Julio Santoyo

Intrahepatic cholangiocarcinoma or mixed hepatocellular-cholangiocarcinoma in patients undergoing liver transplantation: a Spanish matched cohort multicenter study.

Objective:To evaluate the outcome of patients with hepatocellular-cholangiocarcinoma (HCC-CC) or intrahepatic cholangiocarcinoma (I-CC) on pathological examination after liver transplantation for HCC. Background:Information on the outcome of cirrhotic patients undergoing a transplant for HCC and with a diagnosis of HCC-CC or I-CC by pathological study is limited. Methods:Multicenter, retrospective, matched cohort 1:2 study. Study group: 42 patients undergoing a transplant for HCC and with a diagnosis of HCC-CC or I-CC by pathological study; and control group: 84 patients with a diagnosis of HCC. I-CC subgroup: 27 patients compared with 54 controls; HCC-CC subgroup: 15 patients compared with 30 controls. Patients were also divided according to the preoperative tumor size and number: uninodular tumors 2 cm or smaller and multinodular or uninodular tumors 2 cm or larger. Median follow-up: 51 (range, 3–142) months. Results:The 1-, 3-, and 5-year actuarial survival rate differed between the study and control groups (83%, 70%, and 60% vs 99%, 94%, and 89%, respectively; P < 0.001). Differences were found in 1-, 3-, and 5-year actuarial survival rates between the I-CC subgroup and their controls (78%, 66%, and 51% vs 100%, 98%, and 93%; P < 0.001), but no differences were observed between the HCC-CC subgroup and their controls (93%, 78%, and 78% vs 97%, 86%, and 86%; P = 0.9). Patients with uninodular tumors 2 cm or smaller in the study and control groups had similar 1-, 3-, and 5-year survival rate (92%, 83%, 62% vs 100%, 80%, 80%; P = 0.4). In contrast, patients in the study group with multinodular or uninodular tumors larger than 2 cm had worse 1-, 3-, and 5-year survival rates than their controls (80%, 66%, and 61% vs 99%, 96%, and 90%; P < 0.001). Conclusions:Patients with HCC-CC have similar survival to patients undergoing a transplant for HCC. Preoperative diagnosis of HCC-CC should not prompt the exclusion of these patients from transplant option.

“Very Early” Intrahepatic Cholangiocarcinoma in Cirrhotic Patients: Should Liver Transplantation Be Reconsidered in These Patients?

A retrospective cohort multicenter study was conducted to analyze the risk factors for tumor recurrence after liver transplantation (LT) in cirrhotic patients found to have an intrahepatic cholangiocarcinoma (iCCA) on pathology examination. We also aimed to ascertain whether there existed a subgroup of patients with single tumors ≤2 cm (“very early”) in which results after LT can be acceptable. Twenty‐nine patients comprised the study group, eight of whom had a “very early” iCCA (four of them incidentals). The risk of tumor recurrence was significantly associated with larger tumor size as well as larger tumor volume, microscopic vascular invasion and poor degree of differentiation. None of the patients in the “very early” iCCA subgroup presented tumor recurrence compared to 36.4% of those with single tumors >2 cm or multinodular tumors, p = 0.02. The 1‐, 3‐ and 5‐year actuarial survival of those in the “very early” iCCA subgroup was 100%, 73% and 73%, respectively. The present is the first multicenter attempt to ascertain the risk factors for tumor recurrence in cirrhotic patients found to have an iCCA on pathology examination. Cirrhotic patients with iCCA ≤2 cm achieved excellent 5‐year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs.

Transección de órganos sólidos. Cirugía abierta y laparoscópica

Recent advances in liver surgery have reduced post-hepatectomy mortality to less than 5% in most units specialized in hepato-pancreatic-biliary surgery. Possibly, the single most important factor contributing to these improved results has been the reduction in intraoperative bleeding during liver parenchymal transection. Liver transection is the most risky part of the intervention due to the risk of massive hemorrhage. Some technological advances and refinements to the surgical technique have contributed to making this critical phase of liver surgery safer. Among these advances, the most notable are detailed knowledge of the surgical anatomy of the liver, vascular control techniques and methods of liver parenchymal transection. The present review describes current transection techniques, as well as their advantages and disadvantages. Until there is solid evidence on the best method, the choice of technique and instrument for liver transection depends mainly on the surgeons personal preference. Nevertheless, some factors can influence the choice of method, such as the surgeons experience, anesthetic management, type of hepatectomy (central, peripheral), type of approach (open, laparoscopic), quality of the liver (normal, cirrhotic, steatotic) and the availability of the instruments in the center.Recent advances in liver surgery have reduced post-hepatectomy mortality to less than 5% in most units specialized in hepato-pancreatic-biliary surgery. Possibly, the single most important factor contributing to these improved results has been the reduction in intraoperative bleeding during liver parenchymal transection. Liver transection is the most risky part of the intervention due to the risk of massive hemorrhage. Some technological advances and refinements to the surgical technique have contributed to making this critical phase of liver surgery safer. Among these advances, the most notable are detailed knowledge of the surgical anatomy of the liver, vascular control techniques and methods of liver parenchymal transection. The present review describes current transection techniques, as well as their advantages and disadvantages. Until there is solid evidence on the best method, the choice of technique and instrument for liver transection depends mainly on the surgeons personal preference. Nevertheless, some factors can influence the choice of method, such as the surgeons experience, anesthetic management, type of hepatectomy (central, peripheral), type of approach (open, laparoscopic), quality of the liver (normal, cirrhotic, steatotic) and the availability of the instruments in the center.

