Dissertations / Theses on the topic 'Portosystemic'

The purpose of this thesis was to evaluate (i) the effect of TIPSS on the natural history of cirrhosis (ii) the changes in shunt function following its insertion and study the potential pathogenic mechanisms (iii) the place of TIPSS in the management of variceal haemorrhage in patients with cirrhosis and (iv) the use of TIPSS as a 'model' to study the pathogenesis of sodium retention in patients with cirrhosis. The thesis aims to answer these questions by studying defined cohorts of patients with cirrhosis and portal hypertension undergoing TIPSS insertion for a variety of indications. The thesis is divided into various sections which deal with the above questions. The first section deals with the outcome of patients with cirrhosis treated with TIPSS and assesses the factors predicting mortality, rebleeding, encephalopathy and shunt insufficiency. It also prospectively assesses changes in liver function, neuropsychological profile, haematological profile and appraises their relationship with changes in the portal pressure. Studies in the next section were designed to evaluate the methods for assessment of shunt function and to study the pathogenesis of shunt insufficiency. The place of TIPSS in the management of variceal haemorrhage in patients with cirrhosis is evaluated in a randomised and controlled study in comparison with variceal band ligation. The last section looks at the mechanisms of sodium retention in cirrhosis particularly with reference to the 'hepatorenal reflex'. The final chapter is dedicated to discussing the findings of this study in the light of the available literature and define the areas of deficiency in our understanding and to outline future perspectives. In conclusion, TIPSS is an exciting innovation which is relatively safe and can be performed in the vast majority of patients with cirrhosis with a very low procedure related mortality. Although its place in the management of uncontrolled variceal haemorrhage appears certain, further controlled studies are needed to assess its role in the secondary prophylaxis of variceal haemorrhage and in refractory ascites.

Portal hypertension (PHT) is a condition with serious complications, such as variceal bleeding, refractory ascites and bowel ischemia. The cause of PHT may be pre-, intra- or post-hepatic. Initial treatment is pressure-reducing drugs and the treatment of acute symptoms. Ten patients presented with severe abdominal pain and acute portomesenteric venous thrombosis. Their response to systemic anticoagulation was insufficient. Treatment with primary continuous thrombolysis by a transhepatic or transjugular approach in four patients resulted in major complications, incomplete recanalization and a 75% survival rate. Treatment with repeated transjugular thrombectomy (TT) combined with the creation of a transjugular intrahepatic portosystemic shunt (TIPS) achieved near complete recanalization, prompt symptom relief and 100% survival in five patients treated with this method as the primary intervention. In one patient, treated with TT and TIPS secondary to surgical thrombectomy and bowel resection, the outcome was fatal. Nineteen patients with portal vein thrombosis presented with acute or threatening variceal bleeding or refractory ascites. TIPS was feasible in 16 of the 18 patients in whom it was attempted and symptom relief was achieved in the majority of them. In 14 patients with Budd-Chiari syndrome, 13 patients were treated with TIPS, four of them after previous liver vein angioplasty. The 5-year transplantation-free survival rate was 100% in patients treated with primary TIPS. In 131 patients with variceal bleeding treated with TIPS, the survival at 12 months in patients with and without cirrhosis was 70% and 100% respectively and in accordance with previous studies. A high Child-Pugh score prior to TIPS and severe HE within 12 months after TIPS was related to an increased mortality. The occurrence of HE after TIPS did not correlate with the PSG after TIPS. Re-bleeding within 12 months after TIPS occurred in 10 patients and was associated with TIPS dysfunction. In conclusion, endovascular intervention, mainly TIPS, seems to be safe and effective for treating patients with complications of PHT, regardless of the underlying cause of disease and site of venous blood flow obstruction. HE may occur more frequently after TIPS than medical and endoscopic treatment, but is often mild and easily treated. In selected patients with PHT, TIPS may improve survival.

No desvio portossistêmico, o sangue proveniente do trato gastrintestinal não é direcionado ao fígado para ser metabolizado e sim desviado para a circulação sistêmica. O acúmulo dessas substâncias tóxicas associado às alterações funcionais do órgão pode resultar em encefalopatia hepática. O manejo nutricional é o ponto chave para o sucesso da terapia. Dessa forma, o presente estudo objetivou avaliar os efeitos do emprego de um alimento hipoproteico nas concentrações séricas aminoacídicas de cães com desvio portossistêmico. Foram incluídos nove cães com diagnóstico de desvio portossistêmico (Shunt) e nove cães saudáveis (Controle). Os animais foram avaliados no dia um (T0) e após 60 dias (T60) de ingestão de uma dieta hipoproteica comercial. Nos dois momentos foram coletadas amostras de sangue para realização de hemograma, leucograma, bioquímica sérica, determinação dos aminoácidos séricos e amônia. A análise estatística dos resultados referentes aos hemogramas e exames bioquímicos foi baseada em um modelo misto que considerou efeito fixos de grupo, tempo e interação e, para os aminoácidos somente efeitos fixos de grupo (p<0,05). Os animais do grupo controle apresentaram maiores valores de proteína total (p<0,0001), ureia (p<0,0001), creatinina (p=0,0163), albumina (p<0,0001) e colesterol (p=0,0012) quando comparado ao grupo Shunt que apresentou maiores valores de hematócrito (p=0,0213), ALT e FA (p=0,0253 e p=0,0004, respectivamente), amônia em jejum (p=0,0083) e amônia pós-prandial (p=0,0036). Em relação aos aminoácidos séricos, o grupo Shunt apresentou valores maiores quando comparados ao grupo Controle nas concentrações dos aminoácidos fenilalanina (p=0,0054), glutamato (p=0,0066), serina (p=0,0054) e tirosina (p=0,0106), já o aminoácido sérico alanina (p=0,0280), a razão de Fischer (p=0,0093) e a razão da concentração sérica de aminoácidos de cadeia ramificada e tirosina (p=0,0243) foram maiores no grupo Controle. Concluiu-se que o manejo dietético foi eficiente em prevenir a progressão da doença e controlar os sinais clínicos, sem promover aumento nas concentrações séricas dos aminoácidos de cadeia ramificada.
In the portosystemic shunt, the blood coming from the gastrointestinal tract is not directed to the liver to be metabolized but rather diverted to the systemic circulation. The accumulation of these toxic substances associated with functional alterations of the organ can result in hepatic encephalopathy. Nutritional management is the key to successful therapy. Thus, the present study aimed to evaluate the effects of the use of a hypoproteic food on the protein and amino acid profile of dogs with portosystemic shunt. For this, nine dogs with a diagnosis of portosystemic shunt (Shunt) and nine healthy dogs (Control) were included. The dogs were evaluated on day one (T0) and after 60 days (T60) feeding a commercial hypoprotein diet. Blood samples were collected for hemogram, leukogram, serum biochemistry, determination of serum amino acids and ammonia. For the analysis of hemograms and biochemistry, a mixed model was used considering group fixed effects, time and interaction, and for amino acids only group fixed effects (p<0.05). The results showed that the animals in the Control group presented higher values of total protein (p<0.0001), urea (p<0.0001), creatinine (p=0.0163), albumin (p<0.0001) and cholesterol (p=0.0012) when compared to the Shunt group that presented higher values of hematocrit (p=0.0213), ALT and FA (p=0.0253 and p=0.0004, respectively), fasting ammonia (p=0.0083) and postprandial ammonia (p=0.0036). Serum amino acids (p=0.0054), glutamate (p=0.0066), serine (p=0.0054) and tyrosine (p=0.0054) were higher in the Shunt group than in the Control group (0.0106). The Fischer ratio (p=0.0093) and the ratio of serum concentration of branched-chain amino acids and tyrosine (p=0.0243) were higher for the Control group. In conclusion, that dietary management was efficient in preventing disease progression and controlling clinical signs without increasing branched-chain amino acids.

