Rafael López Andújar

Reflexiones sobre 250 intervenciones de metástasis hepáticas de carcinoma colorrectal

Resumen Introduccion Los mejores resultados en el tratamiento de las metastasis hepaticas de carcinoma colorrectal se obtienen con la reseccion quirurgica, que debe realizarse con unos estandares de calidad. Objetivos Presentar la experiencia de 11 anos en el tratamiento quirurgico de las metastasis hepaticas de carcinoma colorrectal en una unidad de referencia y comprobar si se cumplen los estandares actuales de calidad. Pacientes y metodo Desde enero de 1995 hasta diciembre de 2005 se realizaron 250 intervenciones en 221 pacientes diagnosticados de metastasis hepaticas de origen colorrectal, con 201 resecciones hepaticas. Resultados El 19% de los pacientes tenian una edad ≥ 70 anos, con factores comorbidos asociados en el 54% de los casos. De las 201 resecciones, el 8,5% fue una segunda reseccion. En el 39% se realizo una hepatectomia mayor. La reseccion fue R0 en el 85% de los casos. No se transfundio en el 80% de los casos. La mediana de estancia postoperatoria fue de 6 dias, la mortalidad postoperatoria fue del 0% y la morbilidad, del 19%. Se relacionaron con la morbilidad el numero de segmentos resecados y la transfusion peroperatoria. Las supervivencias actuariales generales a 1, 3 y 5 anos fueron del 96, el 69 y el 52% y las supervivencias actuariales libres de enfermedad para los mismos periodos fueron del 58, el 32 y el 24%, respectivamente. Conclusiones La reseccion de las metastasis hepaticas de carcinoma colorrectal es una buena opcion terapeutica cuando se cumplen los estandares de calidad actuales.

Sarcoma indiferenciado (embrionario) de hígado del adulto: informe de un caso y revisión de la literatura médica

Resumen El sarcoma indiferenciado (embrionario) de higado (SIH) es un tumor hepatico maligno que en raras ocasiones afecta al adulto. Presentamos el caso de un varon de 40 anos de edad con SIH, tratado con cirugia y quimioterapia basada en iofosfamida y adriamicina con buenos resultados. Segun nuestros datos, solo hay 70 casos publicados en la literatura medica de pacientes adultos con SIH desde que se definio esta entidad clinicopatologica. En general, los pacientes tratados con cirugia asociada a quimioterapia obtuvieron mejores resultados que los sometidos unicamente a cirugia, si bien el pronostico de este tipo de tumores sigue siendo poco esperanzador.

Veinticinco años de colecistectomía laparoscópica en régimen ambulatorio

It is accepted by the surgical community that laparoscopic cholecystectomy (LC) is the technique of choice in the treatment of symptomatic cholelithiasis. However, more controversial is the standardization of system implementation in Ambulatory Surgery because of its different different connotations. This article aims to update the factors that influence the performance of LC in day surgery, analyzing the 25 years since its implementation, focusing on the quality and acceptance by the patient. Individualization is essential: patient selection criteria and the implementation by experienced teams in LC, are factors that ensure high guarantee of success.

Donantes de ayer y de hoy: ¿han cambiado las características de los donantes de hígado durante los últimos 15 años?

