Revista Española de Enfermedades Digestivas

El trasplante hepático de donante vivo como muestra de inteligencia social

Actitud hacia la donación de vivo relacionada entre los candidatos a trasplante hepático en lista de espera

Objetivo: analizar la actitud hacia la donación de vivo de los pacientes en lista de espera para trasplante hepático. Diseño y pacientes: seleccionados los pacientes incluidos en lista de espera para trasplante hepático (2003-2005) (n = 164). La actitud hacia la donación de vivo se valora mediante un cuestionario validado. La cumplimentación fue mediante entrevista por un profesional sanitario independiente de la Unidad de Trasplantes. Resultados: el grado de cumplimentación: 97% (n = 159). El 87% (n =138) de los pacientes indican que donarían en vida un órgano si un familiar o amigo íntimo lo necesitase. Sin embargo, solo el 39% (n = 61) aceptaría una donación hepática de vivo relacionada, prefiriendo esperar en Lista de Espera el 50% (n = 80). El 90% asume que existe algún riesgo en la donación hepática de vivo. Sin embargo, no se asocia con la aceptación de la donación de vivo relacionada (p = 0,170). De las diferentes variables analizadas, solo se relaciona con la actitud hacia la aceptación de la donación de vivo el conocer la actitud de su familia para donarles un órgano (p = 0,027). Conclusiones: los pacientes en lista de espera para trasplante hepático tienen una actitud favorable hacia la donación de vivo hepática. Un núcleo familiar propicio hacia la donación de vivo favorece la aceptación de dicha donación, por ello, es fundamental hacer un sondeo familiar entre los pacientes para detectar aquellos casos en los que se puede solicitar con éxito dicha donación de vivo.

Objective: to analyze attitude of patients on the liver transplant waiting list toward living donation (LD). Design and patients: patients on the transplant waiting list -2003-2005 (n = 164)- were selected. Attitude was evaluated using a validated questionnaire, completed by an independent healthcare professional. Results: the questionnaire completion rate was 97% (n = 159). A total of 87% (n = 138) of patients stated that they would donate an organ while alive if a family member needed one. However, only 39% (n = 61) would be prepared to receive a liver donation from a living relative and 50% would prefer to wait on the list (n = 80). 90% accepted that living liver donation involves a certain amount of risk. This assumption was not associated with a willingness to accept related LD (p = 0.170). A willingness to accept LD was related to patient's knowledge of his or her family's attitude toward donating an organ to the patient (p = 0.027). Conclusions: patients had a favorable attitude toward living liver donation. When there was a family base that is in favor of LD then this encouraged acceptance, and therefore, it is essential to carry out family screening of patients to detect those cases in which this type of LD can be successfully requested.

Diagnóstico definitivo de los tumores neuroendocrinos (TNE) mediante PAAF ecodirigida por ultrasonografía endoscópica (USE)

Background: the detection and diagnosis of neuroendocrine tumors (NETs) is challenging. Endoscopic ultrasonography (EUS) has a significant role in the detection of NETs suspected from clinical manifestations or imaging techniques, as well as in their precise localization and cytological confirmation using EUS-Fine-needle aspiration-puncture (FNA). Objective: to assess the usefulness and precision of EUS-FNAP in the differential diagnosis and confirmation of NETs, in a retrospective review of our experience. Patients and methods: in a total of 55 patients with suspected NETs who underwent radial or sectorial EUS, 42 tumors were detected in 40 cases. EUS-FNA using a 22G needle was performed for 16 cases with suspected functional (hormonal disorders: 6 cases) and non-functional NETs (10 cases). Ki 67 or immunocytochemistry (ICC) testing was performed for all. There was confirmation in 9 cases (5 female and 4 male) with a mean age of 51 years (range: 41-81 years). All tumors were located in the pancreas except for one in the mediastinum and one in the rectum, with a mean size of 19 mm (range: 10-40 mm). Results: there were no complications attributable to FNA. Sensitivity was 100% and both precision and PPV were 89%, as a false positive result suggested a diagnosis with NET during cytology that surgery finally revealed to be a pancreatic pseudopapillary solid tumor. Conclusions: EUS-FNA with a 22G needle for NETs has high sensitivity and PPV at cytological confirmation with few complications.