Foi realizado o estudo morfométrico e o estudo hemodinâmico da veia porta em vinte cães normais, de idade igual e inferior a 120 dias, e em cinco cães portadores de desvio portossistêmico, de idades entre 90 e 360 dias. Dois animais do grupo de cães portadores de desvio portossistêmico foram submetidos ao tratamento cirúrgico (colocação de anel ameróide) e avaliações subseqüentes ao procedimento cirúrgico foram realizados. Nos cães do grupo normal, as margens hepáticas apresentaram-se entre 1,50cm e 3,00cm depois da margem costal. As médias dos diâmetros médios da veia porta (VP), veia cava caudal (VCC) e aorta abdominal (AO) obtidas foram respectivamente, 0,38cm, 0,37cm e 0,41cm. As proporções entre os diâmetros médios VP/VCC e VP/AO apresentaram médias de 1,10 e 0,94, respectivamente. As médias das áreas de VP, VCC e AO mediram respectivamente, 0,12cm2, 0,11cm2 e 0,14cm2. No estudo hemodinâmico de VP destes animais, utilizando-se o ultra-som Doppler, a velocidade média de fluxo sangüíneo portal (VMFSP) mediu 17,77cm/s. A média de fluxo sangüíneo portal (FSP) mediu 83,11ml/min/kg. O índice de congestão (IC) apresentou média de 0,009. Para o grupo de cães portadores de desvio portossistêmico, o fígado apresentou redução de seu volume, sendo visibilizado entre 1,00cm e 2,00cm antes da margem costal. No estudo morfométrico, as médias dos diâmetros médios obtidos de VP, VCC e AO mensuraram respectivamente, 0,52cm, 0,79cm e 0,58cm. As proporções entre os diâmetros médios VP/VCC e VP/AO mediram respectivamente, 0,62 e 0,84. As médias das áreas de VP, VCC e AO mediram respectivamente, 0,22cm2, 0,56cm2 e 0,27cm2. Ao ultra-som Doppler a VMFSP mediu 26,10cm/s e a média do IC obtido foi de 0,009. Nos animais do grupo de cães portadores de desvio portossistêmico submetidos ao procedimento cirúrgico, foi observado aumento de volume hepático na semana seguinte à colocação do anel ameróide e a VMFSP manteve-se inferior a 19,50cm/s em todos exames subseqüentes à cirurgia no cão 1.
The morphometry and haemodynamic aspects of portal vein were studied in 20 normal dogs with less than 120 days of age and in 5 dogs presenting portosystemic shunting with ages between 90 and 360 days. 2 dogs of the group of animals with portosystemic shunting were submitted to surgical treatment, using a specialized device (ameroid constrictor). Subsequent evaluations were made after the surgical procedure. In the normal group the hepatic margins were seen 1.50cm to 3.00cm below de costal margin. Collected data indicated that the mean diameter of portal vein (VP), caudal vena cava (VCC) and abdominal aorta (AO) measured respectively, 0.38cm, 0.37cm and 0.41cm. The VP/VCC and VP/AO mean ratios were respectively, 1.10 and 0.94. The average of VP, VCC and AO areas were respectively, 0.12cm2, 0.11cm2 and 0.14cm2. The haemodynamic of portal vein was studied by ultrasound Doppler and the mean velocity of portal blood flow (VMFSP) measured was 17.77cm/s. It was verified that portal blood flow (FSP) average was 83.11ml/min/kg and the congestion index (IC) average was 0.009. In the group of animals presenting portosystemic shunting, the hepatic margins were seen 1.00cm to 2.00cm above the costal margin. The morphometry of VP, VCC and AO presented a mean diameter of 0.52cm, 0.79cm and 0.59cm, respectively. The VP/VCC and VP/AO mean ratios were respectively, 0.62 and 0.84. The average of VP, VCC and AO areas were respectively, 0.22cm2, 0.56cm2 and 0.27cm2. The haemodynamic study demonstrated that the VMFSP measured was 26.10cm/s and de IC average was 0.009. In the group of animals with portosystemic shunting which were submitted to surgical treatment, an increase of the liver size was seen from the first ultrasonographic evaluation. The measurements of VMFSP collected in the post surgical period were <= 19.50cm/s in dog 1.

