1. BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION WITH AND WITHOUT T-TUBE
Benítez Cantero, J.1; Costán Rodero, G.1; Naveas Polo, C.1; Montero Álvarez, J.1; Ayllón Terán, M.2; Fraga Rivas, E.1; Barrera Baena, P.1; López Cillero, P.2; Luque Molina, A.2; de La Mata García, M.1
1REINA SOFIA HOSPITAL, CLINICAL MANAGEMENT UNIT, GASTROENTEROLOGY SERVICE; 2REINA SOFIA HOSPITAL, GENERAL SURGERY SERVICE.
Biliary complications after liver transplantation are frequent causes of morbidity and mortality (10-30%). The use of the T-tube in bile duct reconstruction is being abandoned. Aims of this study Compare biliary complications in groups of patients with and without T-tube and identify possible risk factors.
Material and approaches
Retrospective study of 95 consecutive adult liver transplants, with T-tube (group 1, n=45) and without Kehr's T-tube (group 2, n=50). Variables were collected from recipient, surgery and donor.
The study included 70 men (78.9%) whose mean age was 53.9 ± 0.94 (21-73). The main indications were liver failure (46, 48.4%) and hepatocellular carcinoma (28, 29.5%); caused by: alcohol in 50 patients (52.6%) (10 with HCV (10.5%), 12 HCC (12.6 %)); and 37 HCV (38.9%): 15 with HCC (15.8%). Median follow-up: 665 days. Overall survival was 86.3% with 6.3% retransplantation. Only 18 patients (18.9%) had major biliary complications (and needed interventional treatment). Treatments applied: 11 ERCP (11.6%), 3 THC (3.2%) and 4 surgery (4.2%). There were no differences in mortality, and the incidence of major biliary complications was similar in both groups (9/45 vs 12/50, p0.64), as well as the treatment used, although the biliary anastomotic stenosis was more frequent in the group without Kehr's T-tube (14/50 vs 4/45, p0.01).
Liver transplantation with biliary anastomosis without T-tube, does not show, in general, increased biliary complications, although the biliary anastomotic stenosis is more common. The most common procedure for the resolution of the stenosis was ERCP.
2. RISK-ADJUSTED MORBIDITY AND MORTALITY SCORING SYSTEMS IN COLORECTAL CANCER SURGERY.
Gomez Sotelo, A.1; Galindo Galindo, A.1; Briones Perez de La Blanca, E. 2
1VALME HOSPITAL, DIGESTIVE SURGERY AND MEDICAL SERVICES. SEVILLE; 2VALME HOSPITAL, CLINICAL QUALITY AND DOCUMENTATION SERVICE. SEVILLE.
Aim of this study
Analyze the present state of the morbidity and mortality scoring systems in patients undergoing surgery for colorectal cancer and their validity for comparisons between the results obtained by different surgeons, units and hospitals.
Material and approaches
Databases consulted between 1998 and 2011: Cinahl, Embase, Eric, IME-Biomedicine, Medline, PubMed and SciELO. Inclusion criteria: studies with colorectal cancer-specific data, accesibility to the complete publication/article; bases written both in English and Spanish.
20 articles which assess the scoring systems were included in the final review: Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSUMM) as well as the Portsmouth and Colorectal variations of it (P-POSSUM, CR-POSSUM) and the scoring system from the Association of Coloproctolgy of Great Britain and Ireland (ACPGBI).
The risk-adjusted morbidity and mortality scoring systems are needed to compare results after surgery. The comparison of the results of surgical procedures could help to detect and correct deficiencies in surgical care and to improve their performance. The original POSSUM scoring system is the only one able to predict postoperative morbidity in a precise way. P-POSSUM and CRPOSSUM, compared with the original POSSUM are better predictors of postoperative mortality after colorectal cancer surgery. There are few studies that validate the ACPGBI scoring system. Knowing the individual risk of morbidity and mortality of a patient before surgery facilitates treatment planning and the quality of informed consent.
3. PREVALENCE AND CHARACTERISTICS OF BONE DISEASE IN CIRRHOTIC PATIENTS WHO ARE POTENTIAL CANDIDATES FOR LIVER TRANSPLANTATION
Alcalde Vargas, A.1; Pascasio Acevedo, J.1; Gutierrez Domingo, I.2; Garcia Jimenez, R.3; Sousa Martín, J.4; Ferrer Rios, M.4; Sayago, M.4; Giráldez, A.4; Márquez Galán, J.4
1VIRGEN DEL ROCIO UNIVERSITY HOSPITAL, CLINICAL MANAGEMENT UNIT, GASTROENTEROLOGY SERVICE. SEVILLE 2VIRGEN DEL ROCIO UNIVERSITY HOSPITAL, CLINICAL MANAGEMENT UNIT, GASTROENTEROLOGY SERVICE. SEVILLE 3VIRGEN DEL ROCIO UNIVERSITY HOSPITAL, NUCLEAR MEDICINE SERVICE. SEVILLE. 4VIRGEN DEL ROCIO UNIVERSITY HOSPITAL, CLINICAL MANAGEMENT UNIT, GASTROENTEROLOGY SERVICE. SEVILLE
Aims of this study
Studying the prevalence and characteristics of bone disease (BD) in cirrhotic patients evaluated for liver transplantation (LT).
