E. de Santibañes

Bile duct injuries: management of late complications

BackgroundLaparoscopic cholecystectomy is the treatment of choice for gallbladder stones. In the current study, this approach was associated with a higher incidence of biliary injuries. The authors evaluate their experience treating complex biliary injuries and analyze the literature.MethodsIn a 15-year period, 169 patients with bile duct injuries (BDIs) resulting from open and laparoscopic cholecystectomies were treated. The patients were retrospectively evaluated through their records. Biliary injury and associated lesions were evaluated with imaging studies. Surgical management included therapeutic endoscopy, percutaneous interventions, hepaticojejunostomy, liver resection, and liver transplantation. Postoperative outcome was recorded. Survival analysis was performed with G-Stat and NCSS programs using the Kaplan–Meier method.ResultsOf the 169 patients treated for BDIs, 148 were referred from other centers. The injuries included 115 lesions resulting from open cholecystectomy and 54 lesions resulting from laparoscopic cholecystectomy. A total of 110 patients (65%) fulfilled the criteria for complex injuries, 11 of whom met more than one criteria. Injuries resulting from laparoscopic and open cholecystectomies were complex in 87.5% and 72% of the patients, respectively. The procedures used were percutaneous transhepatic biliary drainage for 30 patients, hepaticojejunostomy for 96 patients, rehepaticojejunostomy for 16 patients, hepatic resection for 9 patients, and liver transplantation projected for 18 patients. Hepaticojejunostomy was effective for 85% of the patients. The mean follow-up period was 77.8 months (range, 4–168 months). The mortality rate for noncomplex BDI was 0%, as compared with the mortality rate of 7.2% (8/110) for complex BDI. Mortality after hepatic resection was nil, and morbidity was 33.3%. The actuarial survival rate for liver transplantation at 1 year was 91.7%.ConclusionsComplex BDIs after laparoscopic cholecystectomy are potentially life-threatening complications. In this study, late complications of complex BDIs appeared when there was a delay in referral or the patient received multiple procedures. On occasion, hepatic resections and liver transplantation proved to be the only definitive treatments with good long-term outcomes and quality of life.

Liver resection for non-colorectal, non-neuroendocrine metastases: analysis of a multicenter study from Argentina

BACKGROUND AND AIM Resection of colorectal liver metastases has become a standard of care, although the value of this procedure in non-colorectal non-neuroendocrine (NCRNNE) metastases remains controversial and is still a matter of debate. The aim of the study was to determine the utility of liver resection in the long-term outcome of patients with NCRNNE metastases. MATERIAL AND METHODS The records of 106 patients who underwent liver resection for NCRNNE metastases in the period 1989 to 2006 at 5 HPB Centers in Argentina were analyzed. Patient demographics, tumor characteristics, type of resection, long-term outcome and prognostic factors were analyzed. Depending on primary tumor sites, a comparative analysis of survival was performed. RESULTS Mean age was 54 (17-76). Hepatic metastases were solitary in 62.3% and unilateral in 85.6%. Primary tumor sites: Urogenital (37.7%), sarcomas (21.7%), breast (17.9%), gastrointestinal (6.6%), melanoma (5.7%), and others (10.4%). Fifty-one major hepatectomies and 55 minor resections were performed. Twenty patients underwent synchronous resections. An R0 resection could be achieved in 89.6%. Perioperative mortality was 1.8%. Overall, 1-year, 3-year, and 5-year survival rates were 67%, 34%, and 19%, respectively. Survival was significantly longer for metastases of urogenital (p=0.0001) and breast (p=0.003) origin. Curative resections (p=0.04) and metachronous disease (p=0.0001) were predictors of better survival. CONCLUSIONS Liver resection is an effective treatment for NCRNNE liver metastases; it gives satisfactory long-term survival especially in metachronous disease, in patients with metastases from urogenital and breast tumors and when R0 procedures can be performed.

Complex bile duct injuries: management

BACKGROUND Laparoscopic cholecystectomy is the present treatment of choice for patients with gallbladder stones, despite its being associated with a higher incidence of biliary injuries compared with the open procedure. Injuries occurring during the laparoscopic approach seem to be more complex. A complex biliary injury is a disease that is difficult to diagnose and treat. We considered complex injuries: 1) injuries that involve the confluence; 2) injuries in which repair attempts have failed; 3) any bile duct injury associated with a vascular injury; 4) or any biliary injury in association with portal hypertension or secondary biliary cirrhosis. The present review is an evaluation of our experience in the treatment of these complex biliary injuries and an analysis of the international literature on the management of patients.

Liver transplantation for the sequelae of intra-operative bile duct injury.

