Emilio Vicente

Spanish Experience in Liver Transplantation for Hilar and Peripheral Cholangiocarcinoma

Objective:To assess the real utility of orthotopic liver transplantation (OLT) in patients with cholangiocarcinoma, we need series with large numbers of cases and long follow-ups. The aim of this paper is to review the Spanish experience in OLT for hilar and peripheral cholangiocarcinoma and to try to identify the prognostic factors that could influence survival. Summary Background Data:Palliative treatment of nondisseminated irresectable cholangiocarcinoma carries a zero 5-year survival rate. The role of OLT in these patients is controversial, due to the fact that the survival rate is lower than with other indications for transplantation and due to the lack of organs. Methods:We retrospectively reviewed 59 patients undergoing OLT in Spain for cholangiocarcinoma (36 hilar and 23 peripheral) over a period of 13 years. We present the results and prognostic factors that influence survival. Results:The actuarial survival rate for hilar cholangiocarcinoma at 1, 3, and 5 years was 82%, 53%, and 30%, and for peripheral cholangiocarcinoma 77%, 65%, and 42%. The main cause of death, with both types of cholangiocarcinoma, was tumor recurrence (present in 53% and 35% of patients, respectively). Poor prognosis factors were vascular invasion (P < 0.01) and IUAC classification stages III–IVA (P < 0.01) for hilar cholangiocarcinoma and perineural invasion (P < 0.05) and stages III-IVA (P < 0.05) for peripheral cholangiocarcinoma. Conclusions:OLT for nondisseminated irresectable cholangiocarcinoma has higher survival rates at 3 and 5 years than palliative treatments, especially with tumors in their initial stages, which means that more information is needed to help better select cholangiocarcinoma patients for transplantation.

Fournier's syndrome of urogenital and anorectal origin a retrospective, comparative study

Twenty-eight patients with genital and perianal necrotizing infections are described. The patients were divided into three groups according to the primary site of infection: group 1, anorectal (14 patients); group 2, urologic (ten patients), and group 3, idiopathic (four patients). The overall mortality was 25 percent, 28.5 percent for the anorectal group and 10 percent for the urologic group, although this difference is not statistically significant. Necrotizing infections of anorectal origin were more severe and had a less typical way of presentation, with subsequent delay in diagnosis and a higher rate of myonecrosis. As a consequence, more debridements and more fecal derivations had to be performed. The etiologic agents were the same among the three groups and comprised a number of anaerobes (Bacteroides spp, gram-positive cocci) as well as aerobes (microorganisms belonging to theEnterobacteriaceae andS. faecalis). Necrotizing fasciitis was the pathologic picture of nine of ten patients with Fourniers gangrene of urogenital origin and seven of 14 with an anorectal source. Synergistic necrotizing cellulitis was identified in half of those secondary to anorectal origin and only one of those with a urologic source.

Total fecal incontinence-a new method of gluteus maximus transposition: Preliminary results and report of previous experience with similar procedures

Since 1986, different procedures of gluteus maximus transposition have been performed, by one of the authors, in 10 patients with total anal incontinence not amenable to sphincter repair, due to congenital anomalies (four), sphincteric denervation (three) or after severe trauma (three). Variable degrees of long-lasting fecal control were obtained in all but one patient, with great improvement in six. Difficulties for achieving a closed anus without muscular tension of the neosphincter, together with the morbidity associated with anal wound infection, determined the reasons for the successive use of different techniques (Biström, Hentz, Schoamaker) until the authors, in 1990, designed a new procedure (Devesa). Although the reported experience with this technique described here is limited to only four patients, our impression is that the method is easier, has less morbidity, and achieves better short-term functional results, derived from a thick, tension-free neosphincter.

Bilateral gluteoplasty for fecal incontinence.

PURPOSE: This study describes our clinical experience with adynamic bilateral gluteoplasty in 20 patients with total fecal incontinence, in whom a sphincter repair had failed (n=17) or was nonviable. METHODS: Between 1986 and 1995, 12 women and 8 men ranging in age from 15 to 58 (mean, 37) years underwent different techniques of adynamic gluteoplasty. The indications for the operation were congenital anomalies, denervation, or sphincter destruction. Postoperative evaluation was clinical (Pescatori grading; self-evaluation) and manometric. RESULTS: Morbidity was only related to wound infection (n=7) requiring late reoperations for neosphincter repair (n=5), anal stenosis (n=2), and incisional hernia after colostomy closure (n= 1). Two other patients with no complications also had further surgery for tightening of the neosphincter; they had a successful outcome. Of the 17 evaluable patients, 9 (53 percent) achieved normal control or were graded as Pescatori A-1, A-2, B-1, or C-1, 1 (6 percent) as Pescatori C-2, and 7 (41 percent) as Pescatori C-3. Six patients (35 percent) judged their results as excellent, three (18 percent) as good, one (6 percent) as fair, and seven (41 percent) as bad. Eight patients are able to retain 200 ml of water instilled into the rectum for between five minutes and two hours. For the nine patients with better results, the mean ± standard deviation of the differences between postgluteoplasty and pregluteoplasty anal pressures were 40±25 mmHg (resting pressure) and 122±85 mmHg (squeeze pressure). These findings demonstrate a tonic and voluntary activity of the plasty. The authors technique has less morbidity, and excellent or good results were achieved in 67 percent of the patients. Failures were attributable to suture disruption (n=4), poor muscular contraction (n=2), and intractable constipation (n=1). CONCLUSIONS: Adynamic gluteoplasty is efficient for achieving good or very good continence status in a higher proportion of patients than with other adynamic muscle transfer procedures.