Dissertação de Mestrado Integrado em Medicina Veterinária
Os shunts portossistémicos congénitos (SPS) correspondem a malformações vasculares que estabelecem uma comunicação entre a circulação venosa portal e a circulação sistémica, e afetam mais frequentemente os cães de raça pura. Apesar de o tratamento médico ser a primeira abordagem em cães com SPS congénito, a completa resolução clínica está dependente da correção cirúrgica. Este estudo pretendeu caracterizar uma amostra de 13 cães com diagnóstico de SPS que foram submetidos a correção cirúrgica, procurando correlacionar os parâmetros clínicos e laboratoriais com a ocorrência de complicações pós-cirúrgicas a curto e a longo prazo. A amostra em estudo incluiu 8 fêmeas e 5 machos, com idades compreendidas entre os 2 meses e os 4 anos, pertencentes às raças Yorkshire terrier (n=5), Caniche anão (n=2), Chihuahua (n=1), Retriever do Labrador (n=1), Schnauzer miniatura (n=1) e Shih Tzu (n=1), incluindo também cães sem raça definida (n=2). Todos os indivíduos foram submetidos a correção cirúrgica de shunt portossistémico através de técnicas extravasculares de oclusão parcial, que tiveram lugar no Centro Hospitalar Veterinário e no Hospital Referência Veterinária Montenegro. A grande maioria dos cães apresentava SPS de localização extra-hepática (n=12) e apenas um cão apresentava um SPS intra-hepático. As complicações pós-cirúrgicas afetaram mais de metade da amostra (n=7) e incluíram hipertensão portal (n=3), alterações neurológicas (n=1), hipoglicemia (n=1), recorrência de sinais clínicos (n=2) e morte (n=1). Apesar de não existir uma correlação estatisticamente significativa entre o BUN e a ocorrência de complicações pós-cirúrgicas, verificou-se haver uma tendência para os cães com valores inferiores de BUN apresentarem uma maior incidência de complicações pós-cirúrgicas a curto prazo. Concluímos que a manifestação clínica desta doença tende a ser precoce (cães com idade inferior a 1 ano), sendo os sinais gastrointestinais os mais frequentemente descritos e a raça Yorkshire terrier a mais frequentemente afetada. O tamanho reduzido da amostra, a existência de historiais médicos incompletos e a discrepância entre protocolos médicos foram as principais limitações deste estudo, impedindo a obtenção de resultados estatisticamente significativos. Mais estudos serão necessários para padronizar as inúmeras variações morfológicas dos shunts e para determinar quais os fatores associados a um melhor prognóstico.
ABSTRACT - SURGICAL TREATMENT OF CONGENITAL PORTOSYSTEMIC SHUNTS IN DOGS: RETROSPECTIVE STUDY OF 13 CLINICAL CASESCongenital portosystemic shunts are vascular malformations that provides communication between portal and systemic circulation, which typically affects purebred dogs. Although medical treatment is the first-line option for dogs with congenital portosystemic shunt, the complete clinical recovery depends of surgical intervention. This study intended to characterize a sample of 13 dogs with portosystemic shunt diagnosis which were submitted to surgical correction and to correlate the clinical and laboratory parameters with the occurrence of short-term and long-term postoperative complications. The studied sample included 8 females and 5 males, with an age interval between 2 months and 4 years, belonging to the breeds Yorkshire terrier (n=5), Toy Poodle (n=2) , Chihuahua (n=1), Labrador Retriever (n=1), Miniature Schnauzer (n=1) and Shih Tzu (n=1), including mixed-breed dogs (n=2). All dogs were treated using extravascular surgical techniques for gradual occlusion portosystemic shunts, which took place at the Centro Hospitalar Veterinário and Hospital Referência Veterinária Montenegro. The majority of the dogs had an extrahepatic shunt (n=12) and only one dog presented an intrahepatic shunt. Postoperative complications affected more than half of the sample (n=7) and included portal hypertension (n=3), post attenuation neurological signs (n=1), hypoglycemia (n=1), recurrence of clinical signs (n=12) and death (n=1). Although there isn’t a significant correlation between BUN and postoperative complications, it was observed a tendency for dogs with lower BUN to have a higher incidence of short-term postoperative complications. We conclude that the clinical manifestation of this disease tends to be early (dogs under 1- year age), the gastrointestinal symptoms were the most reported and the Yorkshire terrier were the breed most affected. A small sample size, incomplete medical records and discrepancy between the medical protocols were the major limitations in this study, that could explain the upsense of statistically significant results. More studies will be required to describe the numerous variations in the morphology of the shunts and to identify the factors associated with a better prognosis.
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Es wurden 44 Hunde mit einem kongenitalen Portosystemischen Shunt präoperativ hinsichtlich ihrer Leberzellintegrität (ALT, AP, GLDH, GGT) und ihrer hepatischen Synthese- (Harnstoff, Cholesterin, Albumin) bzw. Metabolisierungsrate (Ammoniak) untersucht. Die hepatische Durchblutungs- und Resorptionsrate wurde anhand des Verlaufs der Serumgallensäuren im Gallensäuren-Stimulationstest mit Ceruletid (0,3µg/kg KM i.v.)vor und 30 min nach Stimulation (FSBA; PSBA) beurteilt. Eine Verlaufsuntersuchung erfolgte bei den Hunden, bei denen das Shuntgefäß in zwei Operationen verschlossen worden war. Die Untersuchungen wurden jeweils prae operationem, am zweiten, vierten und siebten Tag post operationem sowie abschließend mindestens 120 Tage nach vollständigem Verschluss des Shuntgefäßes durchgeführt. Es wurden die Ergebnisse der einzelnen Untersuchungstage untereinander mit Hilfe des gepaarten t-Tests sowie mit einer Kontrollgruppe (63 lebergesunde Hunde)unter Anwendung des unpaaren t-Tests verglichen
The hepatic enzymes: alanine aminotransferase (ALT), alkaline phosphatase (AP), glutamat dehydrogenase (GLDH), gamma-glutamyl transferase (GGT); the hepatic synthetic (urea, cholesterol, albumin) and metabolic activity (ammonia) and the hepatic blood flow (serum bile acid stimulation test) were determined in 44 dogs with congeintal portosystemic shunt and in 63 healthy dogs. After determination of fasting serum bile acids (FSBA), the gallbladder contraction was induced by administration of 0,3µg/kg iv ceruletide (Takus). Blood samples of the poststimulatin serum bile acids (PSBA) were taken 30 minutes post administration. The portosystemic shunt was first attenuated (surgery 1) and 4 weeks later completely ligated (surgery 2). All dogs treated with this surgical procedure were examined with the described laboratory design before surgery, the second, the fourth, the seventh day after surgery and approxiamtely 120 days after complete ligation in a follow up study. To compare the developmentof the biochemical and hepatic alterations the paired and unpaired t-test were used

