RESUMEN
Type 1 primary hyperoxaluria (PH1) causes renal failure, for which isolated kidney transplantation (KT) is usually unsuccessful treatment due to early oxalate stone recurrence. Although hepatectomy and liver transplantation (LT) corrects PH1 enzymatic defect, simultaneous auxiliary partial liver transplantation (APLT) and KT have been suggested as an alternative approach. APLT advantages include preservation of the donor pool and retention of native liver function in the event of liver graft loss. However, APLT relative mass may be inadequate to correct the defect. We here report the first case of native portal vein embolization (PVE) to increase APLT to native liver mass ratio (APLT/NLM-R). Following initial combined APLT-KT, both allografts functioned well, but oxalate plasma levels did not normalize. We postulated the inadequate APLT/NLM-R could be corrected by trans-hepatic native PVE. The resulting increased APLT/NLM-R decreased serum oxalate to normal levels within 1 month following PVE. We conclude that persistently elevated oxalate levels after combined APLT-KT for PH1 treatment, results from inadequate relative functional capacity. This can be reversed by partial native PVE to decrease portal flow to the native liver. This approach might be applicable to other scenarios where partial grafts have been transplanted to replace native liver function.
Asunto(s)
Embolización Terapéutica , Hiperoxaluria Primaria/terapia , Fallo Renal Crónico/terapia , Trasplante de Riñón , Trasplante de Hígado , Vena Porta , Adulto , Terapia Combinada , Humanos , Masculino , Oxalatos/metabolismo , Pronóstico , Trasplante HomólogoRESUMEN
PURPOSE: To describe the pathophysiology, identification and management of inferior pancreaticoduodenal artery aneurysms in association with celiac axis stenosis or occlusion has been reported. REVIEW FINDINGS: These aneurysms are thought to arise due to increased flow through the pancreaticoduodenal arcades. The arcades first enlarge, and then form focal aneurysms which may rupture. The aneurysms can be treated through endovascular techniques or by surgery, though the former is a preferred approach.
Asunto(s)
Aneurisma/etiología , Arteriopatías Oclusivas/complicaciones , Arteria Celíaca , Duodeno/irrigación sanguínea , Páncreas/irrigación sanguínea , Procedimientos Quirúrgicos Vasculares/métodos , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Angiografía , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Humanos , Tomografía Computarizada por Rayos XAsunto(s)
Angiografía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Angiografía por Resonancia Magnética , Complicaciones Posoperatorias , Falla de Prótesis , Stents/efectos adversos , Tomografía Computarizada por Rayos X , Anciano , Estudios de Seguimiento , Humanos , Masculino , Reproducibilidad de los ResultadosRESUMEN
We report our experience in percutaneous treatment of non-tumoral superior vena cava syndrome (SVCS) between December 1998 and July 2001. During a period of 2.5 years, 9 patients (age range 27-84 years, mean age 50 years) were treated percutaneously for significant non-tumoral SVCS. Symptomatic SVCS were due to dialysis catheters (7), central line (1) and radiation therapy (1). In thrombotic occlusions and severe stenosis, a preliminary in situ thrombolysis was achieved before angioplasty. Patients were followed by echo-Doppler, computed tomography angiography (CTA), magnetic resonance angiography (MRA), or phlebography. Complete recanalization of the veins and immediate resolution of symptomatic SVCS were obtained in all patients, with no procedure-related complication. Thirteen stents were placed in 9 patients with a mean clinical follow-up of 9.1 months (range 2-23 months). One hundred percent patency at 6 months was obtained. Two patients recurred twice and were treated with new stent placement. At 12 months the patency was 67% and assisted patency was 100%. Stent placement in benign symptomatic SVCS is a safe and minimally invasive procedure, with no technical and clinical complications in our experience. It allowed immediate relief of symptoms, and in dialysed patients could provide continued use of hemodialysis access. Close clinical surveillance is mandatory to assess stent patency.