Análisis farmacoeconómico del tratamiento hemostático en cirugía con una esponja medicamentosa de fibrinógeno y trombina

ResumenObjetivo: Comparar la eficiencia de una esponja medicamentosa con fibrinógeno y trombina (EFT, TachoSil®) para mejorar la hemostasia en cirugía hepática y pulmonar, cuando las técnicas estándares son insuficientes. Métodos: Diseño: análisis de costes y efectos. Efectividad y utilización de recursos: se estimó a partir de ensayos clínicos aleatorizados en cirugía pulmonar y hepática en comparación con una solución de fibrinógeno y trombina humana (SFT, Tissucol Duo®) y con el coagulador de argón. Perspectiva: Sistema Nacional de Salud (costes directos sanitarios). Costes: se estimaron los costes diferenciales: costes de adquisición, tiempo de preparación y aplicación de los fármacos y, en cirugía pulmonar, coste de los días adicionales de hospitalización por pérdidas de aire postquirúrgicas. Caso básico: valores medios de los costes. Análisis de sensibilidad: análisis simple unifactorial, con los valores extremos de los costes. Resultados: Efectividad en cirugía pulmonar: pérdidas secundarias de aire después de la resección pulmonar: EFT: 25% y 36,4%; SFT/coagulador de argón: 33% y 37%, respectivamente. El número de pacientes que era necesario tratar con la EFT fue de 9 y 46 pacientes, respectivamente. Efectividad en cirugía hepática: tiempo de hemostasia intraoperatoria: EFT 3,9 y 3,6 minutos; coagulador de argón 6,3 y 5,0 minutos. Costes incrementales por intervención (coste con SFT-coste con EFT). Cirugía pulmonar: 133,34 €. Cirugía hepática: 187,66 €. Análisis de sensibilidad: en todos los casos la utilización de EFT redujo los costes por intervención. Conclusiones: La utilización de la EFT es un procedimiento más eficiente que la utilización de una SFT o el coagulador de argón en cirugía hepática o pulmonar.

De la hiperplasia nodular focal al adenoma inflamatorio hepático

Mujer de 29 años en tratamiento con anticonceptivos orales desde varios años antes. Es remitida desde otro centro por cuadro de astenia, malestar general, fiebre y dolor abdominal de 2-3 semanas de evolución, acompañado de anemización severa en los ú ltimos dı́as que precisó transfusión de 4 unidades de hematı́es. En la exploración fı́sica destacaba una gran hepatomegalia bajo riesgo de complicación y sin potencial maligno, por lo que no precisa tratamiento ni seguimiento. Desde el punto de vista patogénico se trata de una proliferación de hepatocitos normales en torno a una anomalı́a arterial central, que da lugar a un fenómeno de hiperaflujo sanguı́neo local. En las pruebas de imagen, la HNF aparece como una lesión homogénea con una zona central realzada por el contraste c i r e s p . 2 0 1 1 ; 9 0 ( 3 ) : 1 9 8 – 2 0 9 200

Tratamiento agresivo de las complicaciones arteriales del trasplante hepático. Impacto sobre la supervivencia y las complicaciones biliares

UNLABELLED A study was made of the arterial complications documented in 400 transplants performed between 1997 and 2006. The patients were divided into two groups according to the type of treatment provided. Group I: invasive management (arterial treatment or re-transplant), and Group II: conservative or symptomatic management. The impact of management upon survival and biliary complications was analysed. RESULTS There were 18 arterial complications (4.5%): 10 early (7 thromboses and 3 stenoses) and 8 late (5 thromboses and 3 stenoses). Ninety percent of the early complications were subjected to invasive management (4 emergency thrombectomies, 1 re-transplant and 3 angioplasties), while 25% of the late complications were treated in the form of re-transplant and the remaining 75% were subjected to symptomatic treatment. Survival after 12 and 60 months was lower in Group II (57% and 42%) than in Group I (90% and 68%), although without reaching statistical significance. The overall biliary complications rate among the patients with arterial thrombosis was 50%. The rate was significantly lower in Group I than in Group II (10% versus 71%) (P<04). CONCLUSIONS Invasive management of the arterial complications of liver transplantation is associated with longer short-term survival and significantly fewer biliary complications. In our experience, patients benefit from an early diagnosis and aggressive management of complications of this kind.