Dissertação de Mestrado Integrado em Medicina Veterinária
O shunt portossistémico (SPS) de origem congénita pode ser intra ou extra-hepático, e é uma comunicação macrovascular entre a veia porta ou suas tributárias e a veia cava caudal ou outra veia sistémica (ázigos e frénica) sem atravessar o parênquima hepático, resultando em consequências sistémicas expressas pela sintomatologia clínica do doente, a qual se relaciona com o grau de compromisso hepático e com a localização desse desvio. O presente estudo retrospetivo foi realizado com uma amostra de 26 cães (N=26), diagnosticados com SPS congénito extra-hepático, dividida em dois grupos de acordo com o local de inserção: 1) caudal ao fígado (esplenocava e gastrocava direita) e 2) diafragmática (gastrocava esquerda, gastrofrénica esquerda e gastroázigos esquerda). O objetivo do estudo foi tentar estabelecer uma relação entre os parâmetros clínicos e analíticos laboratoriais do doente com SPS e os principais locais de inserção. De acordo com os resultados obtidos, verificou-se que, a idade do aparecimento dos sinais clínicos parece estar relacionada com o local de inserção (p=0,006), sendo os doentes com shunt com inserção na veia frénica e ázigos diagnosticados com idades ≥ a 2 anos. De igual modo, a encefalopatia hepática esteve presente de forma estatisticamente significativa em quase todos os pacientes com shunt com inserção caudal ao fígado (p=0,05). À exceção do shunt gastroázigos esquerda, verificou-se a presença de atraso no crescimento e baixa condição corporal para todos os doentes com SPS. Da relação com a analítica laboratorial apenas se verificou diferenças significativas para o parâmetro hematócrito (p=0,01), o qual estava mais baixo nos shunts com inserção caudal ao fígado. No que respeita à urinálise, verificou-se que com idade >12 meses, têm maior predisposição para cristalúria e calculose (p=0,02). Por se tratar de um estudo retrospetivo, a falta de uniformidade no que respeita aos dados referentes de cada doente surge como uma limitação que poderá ter contribuído para os resultados obtidos.
ABSTRACT - CLINICAL AND LABORATORIAL CHARACTERIZATION OF THE DIFFERENT MORPHOLOGIC TYPES OF CONGENITAL EXTRAHEPATIC PORTOSYSTEMIC SHUNTS IN THE SPECIES CANIS FAMILIARIS – RETROSPETIVE STUDY - Congenital portosystemic shunt (CPSS) are macrovascular communication between the portal vein or its tributaries and the caudal vena cava or other systemic veins (azygos and phrenic), and they can be intra or extrahepatic. Different systemic consequences with a various clinical signs and symptoms are seen in these patients, being related to the level of hepatic impairment and its location. This retrospective study used a sample of 26 dogs (N=26), diagnosed with extrahepatic CPSS. The sample was divided in two groups according to the region of the shunt insertion: 1) caudal to the liver (spleno-caval and right gastro-caval) and 2) diaphragmatic (left gastro-caval, left gastro-phrenic and left gastro-azygos). The aim of the study was to understand the presence or not, of relationship between the clinical and laboratorial parameters and the region of the CPSS insertion. According to the results, the age of the onset of clinical signs seems to be related to the region of the CPSS insertion (p=0,006), with a insertion in the phrenic and azygos vein being diagnosed in patients with more than 2 years old. Hepatic encephalopathy was presented in almost patients with shunt with insertion caudal to liver (p=0,05), and except for the left gasto-azygos shunt, the presence of stunted growth and poor weight gain was found in all patients with CPSS. Regarding to the laboratory parameters studied, statistical significant differences were registered only for the hematocrit which was lower in CPSS with insertion caudal to the liver (p=0,01). Also, it was possible to notice that patients older than 12 months are more prone to develop crystalluria and calculosis (p=0,02). The lack of uniformity in each patient data was the major limitation presented by the study, and it have contributed to the results obtained.
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L’échoendoscopie thérapeutique occupe une place croissante et incontournable de l’activité médico-chirurgicale en pathologie digestive depuis le développement des sondes sectorielles. Les domaines d’application de cette technique interventionnelle mini-invasive sont de plus en plus nombreux, d’une part en pathologie biliopancréatique et entérale permettant la réalisation d’anastomoses évitant un recours à la chirurgie traditionnelle, et d’autre part en cancérologie digestive car elle permet de délivrer un agent thérapeutique, une source de rayonnement ou des cellules liées au système immunitaire dans une lésion ciblée. L’abord vasculaire est une voie récente et prometteuse de l’échoendoscopie interventionnelle offrant des perspectives thérapeutiques en hépatologie notamment dans le domaine de l’hypertension portale. Ce travail se décompose en trois parties décrivant successivement l’état de l'art des applications de l’échoendoscopie interventionnelle, puis deux travaux originaux expérimentaux : dans un premier temps, le transfert de la technique d’anastomose biliodigestive (réalisée régulièrement dans notre centre) à l’abord vasculaire portosystémique sur animal sain, puis dans un deuxième temps la validité de la technique sur modèle animal de fibrose hépatique. La première série d’expérimentations a permis de mettre au point la technique de création d’un shunt intrahépatique portosystémique par échoendoscopie chez 23 cochons sains, en collaboration avec l’équipe de radiologie vasculaire. Ces procédures ont été réalisées dans une salle de cathétérisme vasculaire expérimentale (laboratoire Caviti) dans le cadre du laboratoire d’accueil ISIT (Image Science for Interventional Techniques, Pr. L. Boyer, Pr. J.-Y. Boire, UMR CNRS/UDA 6284). Les résultats ont été concluants puisque le shunt est apparu faisable dans 91% des cas, fonctionnel dans 81% des cas avec une morbidité de 14,2%. La deuxième série d’expérimentations a permis de valider cette technique d’échoendoscopie chez un modèle porcin de fibrose hépatique par embolisation radiologique, en collaboration avec l’Institut National de Recherche Agroalimentaire de Theix pour la stabulation des animaux. Ce travail multidisciplinaire a permis une collaboration étroite entre endoscopistes, radiologues, chirurgiens viscéraux et anatomopathologistes, s’inscrivant dans une démarche de recherche transversale. Les résultats sont encourageants puisqu’un shunt intrahépatique porto-systémique par échoendoscopie s’est révélé techniquement faisable et fonctionnel sur modèle de fibrose hépatique avec une survie à 7 jours des animaux dans deux tiers des cas. Avant d’envisager une étude princeps chez l’homme, des études complémentaires sont néanmoins nécessaires sur des modèles porcins présentant une fibrose hépatique associée à une hypertension portale en augmentant la durée de stabulation, en homogénéisant la procédure de squelettisation de l’artère hépatique et en adaptant la dose de solution injectée. Cette technique pourrait constituer à terme une alternative en cas d’échec de la technique standard pour complications de l’hypertension portale (shunt intrahépatique portosystémique par voie transjugulaire) chez des patients alors en situation d’impasse thérapeutique
Therapeutic endoscopic ultrasonography is a growing and essential part of the medical and surgical activity in digestive pathology since the development of sectoral probes. The fields of application of this minimally invasive interventional technique are more and more numerous, on the one hand in biliopancreatic and enteral pathology, allowing the realization of anastomoses without traditional surgery, and on the other hand in digestive oncology, because it makes it possible to deliver a therapeutic agent, a source of radiation or cells linked to the immune system in a targeted lesion. The vascular approach is a recent and promising way of interventional endoscopic ultrasound offering therapeutic perspectives in hepatology, especially in the field of portal hypertension.This work is divided into three parts successively describing the state of the art of the applications of interventional ultrasonoscopy, then two original experimental works: initially, the transfer of the technique of biliodigestive anastomosis (performed regularly in our center ) at the portosystemic vascular approach on healthy animal, then in a second time the validity of the animal model technique of liver fibrosis.The first series of experiments led to the development of the technique for the creation of an intrahepatic shunt portosystemic by echoendoscopy in 23 healthy pigs, in collaboration with the vascular radiology team. These procedures were performed in an experimental vascular catheterization room (Caviti laboratory) as part of the ISIT host laboratory (Image Science for Interventional Techniques, Prof. L. Boyer, Pr. J.-Y.Boire, UMR CNRS / UDA 6284). The results were conclusive since the shunt appeared feasible in 91% of cases, functional in 81% of cases with a morbidity of 14.2%. The second series of experiments validated this endoscopic ultrasound technique in a porcine model of liver fibrosis by X-ray embolization, in collaboration with Theix National Institute for Food Research for Animal Stabling. This multidisciplinary work has allowed close collaboration between endoscopists, radiologists, visceral surgeons and anatomopathologists, as part of a transversal research approach. The results are encouraging since a porto-systemic intrahepatic shunt by endoscopic ultrasonography proved to be technically feasible and functional on a hepatic fibrosis model with a 7-day survival of the animals in two-thirds of the cases. Before considering a primary study in humans, additional studies are nevertheless necessary on porcine models presenting hepatic fibrosis associated with portal hypertension by increasing the duration of stabulation, by homogenizing the procedure of skeletonization of the hepatic artery and by adjusting the dose of injected solution. This technique could eventually be an alternative in case of failure of the standard technique for complications of portal hypertension (intrahepatic portosystemic shunt transjugular) in patients then in a situation of therapeutic impasse

