Search

Splenic abscesses are rare but may be associated with high mortality. Usually they occur in patients with systemic infection related to some immunocompromised state. The symptoms are nonspecific and the diagnosis is often late, but the development of better imaging techniques has enabled better diagnosis of splenic abscess and percutaneous drainage is a valid and safe complementary treatment option. We report a case of a patient with splenic abscess secondary to septic emboli after tooth extractions, managed conservatively with antibiotics and percutaneous drainage.

Background: There is no scientific evidence to show which surgical technique should be used in treating hydatidosis of the liver; nor is there consensus on whether laparoscopy should be used in hydatidosis, because of the risk of dissemination or anaphylaxis., Materials: We conducted a multicenter study of laparoscopic radical surgery for hydatidosis of the liver (LRSH). The main objectives of the study were to determine the feasibility of LRSH, to examine the associated morbidity, and to evaluate the associated recurrence rate., Materials and Methods: The present report is based on a retrospective multicenter study of patients with hydatid disease of the liver treated by LRSH. The study period was from January 2000 to April 2012., Results: There were 37 patients (46 % male) with 43 cysts. The median age was 53.1 years. Median cyst size was 5.8 cm. The most common location of the cyst was the left lateral sector (62 %). The median number of trocars used was 4. Protective scolicide-soaked swabs were used in 57 % of patients. We performed 24 total closed cystectomies, 12 left lateral sectionectomies, and 4 liver resections. The median operating time was 185 min and the mean blood loss was 184 mL. The conversion rate was 8 %. Morbidity was 16 % and mortality 0 %. The length of hospital stay was 4.8 days. No cyst recurrence was observed after a follow-up of 30.6 months., Conclusions: Despite the limitations and biases of a retrospective multicenter study, we believe that LRSH is feasible in favorable segments but is technically demanding. The low morbidity and absence of recurrence suggest that LRSH should be performed whenever feasible.

Several minimal access routes have been implemented as a step-up approach to treat infected pancreatic necrosis. We evaluate our experience with a series of consecutive patients with pancreatic collections treated with video-assisted retroperitoneal débridement (VARD). Seven patients were consecutively treated with VARD: five patients after acute necrotizing pancreatitis, one chronic pancreatitis, and one patient with perforation after endoscopic sphincterotomy. The indication for VARD was: development of sepsis, positive direct culture of the necrosis, and compartment syndrome. The procedure was performed under general anesthesia and modified lateral decubitus. There were four left, two right, and one bilateral VARD. Mean hospital stay since admission to VARD procedure was 30 days (range, 12 to 72 days). Mean operative time was 63 minutes. There were no intraoperative complications. Two patients needed a second procedure to control sepsis. Most patients had a long intensive care unit (ICU) stay with 6.1 days (range, 2 to 22 days) mean postoperative ICU stay. One patient had a hypernatremia as a consequence of saline lavage and three patients presented pancreatic fistula that were managed with conservative treatment. There was no mortality. VARD approach is a recommended step-up approach to treat infected pancreatic necrosis, and its indication may be extended to treat other retroperitoneal collections.

Lymphangiomatosis is a rare syndrome that can affect different organs, although simultaneous splenic and adrenal involvement is exceptional. We report the case of a young female with a symptomatic massive splenomegaly and no-nhypersecreating bilateral adrenal masses incidentally discovered that represented a diagnostic challenge. The management of adrenal incidentalomas is controversial, as the presence of large sized bilateral masses are highly indicative of malignancy. Despite the different diagnostic techniques available, it is sometimes impossible to reach an accurate preoperative diagnosis. Elective splenectomy and left adrenalectomy were performed, preserving the functioning of the right adrenal gland, radiologically similar to the left one, to prevent the development of definitive adrenal insufficiency. Postoperative evolution has been favourable without initial increase of the size of the right adrenal lesion. However, the persistence of this mass obligated long-term follow-up and shall assist us in better understanding the behavior of this bening lesion.

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.

Aim: To evaluate the clinical course, diagnostic approach, therapeutic measures and results, in a series of 13 patients with colonic bleeding diverticula., Material and Methods: From 1973 to 1995, 72 patients were admitted with the diagnosis of lower gastroin testinal bleeding. Thirteen presented a colonic diverticula bleeding. Mean age was 65.2 years. Medical history, symptoms, diagnosis, treatment (conservative or surgical) and pathology were recorded., Results: Main bleeding time was 3 days. Eight patients needed blood transfusion. All patients underwent colonoscopic examination and it was diagnostic in every patient. Four patients underwent surgery: one case, because of massive hemorrhage and the other three cases due to bleeding recurrence. Pancolectomy was performed in one patient, ileal resection in another and the other two were treated with a sigmoidectomy and a left hemicolectomy. Pathology analysis corroborated colonic diverticula diagnosis. There was no postoperative mortality. Bleeding recurrence did not occur either in postoperative period or in the follow-up., Conclusions: Colonic diverticular bleeding usually stops spontaneously, obtaining high rates of preoperative diagnosis with colonoscopy. Less than a third of the cases requires surgical resection.

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.

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.