Retrospective study of cirrhotic candidates for LT. It examines the prevalence of BD through bone densitometry in the hip/femoral neck and lumbar spine (osteopenia and osteoporosis are defined as a bone-mineral density T-score according to WHO criteria) and its association with demographic and clinical variables, etiology, and liver function through the analysis of univariate and multivariate logistic regression.
The study included 486 patients (79% men), whose mean age was 53 ± 8.8 (21-69), 62.6% of them were smokers and 23.7% were diabetic. Body mass index (BMI) 28.8 ± 5.7 (16-43). Child-Pugh: A (22%), B (51%), C (27%). MELD 14.6 ± 5.4 (7-33). Etiology: Alcohol (59%), HCV (32%), HBV (10%), primary biliary cirrhosis (PBC) (2.3%), secondary biliary cirrhosis (SBC) (2%), Other (10%).350 patients (72%) had overall BD: total hip, 26% (osteopenia 32%, osteoporosis 4%); femoral neck, 48% (osteopenia 43%, osteporosis 5%); spine, 63% (osteopenia 40%, osteoporosis 23%). The univariate analysis showed a higher risk of BD for women (OR 1.88, p=0.023) and for those with lower BMI (OR 0.95, p=0.012). The following variables were significant in the multivariate analysis: being a woman (OR: 2.43, p=0.004), BMI (OR 0.96, p=0.016) and tobacco smoking (OR: 1.59, p=0.043).Patients who suffered from PBC showed BD in 100% of cases.Adjusting the BD prevalence to age (Z score) in relation to that defined by the T score, a decrease was observed in both the femoral neck (20% vs 48 %) and the spine (44% vs 63%).
Over 70% of cirrhotic patients evaluated for LT showed to be suffering from BD, especially prevalent in the spine. Cirrhosis is a major risk factor for BD, remaining even when the values of bone mineral density are adjusted to age.Being a woman, having a low BMI and smoking tobacco are major risk factors for BD in cirrhotic patients.
4. ROLE OF THE GLUTAMINASE GENE IN THE DEVELOPMENT OF COMPLICATIONS OF LIVER CIRRHOSIS
Cano-medel, C.; Maraver, M.; Ampuero, J.; Millán-lorenzo, M.; Rojas, A.; Romero-gómez, M.
VALME HOSPITAL, DIGESTIVE DISEASES SERVICE. SEVILLE.
The TACC haplotype of the glutaminase gene has been linked to a reduced intestinal production of ammonia and protects against the development of encephalopathy. On the other hand, the impact of this haplotype in the development of other complications of cirrhosis has not been analyzed yet.
Aims of this study
Analyzing the impact of TACC protective haplotype of the glutaminase gene on the development of complications of liver cirrhosis.
Material and approaches
The study included 149 patients (106 men and 43 women) whose mean age was 58 +10 with liver cirrhosis due to: alcohol, 74 (50%); hepatitis C virus, 46 (31%); hepatitis B virus, 13 (9%); and other etiologies, 15 (10%). We recorded the development of ascites, variceal hemorrhage (EVH), hepatorenal syndrome (HRS), spontaneous bacterial peritonitis (SBP) and hepatocellular carcinoma. Patients were classified as TACC (+) (84 patients) or TACC (-) (64 patients). The statistical methods used were chi-square distribution, Kaplan-Meier and Thesias.
52/149 (34.9%) patients developed ascites, 18/149 (12.8%) developed EVH, 20 (13.4%) developed hepatocellular carcinoma, 9 (6%) developed SBP, 9 (6%) HRS and 14/149 (9.5%) underwent a transplantation. We detected a relation between TACC haplotype and a reduced risk of EVH (log-rank: 7.08, p=0.008), protection against the occurrence of ascites at follow up (log-rank: 4.51, p=0.034) and reduced need for liver transplantation (log-rank: 5.33, p=0.021). However, there was not a statistically significant relation in the development of HRS, SBP or hepatocellular carcinoma.
The TACC haplotype is a protective factor against the development of hepatic encephalopathy, esophageal variceal hemorrhage, ascites, and hence for the need for liver transplantation.
5. DISACCHARIDE MALABSORPTION. EXPERIENCES FROM THE DIGESTIVE SYSTEM EXAMINATION UNIT IN THE PROVINCE OF ALMERIA
Patrón Román, O.1; Suarez, J.2
1TORRECÁRDENAS HOSPITAL. GASTROENTEROLOGY SERVICE. ALMERIA 2TORRECARDENAS HOSPITAL. DIGESTIVE SYSTEM EXAMINATION UNIT. ALMERIA.