Introdução – O tratamento da hipertensão portal continua sendo um desafio e muitos desses pacientes necessitam até transplante de fígado, como tratamento definitivo. Nesse contexto a derivação porto-sistêmica intra-hepática transjugular (Transjugular Intrahepatic Portosystemic Shunt – TIPS) surgiu como uma alternativa atraente para esta complicação da doença hepática crônica, sobretudo por não requerer laparotomia e efetivamente reduzir a pressão portal. O conhecimento da distância entre as veias hepáticas e os ramos portais e outros dados anatômicos, no fígado cirrótico, são requisitos importantes no planejamento e execução desse procedimento. Objetivos - Determinar as distâncias e diâmetros das veias hepáticas direita e média para os ramos portais e para a bifurcação da veia porta, no fígado cirrótico humano, com vistas à construção do TIPS. Tipo de estudo – Estudo anatômico descritivo e macroscópico em moldes vasculares de resina obtidos por corrosão de fígados humanos isolados e cirróticos. Material e método – O estudo foi autorizado pelo Comitê de Ética em Pesquisa do HUOC/Procape-UPE e todos os pacientes, ou seus representantes legais, assinaram Termo de Consentimento Livre e Esclarecido. Foram obtidos 21 moldes de resina acrílica dos ramos portais e veias hepáticas de fígados cirróticos, de pacientes transplantados, dos hospitais Jayme da Fonte e Universitário Oswaldo Cruz, do Recife/PE. Após a completa corrosão do parênquima, foram medidas as distâncias e diâmetros das veias hepáticas e ramos da veia porta. Para testar a hipótese de diferença da média estimada em relação a um valor de referência, foi aplicado o teste t-Student para uma amostra. Resultados - A distância média da veia hepática direita para o ramo direito da veia porta e para a sua bifurcação foram, respectivamente, de 33 (±6,4) e 36 (±7,4) mm, ambos significativamente menores (p<0,0001 e p<0,0002) que os resultados encontrados na literatura, em fígados normais. A distância média da veia hepática média para o ramo direito e para o ramo esquerdo da veia porta foi, respectivamente, de 36 (±6,8) e 26 (±8,8) mm . Conclusão – As distâncias entre a veia hepática direita e o ramo direito da veia porta ou a bifurcação da mesma, em fígados cirróticos, foram significativamente menores que as anteriormente relatadas em fígados normais. A veia hepática média é confirmada como uma via alternativa adequada.
Introduction - The treatment of portal hypertension remains a challenge and many of these patients need liver transplantation as definitive treatment. In this context the Transjugular Intrahepatic Portosystemic Shunt (TIPS) has emerged as an attractive alternative to this complication of chronic liver disease, especially for not requiring laparotomy and effectively reducing the portal pressure. Knowing the distance between the hepatic veins and portal branches and other anatomical data in the cirrhotic liver, they are important requirements in the planning and execution of this procedure. Purpose: To determine spatial arrangements and diameters of right and middle hepatic veins relative to portal vein branches in cirrhotic human livers, gaining strategic insight to percutaneous procedures as transjugular intrahepatic portosystemic shunt. (TIPS). Materials and Methods: This study was authorized by an area Research Ethics Committee, and each study subject or legal representative granted signed informed consent. Acrylic corrosion casts of 21 resected cirrhotic livers were generated. Diameters of hepatic veins and portal branches and pertinent intervening distances were measured. To assess differences in estimated average (relative to reference values), Student's t-test for one sample was applied. Results: Mean distances from right hepatic vein to right portal branch and to portal vein bifurcation were 33±6.4 mm and 36±7.4 mm, respectively, both significantly shorter than published reference values in healthy human livers (p<0.0001 and p<0.0002, respectively). Mean distances from middle hepatic vein to right and left branches of portal vein were 36±6.8 mm and 26±8.8 mm, respectively. Conclusion: Distances separating right hepatic vein and portal vein (right branch and bifurcation) are diminished in cirrhotic livers compared to healthy ones. The middle hepatic vein is confirmed as a suitable alternative route.

Neste relatório descreve-se o estágio realizado no Hospital Veterinário das Laranjeiras (HVL), entre de 29 de setembro de 2014 a 30 de março de 2015, essencial à conclusão do mestrado integrado em medicina veterinária. Composto por duas partes, a primeira que relata a casuística acompanhada no estágio e, a segunda, uma revisão bibliográfica acerca de shunts portossistémicos, enfatizando os shunts portoázigos, na sequência de um caso acompanhado no HVL. O shunt portossistémico extra-hepático, congénito, é uma anomalia vascular da circulação venosa intra-abdominal, originando um desvio do fluxo venoso para um vaso que não conflui no fígado. Verificam-se consequências sistémicas por excesso de compostos amoniacais em circulação, que normalmente seriam metabolizadas no fígado. Os sinais podem ser impercetíveis ou vir a ser causa de morte dos pacientes. O tratamento médico ajuda a controlar alguns sinais transitórios (por exemplo: encefalopatia hepática), sendo a resolução cirúrgica uma solução para esta afeção; Abstract: Small animal clinic and surgery This report describes six-month training that took place in Laranjeiras’ Veterinary Hospital, from 29th of September 2014 to 30th of March 2015, as an essential part to complete veterinary medicine integrated master degree. Composed of two parts, first the clinical cases followed during this internship and then, as a bibliographic review, portosystemic shunt is discussed following a portoazigus shunting case seen in this hospital. Portosystemic shunting is a vascular anomaly of the intra-abdominal venous system, as a result venous blood flows through vessels that don’t converge into the liver. There are systemic consequences caused by excessive ammonia compounds in circulation, which under normal circumstances would be metabolized in the liver. Signals can go from undiscriminated, to becoming a cause of death. Medical treatment can control some of the transient signals, such as hepatic encephalopathy, but surgical resolution is, in most cases, the best solution for this disease.

Este relatório foi realizado no âmbito da conclusão do mestrado integrado em medicina veterinária da Universidade de Évora, encontrando-se dividido em duas partes. A primeira é referente à casuística acompanhada ao longo do estágio curricular, decorrido no Hospital Veterinário do Restelo (HVR), desde 29 de Outubro de 2014 a 29 de Março de 2015. A segunda parte tem em conta a monografia sobre o tema “Shunts portossistémicos no cão”, seguida de um caso clínico acompanhado pelo autor durante o estágio e no âmbito do referido tema. Shunts portossistémicos (SPS) são anomalias vasculares em que se estabelece uma comunicação direta entre o sistema venoso portal e a circulação venosa sistémica, podendo ter origem congénita, ou serem adquiridos. Podem ter uma classificação de intra ou extra-hepáticos e geralmente o tratamento de escolha é a cirurgia; Abstract: Small Animal Practice This report was conducted under the context of integrated masters degree in veterinary medicine of Universidade de Évora, and it is divided into two parts. The first refers to the casuistry followed during the practice period, that took place at the Hospital Veterinário do Restelo (HVR), from 29 October 2014 to 29 March 2015. The second part takes consists of a bibliographic review about "portosystemic shunts in dogs", followed by a clinical case accompanied by the author. Portosystemic shunts (SPS) are vascular abnormalities in which is established a direct communication between the portal venous system and the systemic venous circulation, and may have congenital origin, or be acquired. They may be classified as intra or extrahepatic and usually the treatment of choice is surgery.

