RESUMEN
BACKGROUND: The use of a surgical mesh for abdominal wall reconstruction is well established and has been used for long with minor complications, whereas the omental flap has been used for decades in reconstructive surgery. AIM: To demonstrate the increased angiogenic capacity and the reduced inflammatory markers of a synthetic mesh when used in combination with an omental flap. Furthermore, we compare two independent meshes when used alone or in combination with the omental flap. MATERIALS AND METHODS: Twenty-eight rats were included in the study. To determine the effect of using an omental flap under two different meshes, the animals were separated into four groups, i.e., group A (flap + mesh 1), group B (flap + mesh 1 + silicone), group C (flap + mesh 2), and group D (flap + mesh 2 + silicone). A silicone sheet was placed as a barrier between the mesh and the flap. All groups were sacrificed 8 weeks post-operatively. RESULTS: The use of a silicone sheet barrier between any of the two synthetic meshes and the omental flap in an abdominal wall defect is accompanied by a markedly reduced angiogenesis in terms of a cluster of differentiation (CD)-34 (p < 0.001) and factor VIII (p = 0.0012) and by increased inflammatory response CD-68 (p = 0.0024) and visual scoring (p < 0.001). CONCLUSIONS: Τhe increased angiogenic capacity and the reduced inflammatory markers of a synthetic surgical mesh when used in combination with an omental flap make it a useful option in the reconstruction of an abdominal wall defect on a large or contaminated wound.
Asunto(s)
Pared Abdominal , Abdominoplastia , Ratas , Animales , Mallas Quirúrgicas , Estudios Prospectivos , Colgajos Quirúrgicos/cirugía , Siliconas , Pared Abdominal/cirugíaRESUMEN
Endometriosis represents a main cause of infertility and pelvic pain affecting 3-43% among reproductive age women. Deep pelvic endometriosis is defined as subperitoneal infiltration of endometrial implants in the uterosacral ligaments, rectum, rectovaginal septum, vagina or bladder. The authors present a case of a 29-year-old patient who underwent laparoscopic excision of extensive endometriotic plaque in rectovaginal septum accompanied with deeply infiltrating endometriosis (DIE) and chronic pelvic pain (CPP).
Asunto(s)
Fondo de Saco Recto-Uterino/cirugía , Endometriosis/cirugía , Enfermedades del Recto/cirugía , Enfermedades Vaginales/cirugía , Adulto , Fondo de Saco Recto-Uterino/diagnóstico por imagen , Fondo de Saco Recto-Uterino/patología , Endometriosis/complicaciones , Endometriosis/diagnóstico , Femenino , Humanos , Laparoscopía , Imagen por Resonancia Magnética , Dolor Pélvico/etiología , Dolor Pélvico/cirugía , Enfermedades del Recto/diagnóstico , Ultrasonografía , Enfermedades Vaginales/diagnósticoRESUMEN
Struma ovarii represents an ovarian mature teratoma with thyroid tissue comprising more than 50% of the ovarian tumor. It is a rare condition, representing approximately 1% of all ovarian tumors with a potential malignant transformation 5% to10%. When it is combined with pregnancy, it renders its management in this circumstance is extreme challenging. The authors present a case of benign struma ovarii diagnosed as a right adnexal mass during first trimester of pregnancy with an uneventful clinical course.
Asunto(s)
Neoplasias Ováricas/diagnóstico , Complicaciones Neoplásicas del Embarazo/diagnóstico , Estruma Ovárico/diagnóstico , Adulto , Diagnóstico Diferencial , Femenino , Humanos , Neoplasias Ováricas/diagnóstico por imagen , Embarazo , Complicaciones Neoplásicas del Embarazo/diagnóstico por imagen , Primer Trimestre del Embarazo , Estruma Ovárico/diagnóstico por imagen , Ultrasonografía PrenatalRESUMEN
PURPOSE: Liver failure is a major cause of early mortality following hepatectomy. The future-remnant liver function is an important factor when assessing the risk for postoperative liver functional impairment. Several techniques have been established for this evaluation, including the indocyanine green (ICG) test. The aim of this study was to evaluate the ICG clearance in patients scheduled for liver resection regarding perioperative and postoperative risk factors. METHODS: Thirty-one patients, scheduled for liver resection, underwent the ICG test. Peri-operative and postoperative variables were recorded and analyzed using non-parametric tests. RESULTS: Procedures extended from wedge excisions to extended hepatectomies. Plasma disappearance rate (PDR) was found positively correlated with total blood loss, transfusion and operation duration. There were 11 primary hepatic malignancies, including hepatocellular carcinomas and cholangiocarcinomas, 13 metastatic carcinomas, mainly of colorectal origin, and 7 benign lesions. The uninvolved liver parenchyma was normal in 20 (64. 5%) cases. Two patients died due to myocardial infarction and postoperative liver failure, respectively. CONCLUSION: The role of residual liver function and particularly the hepatic reserve assessment on liver surgery may be of most benefit in the routine stratification of risk, enabling surgical procedures to be performed with safety. The ICG clearance markers were found significantly correlated with perioperative risk factors in histologically "normal" liver parenchyma. In addition to computed tomographic (CT) volumetry, functional assessment of the hepatic reserve with the ICG test may persuade the preoperative planning and prevent postoperative liver failure.