BACKGROUND Intra-operative bile duct injuries (IBDI) are potentially severe complications of the treatment of benign conditions, with unpredictable long-term results. Multiple procedures are frequently needed to correct these complications. In spite of the application of these procedures, patients with severe injuries can develop irreversible liver disease. Liver transplantation (LT) is currently the only treatment available for such patients, but little information has been published concerning the results of LT. METHODS Eight patients with LT for end-stage liver disease for IBDI were studied retrospectively. They had failure of multiple previous treatments and experienced recurrent episodes of cholangitis, oesophageal variceal bleeding, severe pruritus, refractory ascites and spontaneous peritonitis. RESULTS Mean recipient hepatectomy time was of 243 minutes (range 140-295 min), the complete procedure averages 545 minutes (260-720) and intraoperative red-blood-cells consumption was 6.5 units (1-7). One patient required reoperation due to perforation of a Roux-en-Y loop, and three developed minor complications (2 wound infections, I inguinal lymphocele). One patient died due to nosocomial pneumonia (mortality rate 12.5%). One patient required retransplantation due to delayed hepatic artery thrombosis. At follow-up 75% of patients are alive with normal graft function and an excellent quality of life. CONCLUSIONS LT represents a safe curative treatment for end-stage liver disease after IBDI, albeit a major undertaking in the context of a surgical complication in the treatment of benign disease. The complications of the surgical procedure and the long-standing immunosuppression impart a high cost for resolutions of these sequelae but LT represents the only long-term effective treatment for these selected patients.

Model for end-stage liver disease-based allocation system for liver transplantation in Argentina: does it work outside the United States?

BACKGROUND In July 2005, Argentina was the first country after the United States to adopt the MELD system. The purpose of the present study was to analyse the impact of this new system on the adult liver waiting list (WL). METHODS Between 2005 and 2009, 1773 adult patients were listed for liver transplantation: 150 emergencies and 1623 electives. Elective patients were categorized using the MELD system. A prospective database was used to analyse mortality and probability to be transplanted (PTBT) on the WL. RESULTS The waiting time increased inversely with the MELD score and PTBT positively correlated with MELD score. With scores >/= 18 the PTBT remained over 50%. However, the largest MELD subgroup with <10 points (n = 433) had the lower PTBT (3%). In contrast, patients with T(2) hepatocellular carcinoma benefited excessively with the highest PTBT (84.2%) and the lowest mortality rate (5.4%). The WL mortality increased after MELD adoption (10% vs. 14.8% vs. P < 0.01). Patients with <10 MELD points had >fourfold probability of dying on the WL than PTBT (14.3% vs. 3%; P < 0.0001). CONCLUSIONS After MELD implementation, WL mortality increased and most patients who died had a low MELD score. A comprehensive revision of the MELD system must be performed to include cultural and socio-economical variables that could affect each country individually.

Use of Liver Grafts From Anti-Hepatitis B Core-Positive Donors: A Multicenter Study in Argentina

Liver transplantation success is limited by the availability of donors. To overcome this limitation, anti-core-positive donors are increasingly being accepted, but underutilization of this resource still occurs. We performed the current study to determine the prevalence of anti-core-positive donors in our region and to describe the management of these donors and their recipients. Between January 2005 and July 2011, the national transplant database included 2,262 registered liver donors among whom 106 (4.7%) were anti-core-positive including 59 (56%) discarded and 47 (44%) implanted organs. A median of 14.5 offers (range 4-60) were rejected before harvesting and implanting the accepted grafts. The only difference between the implanted and the discarded grafts was found for the alanine aminotransferase level, which was higher among the discarded ones (50 ± 59 UI/L vs 25 ± 16, P < .05). Among 40 recipients included in the study, 5 (12.5%) did not receive any prophylaxis; 18 (45%) a nucleos(t)ide analog 11 (25.5%), heptitis B immunoglobulin and nucleos(t)ide analogs and 6 (15%) pretransplant hepatitis B vaccination. Over a mean follow-up of 871 ± 585 days, 4 de novo hepatitis B cases were identified at 545, 720, 748, and 1,080 days posttransplantation. None of these patients had received any prophylaxis. In all cases entecavir successfully controlled viral replication. We believe that better utilization of these donors and careful management of their recipients represent safe strategies to expand the liver donor pool in Argentina.

Major and Minor Duodenal Papilla Neuroendocrine Tumors in Type 1 Neurofibromatosis: Case Report

Type 1 neurofibromatosis (NF1), or von Recklinghausen disease, is one of the most common autosomal-dominant disorders with an incidence of 1 in every 2500 to 3000 births. NF1 is caused by a germline mutation in NF1 tumor suppressor gene located on chromosome 17q11.2. The NF1 gene encodes neurofibromin, a cytoplasmic protein which plays a fundamental role in negative regulation of the Ras cellular proliferation pathway. Therefore, patients with NF1 are at higher risk of developing various tumors, such as neurofibromas, neurofibrosarcomas, stromal tumors, neuroendocrine tumors, and gliomas [1–3]. About 5–25 % of patients with NF1 have gastrointestinal manifestations such as neurofibromas, gastrointestinal stromal tumors (GISTs) of the small bowel, and periampullary neuroendocrine tumors (NETs); however, only 5 % of them have been reported as symptomatic [4, 5]. Neuroendocrine tumors are derived from cells from the Langerhans islets in the pancreas and from enteroendocrine cells in the digestive system. Clinically they may be divided in two groups: functioning and non-functioning tumors. In the first group, the tumors produce a clinical syndrome, due to the secretion of a specific peptide (i.e., insulinoma, gastrinoma, etc.). The term carcinoid is reserved for those which produce a syndrome secondary to the secretion of serotonin and histamine, although originally the term was used to name all neuroendocrine tumors. Non-functioning neuroendocrine tumors may produce compression symptoms according to their location, unspecific abdominal pain, hemorrhage, obstructive jaundice, or a palpable mass [6]. The association between NF1 and neuroendocrine tumors is well described; however, there is only one other report to date of two synchronous neuroendocrine tumors.