Este relatório representa a conclusão de seis meses de estágio curricular incorporado no Mestrado-Integrado em Medicina Veterinária e pretende descrever as atividades médicas realizadas e assistidas, assim como a apresentação de uma monografia intitulada “Tomografia Computorizada no Diagnóstico de Anomalias Vasculares”, a qual representa uma revisão bibliográfica médica atual do estado de arte do tema. A tomografia computorizada (TC) destaca-se das restantes modalidades de imagiologia médica, pelo extraordinário potencial diagnóstico de um vasto leque de condições clínicas, nas quais se destaca a doença vascular, permitindo a sua caracterização e correta abordagem médica e cirúrgica. Permite aquisição de imagens de excelente resolução espacial com muito boa resolução de densidades, o que permite uma excelente discriminação anatómica, permitindo a visualização de alterações com tradução macroscópica, que se manifestem por modificação da forma, dimensão, contorno, densidade ou padrão de captação de contraste, possibilitando a visualização de eventuais modificações na homogeneidade de órgãos parenquimatosos; Abstract: Computed Tomography in the Diagnosis of Vascular Anomalies This report presents the completion of six months of traineeship incorporated into the Integrated Masters in Veterinary Medicine and is intended to describe the medical activities performed and assisted, as well as the presentation of a monograph entitled "Computed Tomography in Diagnosis of Vascular Anomalies", which is an actual medical literature review of the subject state of the art. Computed tomography (CT) stands out from the other variants of the medical radiology by its extraordinary diagnostic potential of a wide range of clinical conditions, in which vascular disease stands out, allowing its characterization and therefore its correct medical and surgical approach. It allows the acquisition of excellent resolution spacial images with a very good resolution of densities, which allows an excellent anatomic discrimination, enabling to visualize the alterations with a macroscopic translation, that manifest by the modification of shape, dimension, outline, density or contrast captation pattern, being possible to visualize the eventual modifications in the homogeneity of the parenchymatous organs.

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Introduction: The transjugular intrahepatic portosystemic shunt (TIPS) is a non-surgical treatment option with low morbidity and mortality, can be realized in patients with severe hepatic dysfunction, minimally invasive surgery that aims to decompress the portal system treating or reducing the complications portal hypertension. Objective: To analyze survival, and overall early mortality related to the etiology of the disease, characterization of the procedure in the emergency or elective and Child-Pugh and MELD classification and analyze the complications presented by patients. Methods: A retrospective study in the database of medical records of patients with cirrhosis who underwent TIPS for treatment of gastrointestinal bleeding due to portal hypertension who have not responded to medical treatment and endoscopic treatment from 1998 to 2010 in the Department of Liver Transplantation, Hospital de Base and Faculty Medicine of Sao Jose do Rio Preto. To check the rate of mortality, survival and complications were excluded patients who have failed the technical procedure and the others were followed until the closure of the study, performing a liver transplant or death occurred. The study was approved by the Ethics and Research Committee. Results: The sample consisted of 72 (84.7%) patients who were successful in the procedure of which 57 (79.2%) were male, mean age 47.4 years (between 16 and 85 years, SD=13), 21(29.2%) patients had a cause excessive consumption of alcohol, 21(29.2%) to contamination by hepatitis virus, 16(22.2%) excessive alcohol consumption associated with virus and 14(19.4%) patients had other causes. Procedure was performed on an emergency basis in 37(51.4%) and electively in 35(48.6%). The initial classification, 14 (20%) had Child-Pugh A, 33 (47.1%) Child-Pugh B and 23 (32.9%) Child-Pugh C. MELD was initially obtained in 68 patients, 37 (54.4%) with more than 15 points, while 31 (45.6%) up to 15 points. Early death occurred in 19 (26.4%). Overall mortality occurred in 41(60.3%). Conclusion: There was no difference regarding the etiology of early mortality, mortality and survival and overall mortality rate of patients undergoing emergency TIPS in characterization compared with elective TIPS. Difference was observed between the groups of patients undergoing emergency TIPS in characterizing compared to elective TIPS in early mortality rate, death is higher in emergency TIPS. Regarding the classification of Child-Pugh and MELD higher overall mortality was observed in patients early and Child-Pugh class C and MELD> 15, and shorter survival in this group of patients. Complications were similar to those described in the literature, but the percentage of occurrence of stent dysfunction (26,4%) was lower than in most studies the incidence of encephalopathy (58,3%) was higher.
Introdução: A derivação portossistêmica transjugular intra-hepática (TIPS) é uma opção de tratamento não cirúrgica com baixo índice de morbimortalidade e com possibilidade de realização em pacientes com disfunção hepática grave, por ser minimamente invasiva e que visa descomprimir o sistema porta tratando ou reduzindo as complicações da hipertensão portal. Objetivo: Analisar a sobrevida, mortalidade precoce e global relacionada à etiologia da doença, caracterização do procedimento em urgência ou eletiva e classificações de Child-Pugh e MELD e analisar as complicações apresentadas pelos pacientes. Casuística e Métodos: Estudo retrospectivo baseado no banco de dados dos prontuários dos pacientes cirróticos submetidos a TIPS para tratamento da hemorragia digestiva por hipertensão portal que não responderam ao tratamento clínico endoscópico e atendidos no período de 1998 a 2010 no Serviço de Transplante de Fígado do Hospital de Base e Faculdade de Medicina São José do Rio Preto. Para verificação da taxa de mortalidade, sobrevida e complicações os pacientes seguidos até o fechamento do estudo, realização de transplante de fígado ou ocorrência de óbito. O estudo foi aprovado pelo Comitê de Ética e Pesquisa. Resultados: A amostra foi composta de 72(84,7%) pacientes que obtiveram êxito no procedimento sendo 57(79,2%) do sexo masculino, idade média de 47,4 anos (entre 16 e 85 anos e DP=13), 21(29,2%) pacientes apresentaram como causa o consumo excessivo de álcool; 21(29,2%) a contaminação por vírus da hepatite, 16 (22,2%) o consumo excessivo de álcool associado a vírus e 14 (19,4%) pacientes apresentaram outras causas. Procedimento foi realizado em caráter de urgência em 37(51,4%) e de forma eletiva em 35 (48,6%). Quanto à classificação inicial, 14(20%) tinham Child-Pugh A, 33(47,1%) Child-Pugh B e 23(32,9%) Child-Pugh C. MELD inicial foi obtido em 68 pacientes sendo 37 (54,4%) com mais de 15 pontos, enquanto 31(45,6%) tiveram até 15 pontos. Óbito precoce ocorreu em 19(26,4%). Mortalidade global ocorreu em 41 (60,3%). Conclusão: Não houve diferença da etiologia com relação à mortalidade precoce, mortalidade global e sobrevida e na taxa de mortalidade global dos pacientes submetidos a TIPS de urgência comparados a TIPS eletivo. Observou-se diferença entre os grupos de pacientes submetidos a TIPS de urgência comparados a TIPS eletivo na taxa de mortalidade precoce, sendo o óbito maior no TIPS de urgência. Com relação as classificações de Child-Pugh e MELD foi observado maior mortalidade global e precoce nos pacientes Child-Pugh classe C e MELD >15, e menor sobrevida nesse grupo de pacientes. As complicações encontradas foram semelhantes às descritas na literatura, porém a porcentagem da ocorrência de disfunção do stent (26,4%) foi menor que na maioria dos estudos e a incidência de encefalopatia (58,3%) foi superior.

