David Saavedra-Perez

Pilot study of living donor liver transplantation for patients with hepatocellular carcinoma exceeding Milan Criteria (Barcelona Clinic Liver Cancer extended criteria)

A subset of patients with hepatocellular carcinoma (HCC) beyond Milan criteria might obtain acceptable survival outcomes after liver transplantation. Living donor liver transplantation (LDLT) has emerged as a feasible alternative to overcome the paucity of donors. In 2001, we started a protocol for LDLT in Child A‐B patients with HCC fulfilling a set of criteria—the Barcelona Clinic Liver Cancer (BCLC) expanded criteria—that expanded the conventional indications of transplantation: 1 tumor ≤ 7 cm, 5 tumors ≤ 3 cm, and 3 tumors ≤ 5 cm without macrovascular invasion or downstaging to Milan after locoregional therapies. We present a prospective cohort of 22 patients with BCLC extended indications based on size/number (n = 17) or downstaging (n = 5) treated with LDLT between 2001 and 2014. Characteristics of the patients were as follows: median age, 57 years old; males/female, n = 20/2; Child‐Pugh A/B, n = 16/6; and alpha fetoprotein < 100 ng/mL, n = 21. Twelve patients received neoadjuvant locoregional therapies. At the time of transplantation, 12 patients had HCC staging beyond Milan criteria and 10 within. Pathological reports showed that 50% exceeded BCLC expanded criteria. Perioperative mortality was 0%. After a median follow‐up of 81 months, the 1‐, 3‐, 5‐, and 10‐year survival was 95.5%, 86.4%, 80.2%, and 66.8%, respectively. Overall, 7 patients recurred (range, 9‐108 months), and the 5‐year and 10‐year actuarial recurrence rates were 23.8% and 44.4%, respectively. In conclusion, a proper selection of candidates for extended indications of LDLT for HCC patients provide survival outcomes comparable to those obtained within the Milan criteria, but these results need confirmation. Liver Transplantation 24 369–379 2018 AASLD.

Total extraperitoneal (TEP) hernioplasty with intestinal resection assisted by laparoscopy for a strangulated Richter femoral hernia.

We describe the first clinical case of a total extraperitoneal hernioplasty combined with intestinal resection assisted by laparoscopy for a strangulated Richter femoral hernia. The patient was a 94-year-old woman admitted to the emergency room with signs and symptoms of acute small bowel obstruction. Diagnosis of a strangulated left Richter femoral hernia was only possible during the initial exploratory laparoscopy. The extraperitoneal approach for mesh positioning was performed gaining access through an infraumbilical 12 mm trocar incision, and assistance of two 5 mm laparoscopic ports at the hipogastrium and right flank. Laparoscopy was resumed and segmental intestinal resection with primary anastomosis was performed. The patient recovered without complications and was discharged home at the fourth postoperative day. The total extraperitoneal approach for acute hernia repair was successful in our particular case. However, factors such as laparoscopic surgical experience, careful patient selection, and correct preoperative diagnosis must be considered before studies in the emergency setting.

Pancreatitis autoinmune: un dilema quirúrgico

Autoimmune pancreatitis (AIP) is defined as a particular form of pancreatitis that often manifests as obstructive jaundice associated with a pancreatic mass or an obstructive bile duct lesion, and that has an excellent response to corticosteroid treatment. The prevalence of AIP worldwide is unknown, and it is considered as a rare entity. The clinical and radiological presentation of AIP can mimic bilio-pancreatic cancer, presenting difficulties for diagnosis and obliging the surgeon to balance decision-making between the potential risk presented by the misdiagnosis of a deadly disease against the desire to avoid unnecessary major surgery for a disease that responds effectively to corticosteroid treatment. In this review we detail the current and critical points for the diagnosis, classification and treatment for AIP, with a special emphasis on surgical series and the methods to differentiate between this pathology and bilio-pancreatic cancer.

Compresión bilateral de vías biliares intrahepáticas por quiste hepático no parasitario gigante: una causa infrecuente de ictericia obstructiva

The patient is an 84-year-old male who came to the emergency room with jaundice. His medical history included: alcoholism 40 g/day, DMNID, alcoholic hepatic cirrhosis (Child–Pugh class A), hepatic cyst in LHD and cholecystectomy due to acute cholecystitis (September 2014). Blood work showed: BT: 12.7 mg/dL; BD: 8.2 mg/dL; GGT: 761U/L; FA: 572U/L; INR: 1.31; creatinine: 0.94 mg/dL and albumin: 2.9 g/dL (MELD: 19). Magnetic resonance cholangiopancreatography detected a giant hepatic cystic lesion measuring 21 18 15 cm (Figure 1), that led to a mass effect on the right and left intrahepatic bile ducts (Figure 2) and peripheral dilation. The extrahepatic duct was normal. Treatment involved percutaneous drainage, which produced a serous liquid (2000 ml) that was negative for malignant cells and microorganisms. The patient’s progress was favorable and showed reduction in the size of the cyst and bile duct dilation, as well as gradual disappearance of the jaundice. The patient was discharged to outpatient follow-up. c i r e s p . 2 0 1 7 ; 9 5 ( 5 ) : 2 9 3

Volvulus of the splenic flexure of colon: The coffee bean and whirl signs.

Fig 1. Abdominal radiography showing the coffee bean sing: a double loop of air-distended colon with the two inner bowel wall edges directly opposed to each other, simulating the central crevice of a coffee bean. A 49-YEAR-OLD WOMAN without a previous medical history of illness presented to the emergency department with severe acute abdominal pain and vomiting. On physical examination she was hemodynamically stable with abdominal distension and signs of peritoneal irritation. The leukocyte count and differential were within normal levels. Abdominal radiography evidenced a coffee bean sign (a double loop of airdistended colon with the two inner bowel wall edges directly opposed to each other, simulating the central crevice of a coffee bean; Fig 1). A contrast-enhanced computed tomography (CT) scan showed a whirl sign at the splenic flexure of the colon (a twisting and engorgement of the mesenteric vessels around a central point; Fig 2). A laparotomy with left hemicolectomy and primary anastomosis was performed. Pathologic findings confirmed the diagnosis of volvulus of the splenic flexure of colon with initial ischemic changes. The patient’s recovery was uneventful.

Pseudoquiste gigante de pared abdominal: una complicación infrecuente de la eventroplastia con malla de sustitución

A 79-year-old woman was referred to our department due to an abdominal wall tumor (Fig. 1). Her medical history included midline laparotomy in 1982 and strangulated incisional hernia repair (with polytetrafluoroethylene prosthesis) in 2006. Computed tomography showed a cyst measuring 31 cm 19 cm 17 cm on the right rectus abdominis muscle (Figs. 2 and 3). The lesion was completely resected, with primary closure of the defect and placement of polypropylene mesh. The pathology study showed evidence of granulation tissue with chronic inflammation (anterior wall), granulomatous reaction to a foreign body, fibrosis (posterior wall) and no malignancy. Pseudocyst is defined as a collection of fluid that is not covered by epithelium. There have been other denominations such as chronic seroma cyst and giant fibrous cyst, but the histology confirms the pseudocyst.