The Hepatic Artery Reconstruction First Approach in Hilar Cholangiocarcinoma Type IIIb

Even though recent advances in liver surgery have led to a more efficient approach to hilar cholangiocarcinoma (HC), resection with curative intent remains a challenge for hepatobiliary surgeons [1]. There is strong evidence to show better survival and long-term outcomes when microscopically tumor-free surgical margins are obtained in these patients [2]. En-bloc resections of liver parenchyma with the extrahepatic bile duct is mandatory to manage tumors with direct hepatic invasion, as well as to accomplish an R0 resection on tumors that frequently extend longitudinally out to involve the hepatic ducts [3–5].

A MELD-SCORE BASED LIVER ALLOCATION SYSTEM HAS A NEGATIVE IMPACT ON WAITING LIST MORTALITY AND IS ASSOCIATED WITH LOWER POST-TRANSPLANT SURVIVAL IN A COUNTRY WITH A UNIQUE, LARGE GEOGRAPHIC ORGAN PROCUREMENT AREA: 1029

Since June 2005 liver allocation in Argentina has incorporated MELD score to stratify patients in the waiting list. Due to an uneven distribution of transplantation centers no organ allocation areas were established, with a unique national waiting list serving a population of 39 million inhabitants. Aim: To evaluate the impact of MELD score in drop out, transplants and 1 year survival post transplantation. Patients and Methods: We included 707 consecutive patients registered in the waiting list. Period Pre-MELD: Listed June 1998/May 2005 in categories elective and urgency according to clinical and biochemical criteria (n=377). Period MELD: Listed June 2005/December 2008 stratified by MELD score (n=325). Overall and subgroup analysis was performed. Comparison between groups for quantitative variables was based on the test of t Student and for qualitative variables with Chi2 test. Actuarial probability of survival and drop out from the waiting list were calculated by Kaplan-Meier and compared using Mantel-Cox test. Results:In MELD period there was a 78 % increase in annual registration of patients without differences between etiologies or presence of HCC (15.3 vs 12.0 %). Mean age at registration was significantly higher in Period MELD (53.35 ±13 vs 49.11±14 years, p<0.05). 59 % of patients in period MELD were listed with MELD scores 12 to 19 (mean MELD16±6), while previously 72 % were listed in elective category. Number of transplants/year remained unchanged (35.2 vs 33.3). Yet time to transplantation was significantly shorter in Period MELD (8.7m vs 14.2m, p<0.001). Mean MELD at transplantation in Period MELD was 24.13±7.6 and 19.63±9.7 at drop out (p <0.001). Drop out was significantly higher in period MELD (18.4 to 14.5%. p<0.001). Rates of listed/transplanted patients decreased for cholestatic disease post MELD (66 to 23 %, p<0.05)and increased for HCC (17 to 91 %, p<0.001). One year patient and graft survival post transplant decreased from 93.1 to 83.5 % (p <0 .001). Mean MELD of patients dying within 3 months post-transplant: was 27.8±5.6 compared to 23.2±7.4 in survivors (p <0.01). Conclusion: Application of MELD score in Argentina has demonstrated a negative impact on waiting list mortality and has been associated with lower early post transplant survival. Further tuning of the application of the system should be performed to optimize results.

FIRST NATIONAL REPORT AFTER THE IMPLEMENTATION OF THE MELD-BASED ALLOCATION SYSTEM FOR LIVER TRANSPLANTATION IN ARGENTINA: 3001

L. McCormack1, E. de Santibañes2, J. Lendoire1, O. Imventarza3, O. Gil4, L. Toselli5, O. Andriani6, L. Bisigniano7, A.C. Gadano8 1General Surgery, Hospital Aleman of Buenos Aires, Buenos Aires/ARGENTINA, 2, Liver Transplantation Unit, Buenos Aires/ ARGENTINA, 3, Hospital Argerich, Buenos Aires/ARGENTINA, 4, Sanatorio Allende, Cordoba/ARGENTINA, 5, CRAI Norte, Buenos Aires/ARGENTINA, 6, Hospital Universitario Austral, Pilar/ ARGENTINA, 7, INCUCAI, Buenos Aires/ARGENTINA, 8Liver Transplantation Unit, Hospital Italiano, Buenos Aires/ARGENTINA