In some breeds of dog, specifically the Yorkshire Terrier, a genetic defect exists that causes a hepatic portosystemic shunt to form. A hepatic portosystemic shunt is a vessel that when present cause blood to bypass the liver, which is responsible for filtering waste from the digestive system and moving it out of the body. An implantable polymeric device was constructed that would slowly occlude the hepatic portosystemic shunt and force the blood to stop flowing through the bypassing vessel and flow through the vessel to the liver over 3-4 months time. The portosystemic shunt occluder device consist of three polyoxymethylene components, a swelling hydrogel (poly (acrylic acid)), and a degrading copolymer – (Poly (lactide-co-caprolactone)). The poly (acrylic acid) was used to move the piston component of the device upward to constrict the portosystemic shunt placed inside the device. Eight milligrams of poly (acrylic acid) had a swelling ratio of 20.10 ± 1.63, a swelling rate of 0.071 mm/s2, and generated 25mN of force. Eight milli-Newtons is the amount of force that is produced by blood flowing in a four milli-meter diameter vessel. The degradation properties of two compositions of poly (lactide-co-caprolactone) (40 percent lactide and 60 percent caprolactone; 86 percent lactide and 14 percent caprolactone) were analyzed and relationships were developed that would aid in determining the degradation rate of the copolymers in respect to the copolymer composition and the environmental temperature. The poly (lactide-co-caprolactone) controlled the rate that the piston moved by providing a counter force to the poly (acrylic acid). The poly (lactide-co-caprolactone) (40:60), when loaded into the device, degraded in 86 days in a phosphate buffered saline solution at a temperature of 37oC.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in Surgery Johannesburg, 2017
Background: Surgical interventions such as shunts and devascularisation procedures are effective therapies to prevent variceal rebleeding in people with hepatosplenic schistosomiasis. As this disease is prevalent in low income countries, the impact of eco-social factors result in poor compliance with nonsurgical therapies that require repeated sessions and long-term follow-up. Objectives: To determine whether surgical portosystemic shunts have better outcomes compared with oesophagogastric devascularisation procedures in the prevention of variceal rebleeding due to schistosomal portal hypertension (SPH). Methodology: This meta-analysis was conducted using standards expected by The Cochrane Collaboration. All randomised clinical trials comparing surgical portosystemic shunts with oesophagogastric devascularisation with or without splenectomy in the prevention of variceal rebleeding due to hepatosplenic schistosomiasis were selected. The risks of bias were assessed according to domains and risk of random errors with Trial Sequential Analysis. The quality of evidence was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group approach. Results: Two trials met the inclusion criteria of this review and were selected. An analysis of 115 participants, 57 who received distal splenorenal shunt (DSRS) and 58 who received devascularisation procedure is presented. The trials were assessed at high risk of bias. There is no difference in overall mortality between DSRS versus devascularisation, risk ratio (RR) is 1.40, (95% confidence interval (CI) 0.32 to 6.15), downgraded to very low quality due to overall risk of bias, imprecision and publication bias. Variceal rebleeding following devascularisation is statistically significant higher than after DSRS (RR is 0.23, 95% CI 0.05 to 1.01), very low quality evidence due to bias, imprecision, and publication bias. The number of participants needed to treat with DSRS to achieve benefit (NNTB) is 8. Serious adverse events reported as procedure specific include: portal vein thrombosis, haemolysis, ascites and shunt dysfunction. There was no report on quality of life. DSRS is associated with a statistically significant higher post procedure encephalopathy (RR 8.10, 95% CI 1.04 to 62.83), downgraded to very low quality due to overall risk of bias, imprecision, and publication bias. Trial sequential analysis shows no strong evidence to accept or reject the difference in variceal rebleeding and encephalopathy rate for both interventions because of bias and inadequate sample size. Outcomes of proximal splenorenal shunt (PSRS) compared to devascularisation were reported by a single trial, therefore no meta-analysis was computed for this comparison, nor subgroup of PSRS compared to DSRS. Conclusion: Available evidence seems to suggest that DSRS is better than devascularisation for the prevention of variceal rebleeding due to hepatosplenic schistosomiasis, but this is at the cost of significant encephalopathy. The review authors are cautious to make this conclusion because overall evidence is very low quality and only few trials with small sample size are available. Further randomised clinical trials with adequate sample size and good methodological quality are needed.
MT2017

A portosystemic shunt (PSS) is defined as a congenital or acquired abnormal blood vessel that redirects blood around the liver without being filtered through hepatic parenchyma. PSS are thought to contribute to the distribution of isolated secondary metastases beyond the liver in 1.7 - 7.2% of all colorectal cancer patients without cirrhosis of the liver. No standardised clinical test for PSS yet exists and subsequently, the majority of PSS cases are detected incidentally through radiological means. To better identify PSS, a simple standardised clinical test for its detection is needed. The aim of this thesis was to develop a cost effective, non-invasive technique that can detect and measure PSS in a healthy liver model. Methods An artificial 8mm diameter PSS was created between the portal vein and the inferior vena in a pig model with a catheter inserted in the confluence of the hepatic veins for sample collection. A spectrum of compounds including indocyanine green (ICG), ¹³C-methacetin, sorbitol and lignocaine, were injected into the portal system. To analyse the pharmacokinetic nature of the shunt and liver, Evans blue dye and ¹⁴C-sucrose were also administered. ICG was measured via a LiMON® spectrometer attached to the pig’s snout, while levels of the other indicators were measured by serial blood and breath sample collection over a 40 minute period. The process was repeated with the PSS clamped as the control. Results Of the administered compounds, only ICG had the potential to clearly identify and quantify the shunt due to the rapid serial sampling via the LiMON®. Further simulations using ICG demonstrated that the shunted fraction can be calculated using the transit times, including mean residence time, lag time and pharmacokinetic modelling. Conclusion Although this study has not yet provided a concise method for PSS detection available for immediate clinical use, it does provide a large foundation for further exploration into a quantitative technique. A future PSS test would allow an added risk assessment for secondary cancer, and consequently individual cancer therapy may be better targeted for individual patient care.
Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2014

Indiana University-Purdue University Indianapolis (IUPUI)
The purpose of this study is to examine the informed consent (IC) procedure as it was experienced by patients who had undergone a de novo transjugular intrahepatic portosystemic shunt (TIPS), chemoembolization (TACE), or radioembolization (TARE) procedure in an Interventional Radiology (IR) Department. The three main study aims and a fourth exploratory aim are as follows: (1) Describe how patients who underwent a de novo TIPS, TACE, or TARE procedure in an IR Department described the IC procedure; (2) Describe what information patients who underwent a de novo TIPS, TACE, or TARE procedure in an IR Department recalled being told during the IC procedure; (3) Describe the satisfaction of patients who underwent a de novo TIPS, TACE, or TARE procedure in an IR Department with the IC procedure; and (4) Explore how the IC experiences of patients who underwent a de novo TIPS, TACE, or TARE procedure in an IR Department differed according to their levels of health literacy. Using a qualitative descriptive design, participants were recruited from an IR department that performed these procedures. A total of 14 participants were interviewed about their IC experiences and the Newest Vital Sign (NVS) Health Literacy assessment was administered. The participants described the IC procedure by discussing the staff they encountered, their feelings during the visit, the support persons who accompanied them, and the decisions they made about the procedure. The participants recalled being told about how their procedure would be performed, the care they would need, and the benefits and risks of the procedure. Most were satisfied with the information received during the IC procedure and found the information consistent with how they experienced the procedure. A few participants would have liked more visual materials, addition details about the procedure, simpler language, or more explanation of the medical terminology. No apparent differences in the IC experience could be attributed to health literacy. These findings suggest that persons’ experiences during the IC process are multi-faceted and affected by their emotions and concerns and the nature of their encounters with their healthcare providers.