Aims of this study
Determining the percentage of positive results in hydrogen breath tests in patients susceptible to have disaccharide intolerance carried out at the digestive system examination unit from the Torrecardenas Hospital in Almeria.
An observational, descriptive study was carried out including patients susceptible to have disaccharide intolerance. The said patients underwent hydrogen breath tests. These patients were referred from different digestive specialist clinics for adults in the province of Almeria, in the period between December 2007 and June 2011. The sample group consisted of the total number of subjects who performed the hydrogen breath test to rule out disaccharide malabsorption (2439 patients). Information was processed in the form of absolute numbers, percentages and division periods. Data were collected from the computer system of digestive system examination unit at the Torrecardenas Hospital, which covers all the health district of the province of Almeria. For the lactose malabsorption breath test, the substrate used was 50 g of lactose dissolved in 500 ml of water, with determinations of basal H2 (hydrogen) exhaled, 30 minutes after administering the lactose and then every half hour and stopping when reaching 120 minutes. The diagnostic criterion for positivity was a value higher than 20 ppm (parts per million) of H2-breath above baseline. In the fructose-sorbitol malabsorption breath test, the substrate used was 25 g of fructose and 5 g of sorbitol, with determinations of exhaled H2 similar to those used for the lactose intolerance. Results were considered to be positive when the value was higher than 20 ppm of H2-breath above the baseline. A percentage and absolute value stratification was carried out in relation to age, sex and time period.
2439 patients with suspected intolerance to disaccharides who underwent a hydrogen breath test to rule out disaccharide malabsorption were included in the study. 35.67% of the tests (870 cases) showed disaccharide malabsorption. 67.40% of the tests (1644 cases) showed lactose intolerance, and positive results for lactose malabsorption were obtained in 31.81% of the tests (523 cases). To a lesser degree, but increasingly by period, intolerance to fructose-sorbitol was also suspected, performing tests to 32.60% of patients (795 cases) of which 43.64% (347 cases) showed fructose - sorbitol malabsorption. It should also be noted that in our research, patients whose results for lactose malabsorption tests were positive (38.2%, 200 cases) also underwent the test to rule out fructose and sorbitol malabsorption, getting positive results in 46% of the tests performed (92 cases). This means that almost 50% of patients who showed lactose malabsorption were also indicated to undergo the test for fructose - sorbitol malabsorption.
One advantage of the hydrogen breath tests is that they make possible to confirm the clinical suspicion of lactose and fructose-sorbitol intolerance in an objective way, and it is very useful and low cost for the clinician when recommending withdrawal of milk products and/or fructose and sorbitol from the diet of a patient susceptible to the disease.
6. INCIDENCE AND DEVELOPMENT OF LIVER TOXICITY CAUSED BY AZATHIOPRINE IN INFLAMMATORY BOWEL DISEASE
Ciria Bru, V.; Rojas Mercedes, N.; Leo Carnerero, E.; de La Cruz Ramirez, M.; Trigo Salado, C.; Herrera Justiniano, J.; Marquez Galan, J.
VIRGEN DEL ROCIO HOSPITAL, CLINICAL MANAGEMENT UNIT, GASTROENTEROLOGY SERVICE. SEVILLE.
Aims of this study
Determining the incidence of liver toxicity (LT) caused by azathioprine (AZA) in inflammatory bowel disease (IBD) as well as its time and analytical pattern and the response to the decisions taken.
Material and approaches
Retrospective analysis of 332 patients suffering from IBD treated with AZA (264 of them suffering from Crohn's disease, 63 from ulcerative colitis and 5 of them from an unclassified disease). We collected data from patients related to sex, toxic habits, IBD type and pattern, age when treatment started, TPMT activity and NOD2/CARD15 mutations. We analyzed the pattern of liver disorders and its chronological relation to treatment.
16/332 patients (4.8%) developed LT caused by AZA, 15 being early reactions (mean of 39 days from initiation of treatment); the other patients suffered from nodular regenerative hyperplasia after 1.5 years of treatment. Mild cholestatic abnormalities predominated (only one case showed jaundice). In 12 cases the treatment was suspended and, apart from the patient with nodular hyperplasia, 9 patients showed normal results in the laboratory tests in less than 3 months. In 3 patients the laboratory tests showed normal results keeping the same dose or decreasing it (2 patients). None of the analyzed factors influenced the LT, except when IBD had more time to develop (102 vs 53 months, p 0.009) and when treatment was initiated at an older age (43 vs 32, p 0.001).
LT caused by AZA is a remarkable side effect which makes necessary to perform analytical tests throughout the treatment, mainly at the beginning of it as idiosyncratic reactions are more frequent then. Early changes are reversible, and in some cases treatment could continue or doses could be reduced. This control should be more exhaustive when treatment is started later in life.