Liver Transplantation in HIV-infected recipients

Liver transplantation is being evaluated as a therapeutic option for human immunodeficiency virus (HIV)‐infected patients with end‐stage liver disease, but experience is still scarce. We describe the outcome of 4 HIV‐infected patients who underwent liver transplantation in our hospital between July 2002 and April 2003. HIV‐infected liver transplant recipients meet the same standard criteria for transplantation as do HIV‐negative candidates. In addition, HIV infected persons are required to have a CD4 T‐cell count greater than 100/mL (CD4 T‐cells are targets for HIV infection). Immunosuppressive regimens, perioperative surgical prophylaxis, and prophylaxis for opportunistic infections are standard in the Liver Transplantation Unit in our hospital. Four patients, including 3 former intravenous drug users, received a liver transplant (2 from deceased donors and 2 from living donors), with a median follow‐up of 510 days. Three patients (75%) are alive, with 1 death occurring 17 months posttransplantation in a patient who developed fibrosing cholestatic hepatitis. Rejection occurred in 1 patient, and was managed with no complications. Hepatitis C virus (HCV) recurrence occurred in 3 patients. HIV‐infection has remained under control with antiretroviral treatment. A combination of 3 nucleoside analogs was used in 3 patients, with no need for drug adjustments. No opportunistic infections or other significant infectious complications developed. In conclusion, orthotopic liver transplantation seems a safe therapeutic option in the short term for HIV‐infected persons with end stage liver disease, including patients with a history of drug abuse. If indicated, an antiretroviral regimen consisting of 3 nucleosides could be used to avoid interactions with immunosuppressive drugs. (Liver Transpl 2005;11:76–81.)

Analysis of the complications of the piggy-back technique in 1112 liver transplants

22. Zutter MM, Martin PJ, Sale GE, et al. Epstein-Barr-virus asso-ciated B cell lymphoproliferative disorders after bone marrowtransplantation. Blood 1988; 72: 520.23. Renard TH, Andrews WS, Foster ME. Relationship betweenOKT3 administration, EBV conversion, and the lymphoprolif-erative syndrome in pediatric liver transplant recipients.Transplant Proc 1991; 23: 1473.24. Davis CL, Harrison KL, McVicar JP, Forg PJ, Bronner MP,Marsh CL. Antiviral prophylaxis and the Epstein Barr virus-related post-transplant lymphoproliferative disorder. ClinTransplant 1995; 9: 53.25. Yao QY, Ogan P, Rowe M, Rickinson AB. Epstein-Barr-virustreated B cells persist in the circulation of aciclovir-treatedvirus carriers. Int J Cancer 1989; 43: 61.26. Kuo PC, Dafoe DC, Alfrey EJ, Sibley RK, Scandling JD. Post-transplant lymphoproliferative disorders and Epstein-Barr vi-rus prophylaxis. Transplantation 1995; 59: 135.27. Darenkov IA, Marcarelli MA, Basadonna GP, et al. Reducedincidence of Epstein-Barr virus-associated posttransplant lym-phoproliferative disorder using preemptive antiviral therapy.Transplantation 1997; 64: 848.28. Neyts J, Andrei G, De Clercq E. The novel immunosuppressiveagent mycophenolate mofetil markedly potentiates the anti-herpesvirus activities of aciclovir, ganciclovir and penciclovirin vitro and in vivo. Antimicrob Agents Chemother 1998; 42:216.29. Tressler RJ, Garvin LJ, Slate DL. Anti-tumor activity of myco-phenolate mofetil against human and mouse tumors in vivo.Int J Cancer 1994; 57: 568.30. Fleiss JL. Statistical methods for rates and proportions, 2nd ed.New York: Wiley, 1981: 38.31. Alfrey EJ, Friedman AL, Grossman RA, et al. A recent decreasein the time to development of monomorphous and polymor-phous posttransplantlymphoproliferative disorder. Transplan-tation 1992; 54: 250.32. Ciancio G, Siquijor AP, Burke GW, et al. Post-transplant lym-phoproliferative disease in kidney transplant patients in thenew immunosuppressive era. Clin Transplant 1997; 11: 243.33. Morris RE. Transplantation. Beware: shifting paradigm ahead.Lancet 1996; 1 (suppl II): 26.Received 3 July 1998.Accepted 11 December 1998.

