Asunción López Conesa

Resección en 2 tiempos de tumores hepáticos perihiliares con torniquete en la cisura umbilical y embolización portal secuencial al cuarto día postoperatorio (ALTPS modificado)

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) achieves the hypertrophy of the future liver remnant in seven days. We achieved the same hypertrophy placing a tourniquet in the parenchimal transection line associating a right portal vein ligation (associating liver tourniquet and right portal vein ligation for staged hepatectomy-ALTPS). In perihiliar tumors a«non touch» technique should be performed. ALPPS y ALTPS do not comply with this technical aspect because a dissection of the hilum is carried out in both procedures during the portal dissection. To avoid this problem we devised a new method called sequential ALTPS. It consists of placing a tourniquet in the umbilical fissure without ligation of the right portal vein during the first stage. Subsequently, on the 4(th) postoperative day we perform a percutaneous right portal vein embolization. We present the first case of this new technique in which we have obtained a hypertrophy of 77% of the future liver remnant seven days after portal vein embolization. In the second stage a right trisectionectomy was performed with inferior vena cava resection with a goretex graft replacement.

Factores pronósticos tras resección hepática de metástasis hepáticas de cáncer colorrectal

INTRODUCTION There are many studies that analyse preoperative factors with a poor prognosis in patients undergoing surgery for colorectal carcinoma liver metastases, in order to avoid unnecessary surgery. However, there are few studies that evaluate the intraand postoperative prognostic factors. The aim of this study is to analyse pre-, intra- and postoperative prognostic factors in a series of 210 patients undergoing surgery for colorectal carcinoma liver metastases, with special emphasis on the postoperative factors that can give us information on the aggressiveness of the tumour and the curative effectiveness of the surgery. PATIENTS AND METHOD Between September 1996 and December 2006, 210 patients undergoing surgery for colorectal carcinoma liver metastases in whom we analysed pre-, intra- and postoperative factors of survival. Mean follow-up was 55+/-3 months (range: 12-124 months). RESULTS The postoperative mortality rate was 1.4% and the morbidity rate was 22%. Actuarial and disease-free survival at 1-, 3- and 5-years was 89.9% vs 63%, 66.9% vs 32%, and 53.8% vs 23%, respectively. Among the preoperative factors analysed, the age>65 years and LM size>5 cm were independent predictors of poor overall survival, whereas the other two significant factors were obtained from those analysed postoperatively: presence of microsatellitosis and postoperative CEA levels (at 1 and 3 months). CONCLUSIONS In patients with colorectal carcinoma liver metastases we must take into account certain postoperative factors that can give us information on the aggressiveness of the tumour and the effectiveness of the surgery.

Ictericia secundaria a quiste hepático simple con hemorragia intraquística traumática