Aggressive management of the arterial complications of liver transplantation. Impact upon survival and biliary complications

Abstract A study was made of the arterial complications documented in 400 transplants performed between 1997 and 2006. The patients were divided into two groups according to the type of treatment provided. Group I: invasive management (arterial treatment or re-transplant), and Group II: conservative or symptomatic management. The impact of management on survival and biliary complications was analysed. Results There were 18 arterial complications (4.5%): 10 early (7 thromboses and 3 stenoses) and 8 late (5 thromboses and 3 stenoses). Ninety percent of the early complications were subjected to invasive management (4 emergency thrombectomies, one re-transplant and 3 angioplasties), while 25% of the late complications were treated with re-transplant and the remaining 75% were subjected to symptomatic treatment. Survival after 12 and 60 months was lower in Group II (57% and 42%) than in Group I (90% and 68%), although without reaching statistical significance. The overall biliary complications rate among the patients with arterial thrombosis was 50%. The rate was significantly lower in Group I than in Group II (10% versus 71%) (P Conclusions Invasive management of the arterial complications of liver transplantation is associated with longer short-term survival and significantly fewer biliary complications. In our experience, patients benefit from an early diagnosis and aggressive management of complications of this kind.

Prolonged Anhepatic Phase for Acute Vascular Failure During Surgery

Introduction: Total hepatectomy with temporary porto caval shunt involves an anhepatic phase until liver transplantation. The severity of the patients state is conditioned by the physiopathologic alterations occurred during the anhepatic phase and the availability or not of organs in the short term. Methods: We report the case of a male patient undergoing liver transplantation for liver failure caused by the hepatitis C virus (HCV). Until liver transplantation, the patient experienced an anhepatic phase of 22 hours secondary to acute vascular failure during surgery. The patient is alive at five follow-up years. Conclusions: Total hepatectomy with temporary portocaval anastomosis in combination with appropriate management of physiopathologic alterations at the Intensive Care Unit improve survival in severely-ill patients awaiting transplantation.

Negative pressure therapy as palliative treatment for a colonic fistula

Colonic fistulas in an open wound are always a challenge for colorectal surgeons, and this report provides a technique for the appropriate management of these cases. We communicate the use of a negative pressure dressing therapy as part of the palliative care for a patient following the development of an enterocutaneous fistula. The use of this therapy allowed us to keep the patient clean and comfortable during the last few days of his life.

Hepatectomía por metástasis de leiomiosarcoma de vena safena

Vascular leiomyosarcomas (VLMS) are uncommon and represent less than 2% of all sarcomas. They are usually seen in low-pressure vascular systems such as the vena cava. The least common locations are the veins of the lower extremities or the arterial system (pulmonary artery or periphery). In spite of being rare, it presents high rates of local recurrence and distant metastasis. Surgical resection is the treatment of choice and achieves acceptable long-term survival rates. We present the surgical treatment of a patient who presented liver metastasis of a saphenous vein leiomyosarcoma. The patient is a 70-year-old woman who was surgically treated in January 2009 for a grade II leiomyosarcoma measuring 10 cm in the right inguinal region. The tumor was removed and vascular resection performed, followed by adjuvant radiotherapy at a dosage of 66 Gy in 40 sessions. In June 2010, a space-occupying lesion (SOL) was discovered in the liver that was consistent with metastasis. Abdominal computed tomography (CT) revealed a hepatic SOL that was approximately 15 mm in the right liver lobe in close proximity to the portal bifurcation. Magnetic resonance (Fig. 1) showed an SOL measuring 26 28 23 mm in segment VIII (hyperintense in sequences T2 and hypointense in sequences T1, with early peripheral enhancement and rapid central wash-out in the post-contrast study) and positron-emission tomography (PET) showed evidence of a hypermetabolic lesion measuring 3.2 cm located in segment VIII (SUVmax: 6.6) (Fig. 2). With a diagnosis of metastasis of VLMS, she was sent to our hospital for scheduled surgery. During the procedure, a 3.5 cm lesion was found resting on the portal bifurcation and proximal to the middle suprahepatic vein, and a right hepatectomy was performed. The pathology diagnosis was leiomyosarcoma metastasis with free margins. During post-op, the patient presented transient mild liver failure, which resolved with conservative treatment. She was discharged on the 8th day post-op. Leiomyosarcomas are aggressive neoplasms with a very poor prognosis compared with other soft tissue sarcomas. The vascular origin has been identified as an adverse prognostic factor that reduces both disease-free survival as well as overall patient survival. In addition, they present a high potential for metastasis, probably because of their easy dissemination through the blood, the biological aggressiveness of these tumors, and their delayed diagnosis. The mean survival of patients with liver metastases of soft tissue sarcomas that go untreated is about 14 months, while the 5-year survival is 27%– 35% after surgery. Out of the 27 cases of leiomyosarcoma of the saphenous vein described in the literature, including ours, 33% presented distant metastasis. Pulmonary involvement is the most frequent (22%) since the normal venous pathway drains through the inferior vena cava to the lung. Approximately 11% have been found in the liver (3 cases). As for the diagnosis of these lesions, the efficacy of PET has yet to be defined, although it has shown promising results in other soft-tissue sarcomas. PET and PET-CT could be especially effective for evaluating patients with previous surgical treatment in order to search for local recurrences or metastases. In spite of the different therapeutic options that are currently available to us for the treatment of metastatic disease of other origins, in the case of VLMS metastases,