estudiantes del primer curso clínico del Grado en Medicina la prueba de Evaluación Clínica Objetivada Estructurada (ECOE) / How medical students perceive the Objective Structured Clinical Examination (OSCE) in their first clinical year

INTRODUCCIÓN: La pruebas de Evaluación Clínica Objetiva Estructurada (ECOE) son cada vez más utilizadas para evaluar a los estudiantes de medicina. Suelen emplearse al finalizar los estudios y no se valora la opinión de los estudiantes. OBJETIVO: Evaluar la utilidad de la ECOE, desde el punto de vista del estudiante de medicina, en su primer año de prácticas clínicas. Material y métodos Se diseñó una ECOE reducida que incluyó tres estaciones clínicas con actores y evaluadores estandarizados. Posteriormente fue evaluada mediante una encuesta con 5 preguntas previamente validadas. RESULTADOS: Participaron 104 estudiantes y se obtuvieron 97 (92,3%) respuestas. El 89,7% consideró que la prueba fue muy útil para su formación. El 92,8% opinó que sería muy positivo incluir ECOE en sus prácticas clínicas y que ayudaría a adquirir competencias clínicas. CONCLUSIONES: La prueba ECOE es una herramienta útil de evaluación y aprendizaje en los primeros años de prácticas clínicas

BACKGROUND: The Objective Structured Clinical Examination (OSCE) is commonly used for the evaluation of medical students. OSCE is normally used at the end of their training and there is no feed-back with the students. AIM: To evaluate the utility of OSCE, from the student point of view, at their first clinical year. MATERIAL AND METHODS: A reduced OSCE with three clinical stations was designed. The participants and evaluators were previously standardised. The students then evaluated the OSCE using a previously validated survey. RESULTS: Of the 104 medical students that participated, 97 (92.3%) completed the questionnaire. The OSCE was considered a useful tool by 89.7%, and 92.8% thought that it would be really positive to include OSCEs in their clinical practice in order to achieve clinical competence. CONCLUSION: The OSCE is a useful tool for evaluation and learning by students in their first clinical years

Effectiveness of arterial embolization in recurrent bleeding due to duodenal ulcer during postoperative cardiac surgery.

Upper gastrointestinal bleeding is one of the most frequent complications after cardiac surgery and endoscopic treatment (ET) is often the first-choice procedure. When it fails, surgery can be an option but has significant mortality and morbidity. We propose arterial embolization (TAE: transcatheter arterial embolization) as an alternative treatment in selected cases.

Efectividad de la embolización arterial en el manejo de la hemorragia recurrente por ulcus duodenal en el postoperatorio de cirugía cardiaca / Effectiveness of arterial embolization in recurrent bleeding due to duodenal ulcer during postoperative cardiac surgery

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Xenotrasplante hepático / No disponible

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Síndrome de HELLP con disfunción hepática severa: presentación de cuatro casos / HELLP syndrome with severe liver dysfunction: A presentation of three cases

El síndrome de HELLP (SH) aparece en el 0,5-0,9% de las gestantes. Se caracteriza por anemia hemolítica, trombopenia y disfunción multiorgánica según los criterios de Tennessee. El objetivo de nuestro trabajo es la presentación de 4 mujeres gestantes diagnosticadas del SH con afectación hepática severa. Pacientes y método Aportamos 4 mujeres gestantes de 24, 27, 28 y 36 semanas de gestación respectivamente, diagnosticadas de SH asociado a hematoma hepático. En los 4 casos se realizó interrupción del embarazo mediante cesárea urgente. El primer caso precisó la realización de hepatectomía derecha con buena evolución postoperatoria, la segunda paciente desarrolló un fallo hepático fulminante, falleciendo por fallo multiorgánico en espera de trasplante hepático. La tercera paciente evolucionó satisfactoriamente con tratamiento médico conservador. La cuarta paciente precisó 2 trasplantes de hígado siendo alta a los 3 meses. Conclusiones Ante la sospecha clínica de un SH es esencial descartar un hematoma hepático, ya que el tratamiento de elección está en función de la severidad clínico-radiológica del mismo. Si hay rotura del hematoma, es imprescindible un abordaje quirúrgico urgente y, en caso de insuficiencia hepática grave, está indicado un trasplante de hígado (AU)

HELLP syndrome (HS) occurs in 0.5-0.9% of pregnant women. According to the Tennessee criteria, it is characterised by haemolytic anaemia, thrombopenia and multi-organ dysfunction. The purpose of this article is to present the cases of four pregnant women diagnosed with HS with severe liver involvement. Patients and method We present the cases of 4 pregnant women of 24, 27, 28 and 36 weeks gestation, respectively. Pregnancy was terminated by urgent Caesarean section in all 4 cases. The first case required a right hepatectomy, with a good post-operative outcome; the second patient developed fulminant liver failure, dying due to multi-organ failure while waiting for a liver transplant. The third patient progressed satisfactorily with conservative medical treatment. The fourth patient required two livers transplants, being discharged from hospital three months later. Conclusions When faced with the clinical suspicion of a HS it is essential to rule out a liver haematoma, since the treatment of choice depends on its clinical-radiological severity. If there is a rupture of the haematoma, urgent surgery is essential and, in the case of severe liver failure, a liver transplant is indicated (AU)

[HELLP syndrome with severe liver dysfunction: a presentation of three cases]. / Síndrome de HELLP con disfunción hepática severa: presentación de cuatro casos.