Does robotic distal pancreatectomy surgery offer similar results as laparoscopic and open approach? A comparative study from a single medical center.

In the field of pancreatic surgery, robotic surgery has yet to be evaluated against open and laparoscopic approaches. The outcomes of robotic surgery for distal pancreatectomy were analysed and the results compared with those of laparoscopic and open procedures.

The role of multimodality therapy for resectable esophageal cancer

BACKGROUND There is an increasing interest in the role of combined therapy to achieve long-term survival for patients with resectable esophageal neoplasms. Surgery provides excellent palliation with relatively low morbidity and mortality rates, but cure remains elusive. MATERIAL AND METHODS From January 1988 to January 1998, a total of 137 patients met eligibility criteria for a combined multimodal therapy, prospective, nonrandomized protocol of induction chemoradiation therapy followed by surgical resection, based on radiological and endoscopic assessment of the extension (all patients were initially considered to be at clinical stages I to III, locoregional). Consequently, patients with high grade Barretts dysplasia or any squamous carcinoma in situ (stage 0) and those with distant metastatic disease (stage IV) were excluded. Among this group, 48 operable patients with biopsy-proven esophageal cancer finally entered and completed the protocol and are the sample of the present study. Multivariate logistic regression models were used to identify risk factors for death or recurrence. Actuarial survival was calculated since the beginning of the induction protocol by the Kaplan-Meier method, and comparisons between groups were made by the log-rank test. RESULTS Mean age was 61.6 (range 45 to 71), and 72.9% were male. The majority of the tumors (70.8%) were located at the lower third/cardia and as many as 18.8% were adenocarcinoma. After a mean of 7.5 weeks (range 5 to 12) after the completion of the induction phase, 68.7% underwent a transthoracic esophagectomy and 31.3% a transhiatal esophagectomy. The in-hospital mortality rate was 10.4% (5 patients). A complete response (no evidence of tumor within the specimen: pT0) was achieved in 25% (12 patients). After a mean follow-up of 20.2 months, mean survival for the entire group was 18.2 months (95% confidence interval 14 to 22). At the end of the study, 25% (12) remained alive. Actuarial survival rates at 12, 23, and 37 months were 56.2%, 36.9%, and 21.9%, respectively. CONCLUSIONS Esophageal resection after induction therapy seems to be related to a slightly higher mortality rate compared with historical series, and for this reason, neoadjuvant therapy must be considered still experimental. However, no statistical significant difference in survival is showed in those cases with complete pathological response (pT0). Factors influencing survival are recurrence and age. Surgery alone remains the standard therapy for esophageal cancer.

Is Liver Transplantation Advisable for Isoniazid Fulminant Hepatitis in Active Extrapulmonary Tuberculosis

Antituberculous treatment is a well‐known cause of fulminant hepatic failure (FHF). This could lead to liver transplantation as the only possible treatment, which on the other hand could be contraindicated due to active tuberculosis. The risk of aggressive dissemination of the disease after transplantation is not clearly determined by the current second‐line antituberculous therapies. We report a case of vertebral tuberculosis treated with rifampin, isoniazid and pyrazinamide. He developed an FHF that was treated with urgent liver transplantation. Despite the immunosuppression, the disease was well controlled with ciprofloxacin, ethambutol and streptomycin and the patient is in good health 23 months after transplantation. In conclusion, active extrapulmonary tuberculosis should perhaps be considered for liver transplantation when FHF develops due to anti‐tuberculous drugs.

Management of biliary duct confluence injuries produced by hepatic hydatidosis.

Abstract. From 1978 to 1999 a total of 850 patients underwent surgical treatment for hydatid disease of the liver at our surgical department. Biliary duct confluence injuries produced by hepatic hydatidosis (HH) were founded in six patients (0.7%). Surgical intervention was undertaken to relieve the obstructive jaundice and clinical manifestations of cholangitis and to treat the hydatid cyst. A partially open cystopericystectomy technique was used in three patients with a double bilioenteric Roux-en-Y reconstruction. The remaining three patients (two with prehepatic portal hypertension and one with triple hepatic duct confluence) were subjected to a cystojejunostomy. There were no hospital deaths. Two cases of anastomotic leakage following a high bilioenteric anastomosis occurred but did not require surgical treatment. During the follow-up (5–19 years) one patient suffered local recurrence of the hydatid disease 7 years after cystojejunostomy. The site of intrahepatic biliary and vascular involvement, the presence of biliary duct anomalies, and the presence of portal hypertension are decisive factors when choosing the “ideal” procedure for reconstruction. Conservative surgical approaches (partial cystectomy and cystojejunostomy) are the treatments of choice. Radical surgery is often a serious matter.