Introducción: la localización y diagnóstico de los tumores neuroendocrinos (TNE) es difícil. La ultrasonografía endoscópica (USE) tiene un papel significativo en la detección de TNE sospechados por la clínica u otras técnicas de imagen, así como en la localización exacta y confirmación citológica mediante USE-PAAF. Objetivo: valorar la utilidad y precisión de la PAAF-USE en el diagnóstico diferencial y de confirmación de los TNE, en una revisión retrospectiva de la experiencia de nuestro grupo. Pacientes y métodos: de un total de 55 enfermos con sospecha de TNE a los que se le practicó USE radial o sectorial, se detectaron 42 tumores en 40 casos. En 16 casos con sospecha de TNE funcionantes (trastornos hormonales: 6 casos) y no funcionantes (10 casos), se les practicó USE-PAAF con 22 G. En todos se efectuó Ki 67 o inmunocitoquímica (ICQ). Hubo confirmación quirúrgica en 9 casos (5 M y 4 V), con una media de edad de 51 años (rango: 41-81 años). Los tumores se localizaban todos en el páncreas, excepto uno en el mediastino y uno en el recto, con un tamaño medio de 19 mm (rango: 10-40 mm). Resultados: no hubo complicaciones atribuibles a la PAAF. La sensibilidad fue del 100% (8/8), y la precisión y el VPP fue del 89% (8/9), ya que hubo un falso positivo que en el estudio citológico sugirió el diagnóstico de TNE pero que su resección quirúrgica confirmó el diagnóstico de tumor sólido seudopapilar del páncreas. Conclusiones: la USE-PAAF con 22 G de los TNE posee una alta sensibilidad y VPP en la confirmación citológica de estos pacientes, con muy escasas complicaciones.

Síntomas atípicos de reflujo gastroesofágico en el embarazo

Background: pregnancy is associated with an increased incidence of heartburn. However, there is no information for other symptoms related to gastro-esophageal reflux (GOR). Aim: to assess the prevalence of atypical symptoms of GOR during pregnancy, and to examine its association with typical GOR symptoms. Methods: we report data for 263 women with a pregnancy of less than 12 weeks. They were interviewed at the end of each trimester of pregnancy and at 1-year post-partum, using the Gastro Esophageal Reflux Questionnaire (GERQ). In the first interview, information about symptoms in the year before pregnancy was also collected with GERQ. Results: women suffered atypical GOR symptoms during pregnancy more frequently than in the year before: non-cardiac chest pain (NCCP) (9.1 vs. 1.9%), dysphagia (12.6 vs. 2.3%), globus (33.1 vs. 4.6%), cough (26.6 vs. 6.8%), belching (66.2 vs. 19.4%) and hiccups (19.0 vs. 8.4%). Atypical GOR symptoms in pregnancy showed an association with suffering the same symptom before pregnancy and NCCP, globus, belching and hiccups with suffering typical GOR symptoms in the first trimester. Conclusions: atypical GOR symptoms are highly prevalent in pregnancy, and are associated with atypical symptoms before pregnancy and with typical symptoms of GOR in the first trimester.

**Laparoscopia versus cirugía abierta en el cáncer gástrico avanzado y resecable: una meta-análisis**

Background: there are few studies in the literature comparing laparoscopic versus open Gastrectomy, predominantly for advanced gastric cancer (AGC). Most of the available studies and meta-analysis compare both approaches in the early gastric cancer. The meta-analysis, here presented, compares the clinical outcomes between these two procedures for AGC. Objectives: to evaluate the current status of both partial and total laparoscopic gastrectomy (LG), with regard to its short and long-term outcomes by comparing it to conventional open gastrectomy (OG) for AGC. Data sources and review methods: original articles published in English language from January 1991 to October 2009 were searched in the Medline, Embase, Current Contents, Science Citation Index databases and Cochrane Controlled Trials Register. All articles comparing LG and OG for AGC were included, and those comparing outcomes only for early gastric cancer (EGC) were excluded. Clinical appraisal and data extraction were conducted independently by 3 reviewers. Statistical analysis was carried out following the DerSimonian-Laird random effects model. Results: out of 2,344 studies, 7 studies were selected. One prospective randomized controlled trial, one comparative prospective study and five comparative retrospective studies were analyzed. These studies include a total of 452 patients with gastric cancer, 174 patients in the LG and 278 in the OG. The analyzed result variables were operative time, operative blood loss, hospital postoperative stay, number of dissected lymph nodes and cancer-related mortality risk. Compared to OG, LG was a longer procedure: weighted mean difference (WMD) 44 minutes; 95% confidence interval (CI) 20 to 69; I-squared = 91.6%, but was associated with a lower blood loss (WMD -122 cc; 95% CI -208 to -37; I-squared = 90.8%); this was more significant for hospital operative stay (WMD -6.2 days; 95% CI -9.4 to -2.8; I-squared = 67.8%). Moreover there were no significant differences between the two groups concerning the number of dissected lymph nodes (WMD -1.57; 95% CI -3.41 to 0.26; I-squared = 8.3) and no significant differences for cancer-related mortality risk (adjusted for 60 months of follow-up) although there was a tendency toward a protective effect for LG (Odds Ratio 0.53; 95% CI 0.23 to 1.22; I-squared 41%). Conclusion: laparoscopic total and partial gastrectomy for AGC is associated with a longer operative time but lower blood loss and shorter postoperative hospital stay. Moreover there were similar outcomes between both approaches in terms of number of dissected lymph nodes and long-term follow-up (survival).