Asunto(s)
Implantación de Prótesis Vascular , Síndrome de la Vena Cava Superior/terapia , Vena Cava Superior/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Cateterismo , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Humanos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Flebografía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Recurrencia , Stents , Síndrome de la Vena Cava Superior/diagnóstico , Análisis de Supervivencia , Suiza , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Grado de Desobstrucción Vascular/fisiología , Vena Cava Superior/diagnóstico por imagenRESUMEN
UNLABELLED: Perturbation of respiratory mechanics produced by general anesthesia and surgery is more pronounced in morbidly obese (MO) patients. Because general anesthesia induces pulmonary atelectasis in nonobese patients, we hypothesized that atelectasis formation would be particularly significant in MO patients. We investigated the importance and resorption of atelectasis after general anesthesia in MO and nonobese patients. Twenty MO patients were anesthetized for laparoscopic gastroplasty and 10 nonobese patients for laparoscopic cholecystectomy. We assessed pulmonary atelectasis by computed tomography at three different periods: before the induction of general anesthesia, immediately after tracheal extubation, and 24 h later. Already before the induction of anesthesia, MO patients had more atelectasis, expressed in the percentage of the total lung area, than nonobese patients (2.1% versus 1.0%, respectively; P < 0.01). After tracheal extubation, atelectasis had increased in both groups but remained significantly more so in the MO group (7.6% for MO patients versus 2.8% for the nonobese; P < 0.05). Twenty-four hours later, the amount of atelectasis remained unchanged in the MO patients, but we observed a complete resorption in nonobese patients (9.7% versus 1.9%, respectively; P < 0.01). General anesthesia in MO patients generated much more atelectasis than in nonobese patients. Moreover, atelectasis remained unchanged for at least 24 h in MO patients, whereas atelectasis disappeared in the nonobese. IMPLICATIONS: We compared the resolution over time of pulmonary atelectasis after a laparoscopic procedure by performing computed tomography scans in two different groups of patients: 1 group had 10 nonobese patients, and in the other group there were 20 morbidly obese patients.
Asunto(s)
Complicaciones Intraoperatorias/etiología , Obesidad Mórbida/complicaciones , Complicaciones Posoperatorias/etiología , Atelectasia Pulmonar/etiología , Adulto , Femenino , Humanos , Laparoscopía , Masculino , Persona de Mediana EdadRESUMEN
A precise knowledge of arterial, portal, hepatic and biliary anatomical variations is mandatory when a liver surgery is planned. However, only certain variations must be searched when a precise intervention is planned. The main liver resection and biliary interventions will be precised. Related anatomical variations will be precised.
Asunto(s)
Neoplasias Hepáticas/cirugía , Hígado/anatomía & histología , Hígado/cirugía , Colecistectomía , Hepatectomía/métodos , Humanos , Hígado/irrigación sanguínea , Neoplasias Hepáticas/diagnóstico por imagen , Trasplante de Hígado , RadiografíaRESUMEN
The purpose of this retrospective study was to report 11 cases of severe vascular complications after central venous catheter misplacement. For each patient, data collection included body mass index, the diagnosis at admission, the site of the procedure, the type of catheter, coagulation parameters, the imaging modalities performed and the applied treatment. Eight patients had a lesion of the subclavian artery. Brachiocephalic vein perforations were assessed in three more patients. All patients had a chest roentgenogram after the procedure, six a CT examination, and four an angiographic procedure. Seven patients had a body mass index above 30, and 5 patients had coagulation disorders prior to the procedure. Seven patients were conservatively managed, 2 patients died despite resuscitation, 1 patient was treated with a stent graft, and one by superselective embolization. Subclavian or jugular vein temporary catheter positioning is a practical approach. Identification of any iatrogenic perforation of the subclavian artery or central veins urges obtaining a chest roentgenogram and, when required, a chest CT, selective angiograms or venograms. Body mass index superior to 30, previous unsuccessful catheterization attempts, and coagulation factor depletion seemed to account for risk factors. Recognition of clinical and radiological complications is mandatory.
Asunto(s)
Cateterismo Venoso Central/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Venas Braquiocefálicas/lesiones , Cateterismo de Swan-Ganz/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Arteria Subclavia/lesionesAsunto(s)
Aneurisma Roto/complicaciones , Aneurisma Roto/terapia , Cianoacrilatos/uso terapéutico , Embolización Terapéutica , Hemorragia/etiología , Hemorragia/terapia , Enfermedades del Mediastino/etiología , Enfermedades del Mediastino/terapia , Enfermedad Aguda , Anciano , Aneurisma Roto/diagnóstico por imagen , Angiografía , Arterias Bronquiales/diagnóstico por imagen , Hemorragia/diagnóstico por imagen , Humanos , Masculino , Enfermedades del Mediastino/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
The Ring-Sling Complex is an uncommon, congenital vascular and tracheobronchial malformation with a persistent high death rate. We report three patients in whom computed tomography (CT) and magnetic resonance imaging (MRI) were used for the preoperative diagnosis and for staging of the morphologic tracheal and vascular anomalies.
