Caridad Marín Hernández

Hemorragia diferida de la arteria hepática derecha tras iatrogenia biliar por colecistectomía laparoscópica que precisó trasplante hepático por insuficiencia hepática aguda: caso clínico y revisión de la literatura

INTRODUCTION Right hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required. PATIENTS AND METHOD We provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury. RESULTS LT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury. CONCLUSIONS RHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion.INTRODUCTION Right hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required. PATIENTS AND METHOD We provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury. RESULTS LT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury. CONCLUSIONS RHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion.

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.

Resección hepática por laparoscopia: lecciones aprendidas tras 132 resecciones

INTRODUCTION After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc. AIM To report our experience in laparoscopic liver resections (LLRs). PATIENTS AND METHOD Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS. SURGICAL TECHNIQUE 6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections. RESULTS There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively. CONCLUSION LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery.

Mastitis granulomatosa idiopática. Una rara entidad benigna que puede simular un cáncer de mama

La mastitis granulomatosa idiopática (MGI) es una entidad benigna poco frecuente (< 1% de las biopsias) de etiologı́a desconocida y en ocasiones de difı́cil diagnóstico por la similitud a otras entidades como el cáncer de mama, o por la histologı́a, con enfermedades inflamatorias granulomatosas. Su evolución es impredecible y actualmente no hay consenso en el tratamiento óptimo para estas pacientes. Presentamos un caso de una mujer de 45 años, hipotiroidea en tratamiento médico, que consulta por un nódulo periareolar superior de 2 cm en mama derecha de un mes de evolución, que provoca retracción espontánea de la piel. La exploración axilar es normal. Se realiza mamografı́a y ecografı́a evidenciando asimetrı́a del tejido fibroglandular retroareolar de la mama derecha de 2,2 1,6 cm, BI-RADS 4b, sin observar nódulos o microcalcificaciones. En la biopsia con aguja gruesa (BAG) aparece inflamación crónica y aguda con presencia de granulomas no necrotizantes ni abscesificantes y reacción giganto-celular, sin que se observen signos de malignidad. En las técnicas de inmunohistoquı́mica (Gram y ZiehlNeelsen) no se identifican microorganismos. Ante la discordancia clı́nica e histo-radiológica se realiza resonancia magnética que informa de asimetrı́a en zona anterior de la mama derecha de 2,6 1,3 cm, hipointensa en secuencias T1 e hiperintensa en STIR, que tras la administración de contraste muestra realce precoz y heterogéneo con curva dinámica ascendente-en meseta. Tras presentar en comité se decide intervención quirú rgica en la que se realiza exéresis de la zona indurada que incluye una cavidad con contenido purulento (fig. 1). La histologı́a definitiva informa de proceso inflamatorio crónico con frecuentes acú mulos de histiocitos, moderado infiltrado inflamatorio linfoplasmocitario, con formación de un seudoquiste a nivel central y moderada inflamación aguda, ası́ como granulomas no necrosantes con presencia de células multinucleadas, a veces tipo Langhans, todo ello sugestivo de mastitis lobulillar granulomatosa idiopática (fig. 2). No se aislaron bacilos ácido alcohol resistente con técnica de Ziehl-Neelsen, estructuras fú ngicas con PAS-diastasa ni microorganismos con técnica de Gram. La paciente fue dada de alta sin recidiva de la enfermedad tras 3 meses de seguimiento. La MGI es una enfermedad inflamatoria crónica benigna de la mama que fue descrita en 1972 por Kessler y Wolloch. Presenta gran variabilidad en su presentación clı́nica (mastitis, fı́stulas, nódulos,. . .) aunque en un 50% de los casos reportados, al igual que en nuestra paciente, el diagnóstico inicial es de carcinoma de mama. Aparece en mujeres de edad fértil (< 50 años en la mayorı́a de los casos descritos) con embarazos recientes (1,5-5 años). La forma de presentación suele ser unilateral presentando una o más masas mamarias periareolares, a veces con inflamación cutánea y que pueden evolucionar a la abscesificación, fistulización y supuración crónica. Su etiologı́a es desconocida aunque se han postulado varias teorı́as: 1) la autoinmune, dadas las similitudes a la tiroiditis y la orquitis granulomatosa. Esta teorı́a es sustentada por la buena respuesta a la terapia con esteroides, sin embargo, no existen evidencias de anormalidades del sistema inmune, como formación de anticuerpos o de complejos antı́geno-anticuerpo; 2) por respuesta inmunitaria local, probablemente por daño al epitelio lobulillar secundario a un traumatismo, irritante quı́mico o infección, que permitirı́a el escape de la secreción luminal hacia el tejido conectivo lobular, provocando una reacción granulomatosa con migración de linfocitos y macrófagos; 3) por causa hormonal,

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.