Resumen Introduccion Los cambios sociosanitarios y demograficos de nuestra poblacion y el crecimiento de las listas de pacientes en espera de un trasplante han condicionado ciertas variaciones en los criterios de seleccion de los donantes de organos. Material y metodo Estudio retrospectivo, descriptivo y comparativo de las caracteristicas de los donantes cadaver de higado utilizados en la Unidad de Trasplante Hepatico del Hospital Universitario La Fe de Valencia en 2 periodos diferentes. Distribuimos los casos en 2 grupos: grupo A, los primeros 200 donantes (entre enero de 1991 y junio de 1995) y grupo B, 200 donantes mas recientes (desde febrero de 2004 hasta diciembre de 2005). Resultados El numero de donaciones se ha incrementado desde los 18 donantes durante 1991 a los 106 en 2006. En el grupo A la edad media fue de 32,4 anos, frente a 52,3 anos del grupo B. En la serie A, la principal causa de muerte fueron los traumatismos craneoencefalicos y en el grupo B, los accidentes cerebrovasculares. El tiempo en la unidad de cuidados intensivos fue mayor en el segundo grupo, con una media de 67,2 h. En el grupo B el 17% presentaba aterosclerosis considerable de la aorta y el 29,5%, esteatosis hepatica macroscopica, frente al 5 y el 12%, respectivamente, en el grupo A. Conclusiones Actualmente, los donantes de higado son de mayor edad, presentan mas enfermedades cronicas, mueren por enfermedades cerebrovasculares, permanecen mas tiempo en cuidados intensivos y sus higados son macroscopicamente peores que los de donantes de anos anteriores.

Agenesia del lóbulo hepático derecho. ¿Dónde está la vesícula?

Resumen Las anomalidades del higado son raras. La agenesia del lobulo hepatico derecho es un hecho poco frecuente, generalmente asintomatico, que se diagnostica mediante las nuevas tecnicas de imagen o durante la cirugia. Presentamos el caso de una mujer de 51 anos con agenesia del lobulo hepatico derecho sometida a colecistectomia dificultosa por colelitiasis sintomatica. Discutimos el diagnostico y las dificultades tecnicas durante la colecistectomia cuando hay agenesia del lobulo hepatico derecho.

Impact of DAAs on liver transplantation: Major effects on the evolution of indications and results. An ELITA study based on the ELTR registry

BACKGROUND & AIMS Direct-acting antivirals (DAAs) have dramatically improved the outcome of patients with hepatitis C virus (HCV) infection including those with decompensated cirrhosis (DC). We analyzed the evolution of indications and results of liver transplantation (LT) in the past 10 years in Europe, focusing on the changes induced by the advent of DAAs. METHODS This is a cohort study based on data from the European Liver Transplant Registry (ELTR). Data of adult LTs performed between January 2007 to June 2017 for HCV, hepatitis B virus (HBV), alcohol (EtOH) and non-alcoholic steatohepatitis (NASH) were analyzed. The period was divided into different eras: interferon (IFN/RBV; 2007-2010), protease inhibitor (PI; 2011-2013) and second generation DAA (DAA; 2014-June 2017). RESULTS Out of a total number of 60,527 LTs, 36,382 were performed in patients with HCV, HBV, EtOH and NASH. The percentage of LTs due to HCV-related liver disease varied significantly over time (p <0.0001), decreasing from 22.8% in the IFN/RBV era to 17.4% in the DAA era, while those performed for NASH increased significantly (p <0.0001). In the DAA era, the percentage of LTs for HCV decreased significantly (p <0.0001) from 21.1% (first semester 2014) to 10.6% (first semester 2017). This decline was more evident in patients with DC (HCV-DC, -58.0%) than in those with hepatocellular carcinoma (HCC) associated with HCV (HCV-HCC, -41.2%). Conversely, three-year survival of LT recipients with HCV-related liver disease improved from 65.1% in the IFN/RBV era to 76.9% in the DAA era, and is now comparable to the survival of recipients with HBV infection (p = 0.3807). CONCLUSIONS In Europe, the number of LTs due to HCV infection is rapidly declining for both HCV-DC and HCV-HCC indications and post-LT survival has dramatically improved over the last three years. This is the first comprehensive study of the overall impact of DAA treatment for HCV on liver transplantation in Europe. LAY SUMMARY After the advent of direct-acting antivirals in 2014, a dramatic decline was observed in the number of liver transplants performed both in patients with decompensated cirrhosis due to hepatitis C virus (HCV), minus 60%, and in those with hepatocellular carcinoma associated with HCV, minus 41%. Furthermore, this is the first large-scale study demonstrating that the survival of liver transplant recipients with HCV-related liver disease has dramatically improved over the last three years and is now comparable to the survival of recipients with hepatitis B virus infection. The reduction in HCV-related indications for LT means that there is a greater availability of livers, at least 600 every year, which can be allocated to patients with indications other than HCV.