Asunto(s)
Cardiopatías Congénitas/diagnóstico , Arteria Pulmonar/anomalías , Estenosis Traqueal/diagnóstico , Preescolar , Ecocardiografía Doppler en Color , Femenino , Cardiopatías Congénitas/diagnóstico por imagen , Humanos , Lactante , Recién Nacido , Angiografía por Resonancia Magnética , Arteria Pulmonar/diagnóstico por imagen , Radiografía , Estenosis Traqueal/diagnóstico por imagenRESUMEN
Tracheo-bronchial injuries occur in less than 1 % of blunt chest trauma patients. Indirect signs, such as pneumomediastinum, pneumothorax, and/or subcutaneous emphysema, are revealed on admission plain films and chest CT survey. In most instances, however, tracheobronchoscopy is mandatory in assessing the definite diagnosis of tracheo-bronchial lesion. Occasionally, an abnormal course of a mainstem bronchus or a "fallen lung" sign, featuring a collapsed lung in a dependent position, hanging on the hilum only by its vascular attachments, may allow for CT diagnosis of a blunt traumatic bronchial injury.
Asunto(s)
Bronquios/lesiones , Broncografía , Aumento de la Imagen , Lesión Pulmonar , Traumatismos Torácicos/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/diagnóstico por imagen , Adulto , Diagnóstico Diferencial , Humanos , Pulmón/diagnóstico por imagen , Masculino , Valor Predictivo de las Pruebas , RoturaRESUMEN
In western European countries most blunt chest traumas are associated with motor vehicle and sport-related accidents. In Switzerland, 39 of 10,000 inhabitants were involved and severely injured in road accidents in 1998. Fifty two percent of them suffered from blunt chest trauma. According to the Swiss Federal Office of Statistics, traumas represented in men the fourth major cause of death (4%) after cardiovascular disease (38%), cancer (28%), and respiratory disease (7%) in 1998. The outcome of chest trauma patients is determined mainly by the severity of the lesions, the prompt appropriate treatment delivered on the scene of the accident, the time needed to transport the patient to a trauma center, and the immediate recognition of the lesions by a trained emergency team. Other determining factors include age as well as coexisting cardiac, pulmonary, and renal diseases. Our purpose was to review the wide spectrum of pathologies related to blunt chest trauma involving the chest wall, pleura, lungs, trachea and bronchi, aorta, aortic arch vessels, and diaphragm. A particular focus on the diagnostic impact of CT is demonstrated.
Asunto(s)
Traumatismos Torácicos/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/diagnóstico por imagen , Diagnóstico Diferencial , Humanos , Traumatismo Múltiple/diagnóstico por imagen , Sensibilidad y Especificidad , Índices de Gravedad del TraumaRESUMEN
The aim of this study was to compare the diagnostic efficiency of plain film and spiral CT examinations with 3D reconstructions of 42 tibial plateau fractures and to assess the accuracy of these two techniques in the pre-operative surgical plan in 22 cases. Forty-two tibial plateau fractures were examined with plain film (anteroposterior, lateral, two obliques) and spiral CT with surface-shaded-display 3D reconstructions. The Swiss AO-ASIF classification system of bone fracture from Muller was used. In 22 cases the surgical plans and the sequence of reconstruction of the fragments were prospectively determined with both techniques, successively, and then correlated with the surgical reports and post-operative plain film. The fractures were underestimated with plain film in 18 of 42 cases (43%). Due to the spiral CT 3D reconstructions, and precise pre-operative information, the surgical plans based on plain film were modified and adjusted in 13 cases among 22 (59%). Spiral CT 3D reconstructions give a better and more accurate demonstration of the tibial plateau fracture and allows a more precise pre-operative surgical plan.