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Hepatectomía/efectos adversos , Verde de Indocianina , Fallo Hepático/diagnóstico , Neoplasias Hepáticas/complicaciones , Complicaciones Posoperatorias , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de los Conductos Biliares/complicaciones , Neoplasias de los Conductos Biliares/patología , Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos/patología , Conductos Biliares Intrahepáticos/cirugía , Carcinoma Hepatocelular/complicaciones , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/cirugía , Colangiocarcinoma/complicaciones , Colangiocarcinoma/patología , Colangiocarcinoma/cirugía , Colorantes , Femenino , Estudios de Seguimiento , Humanos , Fallo Hepático/etiología , Pruebas de Función Hepática , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Factores de RiesgoRESUMEN
BACKGROUND: The surgical approaches to the treatment of bleeding esophageal varices in cirrhotic patients have been reduced since the clinical development of endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation. However, when acute sclerotherapy fails, and in cases where no further treatment is accessible, emergency surgery may be life saving. In the present study we retrospectively analyzed the results of the modified Sugiura procedure, performed as emergency and semi-elective treatment in the patient with bleeding esophageal varices. METHODS: Ninety patients with cirrhosis and portal hypertension were managed in our department for variceal esophageal bleeding between January 1985 and December 1992. The modified Sugiura procedure was performed in 46 patients on an emergency (25 patients) or semi-elective (21 patients) basis. Liver cirrhosis stage according to Child classification was A in 4 patients, B in 16 patients, and C in 26 patients. RESULTS: Acute bleeding was controlled in all patients. Postoperative mortality was 23.9% (11 of 46 patients). The mortality rate was 34.6% in Child class C patients (9 of 26 patients), and 12.5% in Child class B patients (2 of 16 patients). Twenty-four patients had long-term follow-up extending from 14 months to 22 years (mean 83.1 months). Ten of 24 patients (41.6%) did not develop rebleeding for 5-22 years (mean 10.3 years). Overall 5-year survival in these 24 patients was 62.5%. CONCLUSIONS: The modified Sugiura procedure remains an effective rescue therapy for patients with bleeding esophageal varices when alternative treatments fail or are not indicated. Moreover, it can be a life-saving procedure in patients with anatomy unsuitable for shunt surgery or for patients treated in nonspecialized centers where surgical expertise for a shunt operation is not available.
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Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Várices Esofágicas y Gástricas/cirugía , Hemorragia Gastrointestinal/cirugía , Adulto , Anciano , Anastomosis Quirúrgica , Procedimientos Quirúrgicos Electivos , Servicios Médicos de Urgencia , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/mortalidad , Femenino , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/mortalidad , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Cirrosis Hepática/complicaciones , Cirrosis Hepática/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Hepatitis C infection recurs after orthotopic liver transplantation for hepatitis C virus (HCV)-related end-stage liver disease. Overlapping histopathologic features may present difficulties in differentiating recurrent HCV in the allograft from other conditions, especially rejection. METHODS: In this study, we evaluated the presence of HCV-RNA by reverse transcriptase in situ polymerase chain reaction (RT in situ RCR) in hepatic tissue, after orthotopic liver transplantation for HCV-related liver disease. Further, detection of HCV-RNA was correlated with the serum HCV-RNA levels, histopathology, and clinical outcome. RESULTS: Twenty-five patients were part of this study. Seventeen patients were transplanted for HCV cirrhosis and eight for an underlying disease other than HCV. None of the patients in the non-HCV group had in situ RT-PCR detection of HCV-RNA. Positive RT in situ PCR for HCV was found in 9 of 17 HCV patients, and the patients had a clinical course consistent with recurrent hepatitis C disease. Four of these nine patients had an initial histologic diagnosis of rejection. The other eight patients in the HCV group had negative RT in situ PCR, and none of them had a course compatible with recurrent HCV disease, although four patients were histologically diagnosed as having chronic C hepatitis. The mean HCV-RNA level (log/mL) in the patients who had in situ detection of HCV-RNA was 7.01+/-0.26. Although RT-PCR was negative in 8 of 17 HCV patients, the patients were serologically viremic and the mean HCV-RNA level was 6.05+/-0.33 (P=0.03). CONCLUSIONS: Our findings indicate that the HCV in situ RT-PCR assay may be helpful in the differentiation of recurrent hepatitis C disease from rejection. This may further help in the adjustment of immunosuppression.