2018 annual report of the European Liver Transplant Registry (ELTR) - 50-year evolution of liver transplantation

The purpose of this registry study was to provide an overview of trends and results of liver transplantation (LT) in Europe from 1968 to 2016. These data on LT were collected prospectively from 169 centers from 32 countries, in the European Liver Transplant Registry (ELTR) beginning in 1968. This overview provides epidemiological data, as well as information on evolution of techniques, and outcomes in LT in Europe over more than five decades; something that cannot be obtained from only a single center experience.

Malignización de quiste de colédoco en edad adulta: una entidad poco frecuente

El quiste de vı́a biliar o quiste de colédoco es una enfermedad congénita rara, cuya incidencia varı́a de 1/50.000 a 1/2.000.000 nacidos vivos. Es más frecuente en mujeres y en paı́ses orientales, principalmente en Japón. Cerca del 40% de los casos se manifiestan tras la primera década de vida, habitualmente con dolor abdominal, asociado o no a ictericia. El hallazgo de tumoración abdominal, descrito clásicamente, es más frecuente cuando la enfermedad se manifiesta en la edad pediátrica. Paciente mujer de 35 años, sin antecedentes médicos de interés, que consultó por clı́nica de cólicos biliares sin ictericia. Analı́tica sin alteraciones. En la ecografı́a se objetivó imagen quı́stica intrahepática de 20 40 mm, con material ecogénico en su interior y áreas con detritus y litiasis, localizada en ı́ntima relación con la vesı́cula, en los segmentos 8, 5 y 4b. Se realizó estudio por colangiorresonancia magnética, que confirmó la existencia de dilatación quı́stica dependiente de la vı́a biliar (fig. 1A). La paciente se intervino con el diagnóstico de quiste de colédoco tipo V de Todani, objetivando, por ecografı́a intraoperatoria, colelitiasis y un quiste con litiasis en su interior, en los segmentos 8, 5 y 4b. Colangiografı́a transcı́stica intraoperatoria: vı́a biliar no dilatada y relleno del quiste, sin evidenciar continuidad con la vı́a derecha ni izquierda, que aparecı́an separadas del quiste (fig. 1B). Se realizó colecistectomı́a, hepatotomı́a y enucleación del quiste con CUSA, ligando 2 canalı́culos biliares dependientes de las ramas intrahepáticas derecha e izquierda, en comunicación con el quiste (fig. 2A). Se comprobó la estanqueidad de la vı́a biliar con inyección de suero por el catéter transcı́stico. El postoperatorio cursó sin complicaciones. Macroscópicamente se trataba de un quiste de 6 3 cm, multilocular, con mú ltiples formaciones calculosas de color amarillento y lı́quido verdoso en su interior. El estudio microscópico evidenció epitelio de fenotipo biliar que formaba proyecciones micropapilares, tapizadas por células con nú cleos hipercromáticos, dispuestos de forma pseudoestratificada. En algunas zonas, las citadas proyecciones papilares

Carta científicaHepatolitiasis simulando un colangiocarcinoma hiliarHepatolithiasis simulating a cholangiocarcinoma