Asunto(s)
Imagenología Tridimensional , Traumatismos de la Rodilla/diagnóstico por imagen , Fracturas de la Tibia/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Traumatismos de la Rodilla/clasificación , Traumatismos de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sensibilidad y Especificidad , Fracturas de la Tibia/clasificación , Fracturas de la Tibia/cirugíaRESUMEN
Pulmonary edema may be classified as increased hydrostatic pressure edema, permeability edema with diffuse alveolar damage (DAD), permeability edema without DAD, or mixed edema. Pulmonary edema has variable manifestations. Postobstructive pulmonary edema typically manifests radiologically as septal lines, peribronchial cuffing, and, in more severe cases, central alveolar edema. Pulmonary edema with chronic pulmonary embolism manifests as sharply demarcated areas of increased ground-glass attenuation. Pulmonary edema with veno-occlusive disease manifests as large pulmonary arteries, diffuse interstitial edema with numerous Kerley lines, peribronchial cuffing, and a dilated right ventricle. Stage 1 near drowning pulmonary edema manifests as Kerley lines, peribronchial cuffing, and patchy, perihilar alveolar areas of airspace consolidation; stage 2 and 3 lesions are radiologically nonspecific. Pulmonary edema following administration of cytokines demonstrates bilateral, symmetric interstitial edema with thickened septal lines. High-altitude pulmonary edema usually manifests as central interstitial edema associated with peribronchial cuffing, ill-defined vessels, and patchy airspace consolidation. Neurogenic pulmonary edema manifests as bilateral, rather homogeneous airspace consolidations that predominate at the apices in about 50% of cases. Reperfusion pulmonary edema usually demonstrates heterogeneous airspace consolidations that predominate in the areas distal to the recanalized vessels. Postreduction pulmonary edema manifests as mild airspace consolidation involving the ipsilateral lung, whereas pulmonary edema due to air embolism initially demonstrates interstitial edema followed by bilateral, peripheral alveolar areas of increased opacity that predominate at the lung bases. Familiarity with the spectrum of radiologic findings in pulmonary edema from various causes will often help narrow the differential diagnosis.
Asunto(s)
Edema Pulmonar/diagnóstico por imagen , Mal de Altura/complicaciones , Citocinas/efectos adversos , Diagnóstico Diferencial , Embolia Aérea/complicaciones , Humanos , Presión Hidrostática , Enfermedades Pulmonares Obstructivas/complicaciones , Ahogamiento Inminente/clasificación , Ahogamiento Inminente/complicaciones , Inflamación Neurogénica/complicaciones , Permeabilidad , Neumonectomía/efectos adversos , Alveolos Pulmonares/fisiopatología , Edema Pulmonar/clasificación , Edema Pulmonar/etiología , Edema Pulmonar/fisiopatología , Embolia Pulmonar/complicaciones , Enfermedad Veno-Oclusiva Pulmonar/complicaciones , Daño por Reperfusión/complicaciones , Síndrome de Dificultad Respiratoria/complicaciones , Tomografía Computarizada por Rayos XRESUMEN
Bilioma is a rare complication of traumatic liver injury, and the precise site of bile leak is often difficult to demonstrate with a non-invasive technique. We report a case of post-traumatic bile leak in a 15-year-old girl in whom spiral CT after intravenous cholangiography allowed excellent preoperative demonstration of the extent of the liver rupture and an exact location of the bile leak. We think that spiral-CT cholangiography could be an accurate, non-invasive technique to investigate the biliary system in cases of paediatric liver trauma.
Asunto(s)
Conductos Biliares Intrahepáticos/lesiones , Fístula Biliar/diagnóstico por imagen , Colangiografía , Procesamiento de Imagen Asistido por Computador , Hígado/lesiones , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/diagnóstico por imagen , Adolescente , Conductos Biliares Intrahepáticos/diagnóstico por imagen , Conductos Biliares Intrahepáticos/cirugía , Fístula Biliar/cirugía , Medios de Contraste , Extravasación de Materiales Terapéuticos y Diagnósticos/diagnóstico por imagen , Extravasación de Materiales Terapéuticos y Diagnósticos/cirugía , Femenino , Humanos , Hígado/diagnóstico por imagen , Hígado/cirugía , Sensibilidad y Especificidad , Ácidos Triyodobenzoicos , Heridas no Penetrantes/cirugíaAsunto(s)
Enfisema Mediastínico/diagnóstico por imagen , Traumatismos Torácicos/complicaciones , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/complicaciones , Adulto , Femenino , Humanos , Pulmón/patología , Enfisema Mediastínico/etiología , Enfisema Mediastínico/patología , Radiografía Torácica , Traumatismos Torácicos/diagnóstico por imagenRESUMEN
Recently, the material available for endovascular aneurysm repair (covered stents and application systems), real time medical imaging and operator experience have significantly improved. Hence, more and more complex vascular lesions, well beyond the original indications, can now be treated by endovascular surgery. Since 1996 our group has implanted 55 endovascular systems in the clinical setting: 45/55 (80%) for classical indications and 11/55 (20%) for extended indications. In the latter group four different endoprosthetic systems were used according to either their performance and availability or the type of lesion to be treated. For the 11 patients undergoing endovascular procedures with extended indications, 6/11 had thoracic aortic lesions (55%) and 5/11 (45%) had aorto-iliac lesions requiring either progressive embolisation of the internal iliac arteries or suprarenal anchorage. For these extended indications hospital mortality was 0/11 (0%). One patient died after hospital discharge. 1/11 patients (9%) had to be converted to open surgery during the interval between iliac embolisation and endovascular repair. There has been no conversion to open surgery during or after the endovascular procedures. Two major endoleaks were detected (2/11: 18%). One has been corrected by an additional covered stent and endovascular repair is planned for the other one. Spontaneously regressive functional hypoperfusion has been observed in 4/5 patients with progressive internal iliac embolisation. There was no irreversible renal insufficiency. Early results of endovascular aneurysm repair for extended indications are promising. Although the long-term outcome is unknown, it can already be said that traditional open surgery can be avoided for a considerable amount of time in an increasing number of patients.