Simple liver cysts (SLC) are malformations that originate in aberrant bile ducts that have lost their communication with the biliary tree and continue to secrete intraluminal fluid. Most cysts are smaller than 3 cm and are usually asymptomatic. Their incidence increases after the age of 50, with a predominance of women (ratio 1.5:1) and a prevalence of 18% in the adult population. A small percentage of patients present symptoms such as abdominal pain, earlysatiety, nausea and vomiting, all consequences of a mass effect. Due to their large size, physical examination can show evidence of an abdominal mass or hepatomegaly. Complications, such as hemorrhage, rupture or biliary obstruction are uncommon and take place in largesize cysts. Intracystic hemorrhage is rare and normally presents with severe abdominal pain, although it may be asymptomatic. The presence of 2 associated complications, such as intracystic hemorrhage and jaundice due to compression of the intrahepatic bile duct, is a very rare situation, which is why we present the following case. The patient is a 71-year-old woman who came to the emergency department after having an accidental fall with trauma to the right flank of the abdomen, presenting progressive jaundice. The patient’s medical history included: arterial hypertension, type 2 diabetes mellitus, cholecystectomy due to cholelithiasis, IgG lambda multiple myeloma, and ischemic stroke 8 months before. On physical examination, jaundice of the skin and mucous membranes was observed; the abdomen was soft and non-painful, and no masses or enlarged organs were detected. Lab work demonstrated: total bilirubin 16 mg/dL (direct bilirubin 13.7 mg/dL), GOT 276 IU/L, GPT 165 IU/L, GGT 678 IU/L, FA 1.124 IU/L, hematocrit 28.6%, hemoglobin 9.3 g/dL, leukocytes 18 000 (neutrophils 48%), prothrombin activity 100%, Ca 19.9 1036 U/L; CEA and alpha-fetoprotein were normal. Ultrasound revealed a large cystic lesion with dilatation of the intrahepatic bile duct. Computed tomography (Fig. 1) showed evidence of a large SOL in the liver that was cystic in appearance, measuring 12.1 9.4 9.3 cm, which was located in the right lobe and affected segments IV–V. Magnetic resonance (Fig. 2) showed a large cystic mass that, in the hilar region, caused dilatation of the bilobar biliary radicles. Due to suspected malignancy, positron emission tomography was conducted, which showed no metabolic increase in the liver. Serologies for Echinococcus and Entamoeba histolytica were negative. A percutaneous biliary drain was inserted, that resolved the jaundice. Given the suspicion for intracystic hemorrhage and cystadenocarcinoma, the patient was treated surgically through a right subcostal incision. A hepatic cyst was found in segments IV–V, measuring 12 cm in diameter and completely covered by liver parenchyma, while no lesions were observed in the hepatic hilum. The cyst was deroofed and contained abundant old blood. Intraoperative biopsies were taken, which showed no evidence of malignancy and suggested that the lesion was compatible with an SLC. The definitive pathology report defined the mass as an SLC, which coincided with the intraoperative biopsies. Jaundice secondary to obstruction caused by an SLC is uncommon, occurring in cases of large cysts (greater than 10 cm) and close to the porta hepatis. Intracystic hemorrhage is another uncommon complication that requires a differential diagnosis with cystadenocarcinoma. In our case, the size of the cyst, suspicion of intracystic hemorrhage and elevated Ca 19.9 levels led us to consider this possibility. Therefore, it is important to rule out the presence of cystadenoma, cystadenocarcinoma, communication with the biliary tree and other cystic lesions with infectious etiologies before treating the cysts, as the management of most simple cysts is based on a ‘‘wait and see’’ strategy, without requiring

Resección laparoscópica simultánea de tumor neuroendocrino pancreático y metástasis hepática

insuficiente. La mejor opción terapéutica es la resección en bloque del tumor con márgenes libres y posterior reconstrucción de la pared costal. La radioterapia tiene un uso muy limitado por el riesgo de producir sarcomas postradiación, y solo se recomienda cuando el tumor es inicialmente irresecable. A pesar de tratarse de un tumor de bajo grado de malignidad, tiene una alta propensión a la recidiva local (20– 40%), y es poco frecuente la aparición de metástasis (2%). Por estos motivos es aconsejable el seguimiento del paciente postquirúrgico mediante pruebas de imagen. En resumen, hemos descrito un raro caso de TCG derivado del arco anterior costal y recomendamos la resección quirúrgica en bloque del mismo como primera opción terapéutica.

Prognostic factors after resection of colorectal cancer liver metastases

INTRODUCTION: There are many studies that analyse preoperative factors with a poor prognosis in patients undergoing surgery for colorectal carcinoma liver metastases, in order to avoid unnecessary surgery. However, there are few studies that evaluate the intraand postoperative prognostic factors. The aim of this study is to analyse pre-, intra- and postoperative prognostic factors in a series of 210 patients undergoing surgery for colorectal carcinoma liver metastases, with special emphasis on the postoperative factors that can give us information on the aggressiveness of the tumour and the curative effectiveness of the surgery. PATIENTS AND METHOD: Between September 1996 and December 2006, 210 patients undergoing surgery for colorectal carcinoma liver metastases in whom we analysed pre-, intra- and postoperative factors of survival. Mean follow-up was 55+/-3 months (range: 12-124 months). RESULTS: The postoperative mortality rate was 1.4% and the morbidity rate was 22%. Actuarial and disease-free survival at 1-, 3- and 5-years was 89.9% vs 63%, 66.9% vs 32%, and 53.8% vs 23%, respectively. Among the preoperative factors analysed, the age>65 years and LM size>5 cm were independent predictors of poor overall survival, whereas the other two significant factors were obtained from those analysed postoperatively: presence of microsatellitosis and postoperative CEA levels (at 1 and 3 months). CONCLUSIONS: In patients with colorectal carcinoma liver metastases we must take into account certain postoperative factors that can give us information on the aggressiveness of the tumour and the effectiveness of the surgery.