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Hepacivirus/genética , Hepatitis C/cirugía , Trasplante de Hígado , Hígado/patología , ARN Viral/sangre , Adulto , Anciano , Biopsia , Femenino , Amplificación de Genes , Humanos , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa de Transcriptasa InversaAsunto(s)
Ciclosporina/uso terapéutico , Hepatitis C/cirugía , Inmunosupresores/uso terapéutico , Neoplasias Hepáticas/inmunología , Tacrolimus/uso terapéutico , Adulto , Anciano , Ciclosporina/efectos adversos , Femenino , Rechazo de Injerto/epidemiología , Hepacivirus/aislamiento & purificación , Hepatitis C/fisiopatología , Hepatitis C/virología , Humanos , Inmunosupresores/efectos adversos , Incidencia , Masculino , Metilprednisolona/uso terapéutico , Persona de Mediana Edad , ARN Viral/análisis , Recurrencia , Tacrolimus/efectos adversosRESUMEN
BACKGROUND: Immunosuppression in patients with hepatitis C virus (HCV) following orthotopic liver transplantation can lead to significant increases in serum viral loads. Our aim was to analyze the effect of a randomized study of two immunosuppressive agents (tacrolimus vs. microemulsion cyclosporine) on the outcome of HCV patients following orthotopic liver transplantation. METHODS: From December 1995 to September 1996, 50 adult patients transplanted for HCV cirrhosis were randomly assigned to receive tacrolimus (Prograf) (group 1, 25 patients) or microemulsion cyclosporine (Neoral) (group 2, 24 patients). All patients received alpha-interferon after transplantation, and the overall steroid doses were no different between the groups. Serum RNA levels were measured by signal amplification of Chiron. Biopsies were taken when transaminases were greater than 2x base line or when there was an inappropriate response to alterations in immunosuppression regimens. RESULTS: There were more episodes of rejection in the Neoral group, but there were no differences in bacterial and viral infections, nor in the rate of HCV recurrence between the two groups. There were seven deaths in group 1 and eight in group 2. Overall patient and graft survival rates in the Prograf and Neoral groups at 18 months were 72 and 68% and 67 and 64%, respectively. CONCLUSIONS: (a) Both immunosuppression regimens had similar HCV recurrence rates; (b) there were no differences in bacterial or opportunistic infections; and (c) patient and graft survival was similar between the two groups.
Asunto(s)
Ciclosporina/uso terapéutico , Supervivencia de Injerto/inmunología , Hepacivirus/aislamiento & purificación , Hepatitis C/cirugía , Inmunosupresores/uso terapéutico , Cirrosis Hepática/cirugía , Trasplante de Hígado/inmunología , Tacrolimus/uso terapéutico , Adulto , Anciano , Ciclosporina/administración & dosificación , Emulsiones , Femenino , Rechazo de Injerto/epidemiología , Hepatitis C/diagnóstico , Humanos , Inmunosupresores/administración & dosificación , Cirrosis Hepática/etiología , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , ARN Viral/sangre , Recurrencia , Reoperación , Tasa de SupervivenciaRESUMEN
Documented causes of biliary complications following orthotopic liver transplantation have been related to technical imperfections or insufficient arterial supply. Although anatomical variations of the extrahepatic biliary system are not infrequent, neither their incidence, surgical management nor possible association with complications have been reported in liver transplantation. At our institution, the global incidence of biliary complications following 357 consecutive liver transplants performed in 324 patients over a 2-yr period was 15.4% (55/357). Anomalous donor extrahepatic ducts were verified in 10 cases (2.8%) and they were recognized intraoperatively, prior to biliary reconstruction, in 7 cases. Technical complications occurred in 1 of these 7 and in 3 other cases where the anomalous ducts were not identified until later in the postoperative period when serious clinical problems ensued. We herein present a description of these 10 cases, with reference to the techniques employed to manage the anatomical anomalies and to treat complications. As in any hepatobiliary procedure, awareness of possible variations of the extrahepatic biliary system, intraoperative identification of the anomalous ducts and appropriate tailoring of the surgical technique are advisable in order to avoid serious postoperative complications in liver transplantation.