Asunto(s)
Aneurisma/cirugía , Implantación de Prótesis Vascular , Procedimientos Quirúrgicos Vasculares/métodos , Aneurisma/mortalidad , Aneurisma de la Aorta Abdominal/cirugía , Prótesis Vascular , Humanos , Arteria Ilíaca , Estudios Retrospectivos , StentsRESUMEN
BACKGROUND: Respiratory failure secondary to cardiopulmonary bypass (CPB) remains a major complication after cardiac surgery. We tested the hypothesis that post-CPB lung function impairment can be prevented by continuous positive airway pressure (CPAP) applied during the CPB. METHODS: In 6 pigs, CPAP with 5 cmH2O pressure was applied during CPB. Six other pigs served as control, i.e. the lungs were open to the atmosphere during CPB. After median sternotomy, the right atrial appendage as well as the ascending aorta were cannulated. The total CPB duration was 90 min with 45 min cardioplegic arrest. Ventilation-perfusion distribution was measured with the multiple inert gas elimination technique and atelectasis by CT-scanning. RESULTS: Large atelectasis appeared after CPB, corresponding to 14.5% +/- 5.5 (percent of the total lung area) in the CPAP group and 18.7% +/- 5.2 in the controls (P = 0.20). Intrapulmonary shunt increased and PaO2 decreased after the CPB in both groups. CONCLUSIONS: We conclude that in this pig model post-CPB atelectasis is not effectively prevented by CPAP applied during CPB.
Asunto(s)
Puente Cardiopulmonar , Pulmón/fisiología , Respiración con Presión Positiva , Resistencia de las Vías Respiratorias/fisiología , Análisis de Varianza , Animales , Gasto Cardíaco/fisiología , Puente Cardiopulmonar/efectos adversos , Paro Cardíaco Inducido , Rendimiento Pulmonar/fisiología , Oxígeno/sangre , Atelectasia Pulmonar/diagnóstico por imagen , Atelectasia Pulmonar/etiología , Intercambio Gaseoso Pulmonar/fisiología , Distribución Aleatoria , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/prevención & control , Esternón/cirugía , Porcinos , Toracotomía , Factores de Tiempo , Tomografía Computarizada por Rayos X , Relación Ventilacion-Perfusión/fisiologíaRESUMEN
OBJECTIVE: Evaluation of the efficiency of our technique of methylene-blue labelling of pulmonary nodules to facilitate thoracoscopic recognition and excision. DESIGN: Patients with a peripheral pulmonary nodule smaller than 2.5 cm and not in contact with the visceral pleura were included. Under tomodensitometric guidance, the nodules were labelled with methylene-blue within hours before thoracoscopic wedge resection. If frozen section revealed a primary bronchial carcinoma, thoracotomy and classical resection were performed during the same anesthesia. RESULTS: Between July 1992 and August 1996, 54 nodules were removed in 51 patients. Labelling was performed between 75 and 270 min before surgery and was complicated in 13 patients (25.4%) by a small pneumothorax without any clinical consequence. Labelling allowed successful thoracoscopic recognition of 50 nodules (92%) and thoracoscopic wedge resection was possible in all but one cases (91%). Five patients (9%) required thoracotomy. Histology showed a benign lesion in 22 cases, a primary lung carcinoma in 17 and a metastases in 15. Twenty of the 22 benign nodules (91%) were removed without thoracotomy. According to the protocol, 13 patients with a primary lung tumour underwent lobectomy during the same session. There was no mortality nor morbidity amongst patients who had thoracoscopy only. CONCLUSIONS: Our technique of labelling peripheral pulmonary nodules with methylene-blue is very effective and is not associated with any relevant complication. Thoracoscopic excision and diagnosis is possible in more than 90% of the cases. We therefore recommend this simple, low-cost and reliable technique for nodules not in contact with the visceral pleura before thoracoscopic wedge resection.