RESUMEN
Background and rationale for the study. The purpose of this study was to assess the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) reduction for the management of TIPS-induced acute liver decompensation. Between August 2000 and November 2013, 347 patients underwent a TIPS procedure in the authors' institution; 21/347 (6%) developed post-TIPS acute liver decompensation which was managed using a percutaneous shunt reduction technique. Patient demographics, laboratory tests before and after initial TIPS and TIPS reduction, procedural data and clinical follow-up data were analysed. RESULTS: Twenty-one patients (mean age 63 years) who underwent an initial TIPS procedure for variceal bleeding (n = 7; 33%) or refractory ascites (n = 14; 67%) successfully underwent shunt reduction ten days (3-34 days) after the initial TIPS procedure. The portosystemic pressure gradient (PSPG) increased from 8 (3-17) mmHg before reduction to 12 (7-23) mmHg after shunt reduction. Survival at one and six months follow-up was 15 (71%) and 11 patients (52%), respectively. The international normalised ratio (INR) (1.7 vs. 1.5; p = 0.044) was significantly different after TIPS reduction in the non-survival group compared to the survival group. In conclusion, TIPS reduction for the management of TIPS-induced acute liver decompensation is technically feasible and is associated with a one and six-month mortality rate of 29% and 48%, respectively. Higher post-TIPS-reduction INR values may be associated with higher risk of early mortality.
Asunto(s)
Angioplastia de Balón , Implantación de Prótesis Vascular , Cirrosis Hepática/cirugía , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Complicaciones Posoperatorias/cirugía , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Angioplastia de Balón/mortalidad , Bélgica , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/fisiopatología , Masculino , Persona de Mediana Edad , Presión Portal , Derivación Portosistémica Intrahepática Transyugular/mortalidad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Diseño de Prótesis , Reoperación , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
Transmission of Helicobacter pylori is thought to occur mainly during childhood, and predominantly within families. However, due to the difficulty of obtaining H. pylori isolates from large population samples and to the extensive genetic diversity between isolates, the transmission and spread of H. pylori remain poorly understood. We studied the genetic relationships of H. pylori isolated from 52 individuals of two large families living in a rural community in South Africa and from 43 individuals of 11 families living in urban settings in the United Kingdom, the United States, Korea, and Colombia. A 3,406 bp multilocus sequence haplotype was determined for a total of 142 H. pylori isolates. Isolates were assigned to biogeographic populations, and recent transmission was measured as the occurrence of non-unique isolates, i.e., isolates whose sequences were identical to those of other isolates. Members of urban families were almost always infected with isolates from the biogeographic population that is common in their location. Non-unique isolates were frequent in urban families, consistent with familial transmission between parents and children or between siblings. In contrast, the diversity of H. pylori in the South African families was much more extensive, and four distinct biogeographic populations circulated in this area. Non-unique isolates were less frequent in South African families, and there was no significant correlation between kinship and similarity of H. pylori sequences. However, individuals who lived in the same household did have an increased probability of carrying the same non-unique isolates of H. pylori, independent of kinship. We conclude that patterns of spread of H. pylori under conditions of high prevalence, such as the rural South African families, differ from those in developed countries. Horizontal transmission occurs frequently between persons who do not belong to a core family, blurring the pattern of familial transmission that is typical of developed countries. Predominantly familial transmission in urban societies is likely a result of modern living conditions with good sanitation and where physical contact between persons outside the core family is limited and regulated by societal rules. The patterns observed in rural South African families may be representative of large parts of the developing world.