UNLABELLED: HELLP syndrome (HS) occurs in 0.5-0.9% of pregnant women. According to the Tennessee criteria, it is characterised by haemolytic anaemia, thrombopenia and multi-organ dysfunction. The purpose of this article is to present the cases of four pregnant women diagnosed with HS with severe liver involvement. PATIENTS AND METHOD: We present the cases of 4 pregnant women of 24, 27, 28 and 36 weeks gestation, respectively. Pregnancy was terminated by urgent Caesarean section in all 4 cases. The first case required a right hepatectomy, with a good post-operative outcome; the second patient developed fulminant liver failure, dying due to multi-organ failure while waiting for a liver transplant. The third patient progressed satisfactorily with conservative medical treatment. The fourth patient required two livers transplants, being discharged from hospital three months later. CONCLUSIONS: When faced with the clinical suspicion of a HS it is essential to rule out a liver haematoma, since the treatment of choice depends on its clinical-radiological severity. If there is a rupture of the haematoma, urgent surgery is essential and, in the case of severe liver failure, a liver transplant is indicated.

Hemorragia diferida de la arteria hepática derecha tras iatrogenia biliar por colecistectomía laparoscópica que precisó trasplante hepático por insuficiencia hepática aguda: caso clínico y revisión de la literatura / Delayed Right Hepatic Artery Haemorrhage After Iatrogenic Gallbladder by Laparoscopic Cholecystectomy that Required a Liver Transplant Due to Acute Liver Failure: Clinical Case and Review of the Literature

Introducción La lesión de la arteria hepática derecha (AHD) tras colecistectomía laparoscópica (CL) puede pasar desapercibida clínicamente, aunque a veces ocasiona una necrosis del lóbulo derecho. En situaciones excepcionales, cuando la necrosis se extiende al segmento IV, podría ocurrir un fallo hepático fulminante (FHF) y requerir un trasplante hepático urgente (TH).Pacientes y método Presentamos una revisión de la literatura médica de los pacientes en los que se indicó TH debido a una lesión vascular secundaria a lesión biliar por CL. También presentamos el cuarto paciente descrito en la literatura especializada que precisó TH secundario a lesión de la AHD tras CL, el segundo por FHF. Resultados El TH debido a la lesión de la AHD se realizó en 3 de 13 pacientes recogidos en la literatura médica: uno se realizó a los 3 meses de la lesión por FHF, tras realizar una hepatectomía derecha ampliada y los otros 2 debido a cirrosis biliar secundaria. Nuestro paciente se trasplantó a los 15 días de la lesión por FHF. Conclusiones La lesión de la AHD tras CL puede requerir TH por FHF, aunque es excepcional, es necesario pensar en esta posibilidad ante complicaciones de la AHD que requieran su oclusión (AU)

Introduction Right hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required. Patients and method We provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury. Results LT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury. Conclusions RHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion (AU)

[Delayed right hepatic artery haemorrhage after iatrogenic gallbladder by laparoscopic cholecystectomy that required a liver transplant due to acute liver failure: clinical case and review of the literature]. / Hemorragia diferida de la arteria hepática derecha tras iatrogenia biliar por colecistectomía laparoscópica que precisó trasplante hepático por insuficiencia hepática aguda: caso clínico y revisión de la literatura.

INTRODUCTION: Right hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required. PATIENTS AND METHOD: We provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury. RESULTS: LT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury. CONCLUSIONS: RHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion.

Cambios en el manejo diagnóstico-terapéutico del traumatismo hepático. Estudio retrospectivo comparando 2 series de casos en periodos diferentes (1997-1984 vs. 2001-2008) / Changes in the diagnosis and therapeutic management of hepatic trauma. A retrospective study comparing 2 series of cases in different (1997-1984 vs. 2001-2008)