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Conductos Biliares Extrahepáticos/anomalías , Enfermedades de las Vías Biliares/etiología , Trasplante de Hígado/efectos adversos , Trasplantes , Adulto , Enfermedades de las Vías Biliares/patología , Resultado Fatal , Femenino , Humanos , Periodo Intraoperatorio , Trasplante de Hígado/patología , Masculino , Persona de Mediana Edad , Donantes de TejidosAsunto(s)
Hepacivirus/aislamiento & purificación , Hepatitis C/diagnóstico , Hepatitis C/cirugía , Trasplante de Hígado , ARN Viral/análisis , Biopsia , Humanos , Reacción en Cadena de la Polimerasa/métodos , Valor Predictivo de las Pruebas , ARN Viral/sangre , Recurrencia , Trasplante Homólogo , Viremia/diagnósticoRESUMEN
Transplantation of the liver contemporaneously with another organ from the same donor is thought to confer an immunologic advantage. The latter is particularly desirable in intestinal transplantation because of the propensity of the intestinal graft to early and late rejections and because in some cases it may facilitate the operation. In clinical practice, shortage of liver grafts constrains liver transplantation to cases in which there is coexisting end stage liver disease.
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Trasplante de Hígado/métodos , Vísceras/trasplante , Adolescente , Femenino , Humanos , Periodo PosoperatorioAsunto(s)
Infecciones Bacterianas , Trasplante de Hígado/fisiología , Complicaciones Posoperatorias/epidemiología , Donantes de Tejidos , Adulto , Análisis de Varianza , Transfusión Sanguínea , Cadáver , Niño , Femenino , Prueba de Histocompatibilidad , Humanos , Inmunosupresores/uso terapéutico , Incidencia , Trasplante de Islotes Pancreáticos/mortalidad , Trasplante de Islotes Pancreáticos/fisiología , Trasplante de Riñón/mortalidad , Trasplante de Riñón/fisiología , Fallo Hepático Agudo/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado/inmunología , Trasplante de Hígado/mortalidad , Masculino , Reoperación , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
The liver transplant program at the University of Miami, established in 1987, was rejuvenated in June 1994 with the addition of new staff and expanded to include all organs of the gastrointestinal tract. Since its inception, 630 patients have been transplanted in the program. During the past 2 years we performed 349 transplants in 318 patients (livers n = 323 in 298 patients, liver + kidneys n = 13, liver + islet n = 10, liver + kidney + islets n = 1, liver + heart n = 10, liver + lung n = 1). These included 4 split-liver, 3 living-related, multiple reduced-sized and one "Domino" liver transplant. We have an active pediatric program and 10% of our transplanted patients are pediatric. Our overall patient and graft survival rates were 81% and 78%, respectively. The intestinal transplant program was launched in August 1994. To date we have performed 22 intestinal transplants, in 9 adults and 13 children. These transplants included 4 isolated intestinal, 11 combined liver-intestinal and 7 multivisceral transplants. Overall patient and graft survival rates were 55% and 50%, respectively. During the past 2 years several studies involving immunosuppressive agents were carried out: 1)Mycophenolate Mofetil (MMF) was used as induction therapy and as rescue therapy in patients with steroid-resistant rejection. Tacrolimus toxicity, and chronic rejection; 2) Neoral was compared with Tacrolimus in patients with Hepatitis C; and 3) MMF was added as triple therapy for the intestinal transplants. We used alpha interferon-2b (alpha-IFN) in hepatitis C positive patients in the early posttransplant period and found that it appears to be a safe drug. There was no increase in rejection in patients receiving alpha-IFN, and patient and graft survival were the same as in our overall patient population. A combination a-IFN with Ribavirin will be undertaken in the near future. The use of Lamivudine in hepatitis B patients was shown to be effective in preventing and treating recurrence of hepatitis B posttransplant. Unmodified donor bone marrow cells (DBMC) were isolated from the vertebral bodies of the same cadaveric liver donors. Donor bone marrow dose, number of cells and/or number (or timing) of infusions were investigated to determine which variables affected the ability of DBMC to engraft in the liver recipient. The long-term benefit of DBMC needs further follow-up. Although, our patient and graft survival for liver transplant recipients is comparable to other large centers nationally and internationally, we still have some challenges to overcome. These include: 1) control and prevention of recurrent HCV, 2) improved treatment for hepatocellular cancer pre- and posttransplant, and 3) treatment and prevention of chronic rejection. Intestinal transplantation remains an even greater challenge. Diagnostic tests to determine intestinal function need further development and although MMF has shown some promise in this field, newer immunosuppressive medications need to be investigated to prevent rejection and avoid over immunosuppression.