Es wurden 44 Hunde mit einem kongenitalen Portosystemischen Shunt präoperativ hinsichtlich ihrer Leberzellintegrität (ALT, AP, GLDH, GGT) und ihrer hepatischen Synthese- (Harnstoff, Cholesterin, Albumin) bzw. Metabolisierungsrate (Ammoniak) untersucht. Die hepatische Durchblutungs- und Resorptionsrate wurde anhand des Verlaufs der Serumgallensäuren im Gallensäuren-Stimulationstest mit Ceruletid (0,3µg/kg KM i.v.)vor und 30 min nach Stimulation (FSBA; PSBA) beurteilt. Eine Verlaufsuntersuchung erfolgte bei den Hunden, bei denen das Shuntgefäß in zwei Operationen verschlossen worden war. Die Untersuchungen wurden jeweils prae operationem, am zweiten, vierten und siebten Tag post operationem sowie abschließend mindestens 120 Tage nach vollständigem Verschluss des Shuntgefäßes durchgeführt. Es wurden die Ergebnisse der einzelnen Untersuchungstage untereinander mit Hilfe des gepaarten t-Tests sowie mit einer Kontrollgruppe (63 lebergesunde Hunde)unter Anwendung des unpaaren t-Tests verglichen.
The hepatic enzymes: alanine aminotransferase (ALT), alkaline phosphatase (AP), glutamat dehydrogenase (GLDH), gamma-glutamyl transferase (GGT); the hepatic synthetic (urea, cholesterol, albumin) and metabolic activity (ammonia) and the hepatic blood flow (serum bile acid stimulation test) were determined in 44 dogs with congeintal portosystemic shunt and in 63 healthy dogs. After determination of fasting serum bile acids (FSBA), the gallbladder contraction was induced by administration of 0,3µg/kg iv ceruletide (Takus). Blood samples of the poststimulatin serum bile acids (PSBA) were taken 30 minutes post administration. The portosystemic shunt was first attenuated (surgery 1) and 4 weeks later completely ligated (surgery 2). All dogs treated with this surgical procedure were examined with the described laboratory design before surgery, the second, the fourth, the seventh day after surgery and approxiamtely 120 days after complete ligation in a follow up study. To compare the developmentof the biochemical and hepatic alterations the paired and unpaired t-test were used.

Trabalho de Projeto do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
Os shunts porto-sistémicos (SPS) são estruturas vasculares venosas que surgem frequentemente na hipertensão portal. Têm uma localização, calibre e fluxo variáveis e, ao permanecerem após o transplante, podem condicionar complicações e influenciar a sobrevida do enxerto. Este estudo tem como objetivo avaliar o impacto dos SPS na sobrevida do enxerto hepático, procurando identificar alterações que justifiquem a sua oclusão.Foram incluídos 82 doentes transplantados hepáticos, consecutivos, entre 1 de Janeiro de 2013 e 31 de Dezembro de 2015. A amostra (n=82) foi dividida em grupo em estudo, grupo A, com SPS (n=59) e em grupo controlo, grupo B, sem SPS (n=23). O grupo A foi subdividido em grupo A1, com trombose da veia porta (n=18), e grupo A2, sem trombose da veia porta (n=41). Foi colhida informação dos processos clínicos relativa ao recetor, enxerto, procedimento cirúrgico, velocidade portal e dados laboratoriais.Os SPS estavam presentes em 59 (71,95%) dos doentes transplantados. O shunt mais comum foi a repermeabilização da veia para-umbilical (n=43, 32,33%) e a combinação mais frequente a repermeabilização da veia para-umbilical, shunts peri-esofágicos e peri-gástricos (n=14, 24,1%). Não se observaram diferenças estatisticamente significativas no fluxo portal nas ecografias-Doppler ao 4º dia pós-operatório (p=0,971) e aos 6 meses pós-transplante (p=0,578) nem nos parâmetros laboratoriais, avaliados ao 4ºdia pós-operatório.Conclui-se que, apesar da elevada incidência nos doentes transplantados, os SPS não influenciaram negativamente o enxerto hepático.
Portosystemic shunts (PSS) are abnormal venous connections that appear frequently in portal hypertension. They have a variable localization, gauge and flow and, when present after transplantation, may induce complications and influence graft survival. This study was designed to evaluate the impact of portosystemic shunts on liver graft survival and identify factors that cause portosystemic shunts occlusion. 82 patients who underwent consecutive liver transplantation between January 2013 and December 2015 were included. Age less than 18 years and no computed tomography with intravenous contrast before transplantation were exclusion criteria. This sample (n=82) was divided in study group, group A, with PSS (n = 23) and in control group, group B, without PSS (n=59). Group A was subdivided in A1 group, with portal vein thrombosis (n = 18) and A2 group, without portal vein thrombosis (n = 41). Information related to receptor, graft, surgical procedure, portal flow and laboratory data was collected. Portosystemic shunts were present in 59 (71.95%) of transplanted patients. The most common shunt being repermeabilization of para-umbilical vein (n=43, 32,33%) and the most frequent combination being repermeabilization of para-umbilical vein, peri-esophageal and peri-gastric shunts. There were no statistically significant differences in portal flow on Doppler ultrasound at the fourth post-operative day (p = 0.714) and at 6 months post-transplantation (p = 0.761) and in laboratory parameters, evaluated at fourth post-operative day.We concluded that, despite the high prevalence in transplanted patients, PSS do not influence graft survival at 6 months and are not associated with significant reductions in post-transplantation portal flow

Schistosomiasis, a disease of humans caused by helminth parasites of the genus Schistosoma, kills 200 to 500 thousand people annually, endangering over 600 million people world-wide with 200 million people infected in 2003 [1, 2]. Three species of schistosome are primarily responsible for human infections, namely, Schistosoma haematobium, endemic to Africa, India, and the Middle East, S. mansoni, endemic to Africa / South America, and S. japonicum endemic to China and the Philippines [3]. The major pathological effects of schistosomiasis result from the deposition of parasite ova in human tissues and the subsequent intense granulomatous response induced by these eggs. There is a high priority to provide an effective sub-unit vaccine against these schistosome flukes, using proteins encoded by cDNAs expressed by the parasites at critical phases of their development. One technique that may expedite this gene identification is the use of microarrays for expression analysis. A 22,575 feature custom oligonucleotide DNA microarray designed from public domain databases of schistosome ESTs (Expressed Sequence Tags) was used to explore differential gene expression between the Philippine (SJP) and Chinese (SJC) strains of S. japonicum, and between males and females. It was found that 593, 664 and 426 probes were differentially expressed between the two geographical strains when mix sexed adults, male worms and female worms were compared respectively. Additionally, the study revealed that 1,163 male- and 1,016 female-associated probes were differentially expressed in SJP whereas 1,047 male- and 897 female-associated probes were differentially expressed in SJC [4]. Further to this, a detailed real time PCR expression study was used to explore the differential expression of eight genes of interest throughout the SJC life cycle, which showed that several of the genes were down-regulated in different life cycle stages. The study has greatly expanded previously published data of strain and gender-associated differential expression in S. japonicum. Further, the new data will provide a stepping stone for understanding the complexities of the biology, sexual differentiation, maturation, and development of human schistosomes, signaling new approaches for identifying novel intervention and diagnostic targets against schistosomiasis [4].