Introducción Presentamos una serie de 146 casos de traumatismos hepáticos (TH) atendidos en nuestro hospital en un periodo de 8 años (2001-2008), comparándola con una serie previa de 92 casos (1977-1984).Material y método En la serie actual, la edad media fue de 29,6 años, predominando los hombres. Los traumatismos cerrados predominan sobre los penetrantes, siendo la causa más frecuente los accidentes de tráfico. Resultados Para valorar el grado de lesión hepática utilizamos la clasificación de la American Association for the Surgery of Trauma (AAST). El 79,5% de los enfermos presentaron lesiones asociadas abdominales y/o extraabdominales, siendo las más frecuentes los traumatismo torácicos vs. las fracturas óseas en la serie anterior. La lesión intraabdominal asociada más frecuente fue la esplénica en ambas series. La técnica diagnóstica más utilizada, en la serie actual, fue TAC abdominal. En la serie anterior, las exploraciones más utilizadas fueron la punción simple y la punción-lavado peritoneal (PLP). En 98 casos se llevó a cabo un tratamiento no operatorio y en 48 restantes se indicó cirugía. En la serie previa, se intervino al 97,8% de los pacientes. En la serie actual, en los 15 pacientes con lesiones hepáticas severas se realizaron 5 hepatectomías derechas, 2 segmentectomías, 6 packing de compresas y los 2 restantes fueron exitus intraoperatorios por avulsión hepática. La mortalidad global fue del 3,4%, siendo del 1% en el grupo TNO y del 8,3% en los pacientes intervenidos. En la serie previa, la mortalidad global fue del 29,3%.ConclusionesEl factor esencial para utilizar el tratamiento no operatorio (TNO) es controlar la estabilidad hemodinámica del paciente dejando el tratamiento quirúrgico a los pacientes hemodinámicamente inestables (AU)

Introduction: We present a series of 146 cases of hepatic trauma (HT) treated in our hospital over a period of 8 yearsm (2001-2008), and comparing it with a previous series of 92 cases(1977-1984).Material and method: The mean age in the current series was 28.6 years and the majority were male. The closed traumas were mainly penetrating, with the most frequent cause being road traffic accidents. Results: The American Association for the Surgery of Trauma (AAST) classification was used to evaluate the grade of the hepatic injury. Associated abdominal and /or extra-abdominal injuries were seen in 79.5% of the patients, with the most frequent being chest trauma, compared to bone fractures in the previous series. The most common associated intraabdominalinjury was the spleen in both series. The most used diagnostic technique in the current series was abdominal CT. Simple peritoneal puncture and lavage (PLP) were the most used examinations used in the previous series. Non-surgical treatment (NST) was given in 98 cases and the surgery was indicated in the remaining 48. In the previous series,97.8% of patients were operated on. In the current series, on the 15 patients with severe liverinjuries, 5 right hepatectomies, 2 segmentectomies and 6 packing compressions were performed, with the remaining two dying during surgery due to hepatic avulsion. The overall mortality was 3.4%, being 1% in the NST group and 8.3% in the surgical patients. In the previous series, the overall mortality was 29.3%.Conclusions: The key factor for using NST is to control haemodynamic stability, leavingsurgical treatment for haemodynamically unstable patients (AU)

[Changes in the diagnosis and therapeutic management of hepatic trauma. A retrospective study comparing 2 series of cases in different (1997-1984 vs. 2001-2008)]. / Cambios en el manejo diagnóstico-terapéutico del traumatismo hepático. Estudio retrospectivo comparando 2 series de casos en periodos diferentes (1997-1984 vs. 2001-2008).

INTRODUCTION: We present a series of 146 cases of hepatic trauma (HT) treated in our hospital over a period of 8 yearsm (2001-2008), and comparing it with a previous series of 92 cases (1977-1984). MATERIAL AND METHOD: The mean age in the current series was 28.6 years and the majority were male. The closed traumas were mainly penetrating, with the most frequent cause being road traffic accidents. RESULTS: The American Association for the Surgery of Trauma (AAST) classification was used to evaluate the grade of the hepatic injury. Associated abdominal and /or extra-abdominal injuries were seen in 79.5% of the patients, with the most frequent being chest trauma, compared to bone fractures in the previous series. The most common associated intra-abdominal injury was the spleen in both series. The most used diagnostic technique in the current series was abdominal CT. Simple peritoneal puncture and lavage (PLP) were the most used examinations used in the previous series. Non-surgical treatment (NST) was given in 98 cases and the surgery was indicated in the remaining 48. In the previous series, 97.8% of patients were operated on. In the current series, on the 15 patients with severe liver injuries, 5 right hepatectomies, 2 segmentectomies and 6 packing compressions were performed, with the remaining two dying during surgery due to hepatic avulsion. The overall mortality was 3.4%, being 1% in the NST group and 8.3% in the surgical patients. In the previous series, the overall mortality was 29.3%. CONCLUSIONS: The key factor for using NST is to control haemodynamic stability, leaving surgical treatment for haemodynamically unstable patients.

Actitud de la población hacia una legislación de consentimiento presunto a la donación de órganos de cadáver / Population attitude toward presumed consent legislation to cadaveric organ donation

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