Profilaxis y tratamiento de la infección por el virus de la hepatitis B en relación con el trasplante hepático

Without any treatment, the prognosis of hepatitis B in liver transplant recipients is very poor. So, antiviral prophylaxis is very important in patients with hepatitis B who undergo liver transplantation. Before liver transplantation, a suppression of viral replication has to be achieved by nucleos(t)ide analogs. Drugs used in the prophylaxis of post-transplant hepatitis B include immunoglobulin against HBV and nucleos(t)ide analogs. Prophylaxis against graft infection must be based on the individual risk of recurrence. When prophylactic measures have failed and graft infection has occurred, treatment of recurrent hepatitis B may be based on the resistance profile of the virus and previous antiviral exposure. Finally, lamivudine seems to be very effective in the prevention of de novo hepatitis B in patients transplanted with a graft from an anti-HBc positive donor.

La infección por el virus de la hepatitis B en los receptores de trasplante hepático tiene un pronóstico malo en ausencia de tratamiento farmacológico. Por ello, en los pacientes trasplantados por una hepatopatía por virus B, la profilaxis de esta infección es imprescindible. Antes del trasplante, debe intentarse suprimir la replicación viral con un análogo de nucleót(s)idos. Tras el trasplante, la profilaxis de la recidiva de la hepatitis B se basa en el uso de los análogos de nucleót(s)idos y la inmunoglobulina frente al virus de la hepatitis B; la pauta de profilaxis debe basarse en el riesgo de recidiva de la hepatitis B que tenga cada paciente. En el caso de que se produzca una hepatitis B tras el trasplante, el tratamiento con análogos de nucleót(s)idos debe basarse en los estudios de resistencia. Por último, en los pacientes trasplantados que reciben un injerto de un donante antiHBc-positivo, la profilaxis con lamivudina parece ser muy eficaz.

Enfermedad de Hirschprung del adulto

Linfoma intestinal primario

Ileítis por citomegalovirus en paciente inmunocompetente

Cytomegalovirus (CMV) is a virus that belongs to the family of Herpesviridae. Infection can cause a serious disease in immunocompromised patients, but it can also affect immunocompetent patients, creating generally self limiting symptoms. However, in some cases it can be fatal. We present a case of CMV ileitis with serious clinical symptoms that led to an operation in an immunocompetent patient.

El citomegalovirus (CMV) es un virus perteneciente a la familia de los Herperviridae. La infección puede causar una enfermedad grave en inmunodeprimidos, sin embargo también puede afectar a inmunocompetentes, y da lugar a cuadros clínicos generalmente autolimitados, aunque se han descrito casos graves que pueden llevar a la muerte. Presentamos un caso de ileítis por CMV con manifestaciones clínicas graves que motivaron intervención quirúrgica urgente en un paciente inmunocompetente.

Balón intragástrico

Malposición del colon transverso

Pancreatitis autoinmune: respuesta a esteroides como vía de diagnóstico

Pancreatitis aguda como complicación de enteroscopia de doble balón (EDB): primer caso en nuestro centro

Parkinsonismo inducido por cleboprida

Evisceración vaginal espontánea

Complicación vascular excepcional durante la colangiopancreatografía retrógrada endoscópica: canulación de la arteria hepática