Bile duct stenosis in the hepatic hilum is generally secondary to malignant lesions, although a small proportion is due to benign processes. This can sometimes make for a difficult preoperative differential diagnosis. Hepatolithiasis is defined as the presence of calculi located proximally to the confluence of the left and right bile ducts. This disease is endemic in the Asia-Pacific regions, where its prevalence can reach 30%–50%, but it still remains a rare disease in Western countries, where it does not exceed 2%. Both entities are related, and intrahepatic lithiasis is considered a risk factor for the development of cholangiocarcinoma. We report the case of a 63-year-old woman who had undergone cholecystectomy 20 years earlier. She was referred to our consultation due to hepatic profile alterations found on a routine analysis: gamma glutamyl transpeptidase 371 U/L (4–40 U/L), aspartate aminotransferase 62 U/L (0–35 U/l), alanine aminotransferase 145 U/L (0–35 U/L), alkaline phosphatase 264 U/L (40–140 U/L) and total bilirubin 0.96 mg/dl (0.3– 1.4 mg/dl). Abdominal ultrasound demonstrated a dilated right intrahepatic bile duct, although the cause was not able to be identified. Magnetic resonance cholangiography showed a dilated right bile duct with impaired signal in segment 8 at the right bile duct bifurcation, with contrast enhancement and thickening in the bile duct wall (Fig. 1A and B). Given the suspicion of cholangiocarcinoma, the patient was referred to our center. We continued the study by ordering computed tomography (CT) with three-phase multidetector liver study, which demonstrated dilatation of the right intrahepatic bile duct with a change in gauge of the right duct in the bifurcation of the right and left portal branches, with no clearly observed masses or lesions that would justify the stenosis (Fig. 2A). Tumor marker levels (CEA and CA 19.9) were within normal ranges. Due to the radiological findings and not being able to rule out cholangiocarcinoma, we decided to consider the process malignant and scheduled surgery for a radical oncologic resection. The procedure entailed right hepatic trisectionectomy with inclusion of segment 1, resection of the extrahepatic bile duct and lymphadenectomy of the hilar pedicle. Total liver volume was 1310 cc with a calculated remainder (left lateral segment) of 270 cc (21%). With this limited remnant, right percutaneous portal and segment 4 embolizations were used, after which an increased residual liver volume of 30% was achieved in the fourth week after the procedure. During surgery, intraoperative ultrasonography was performed, showing only evidence of the right bile duct dilatation, with good portal flow and no nodular lesions. The planned surgical technique was performed and a sample from the left bile duct margin was sent for intraoperative biopsy, the result of which was absence of malignancy. The reconstruction of biliary continuity was performed with a Roux-en-Y hepaticojejunostomy. The operative time was 325 min and did not require blood transfusion. The patient presented no complications during the postoperative period and was discharged on the 6th postoperative day. The macroscopic examination of the surgical specimen revealed the presence of 2 whitish calculus formations that were hard in consistency and completely obstructed the biliary lumen, with wall thickening. The microscopic study of the right hepatic duct demonstrated fibrous thickening of the wall with areas of erosion in the epithelium and no signs of malignancy (Fig. 2B).

Hepatolitiasis simulando un colangiocarcinoma hiliar

Bile duct stenosis in the hepatic hilum is generally secondary to malignant lesions, although a small proportion is due to benign processes. This can sometimes make for a difficult preoperative differential diagnosis. Hepatolithiasis is defined as the presence of calculi located proximally to the confluence of the left and right bile ducts. This disease is endemic in the Asia-Pacific regions, where its prevalence can reach 30%–50%, but it still remains a rare disease in Western countries, where it does not exceed 2%. Both entities are related, and intrahepatic lithiasis is considered a risk factor for the development of cholangiocarcinoma. We report the case of a 63-year-old woman who had undergone cholecystectomy 20 years earlier. She was referred to our consultation due to hepatic profile alterations found on a routine analysis: gamma glutamyl transpeptidase 371 U/L (4–40 U/L), aspartate aminotransferase 62 U/L (0–35 U/l), alanine aminotransferase 145 U/L (0–35 U/L), alkaline phosphatase 264 U/L (40–140 U/L) and total bilirubin 0.96 mg/dl (0.3– 1.4 mg/dl). Abdominal ultrasound demonstrated a dilated right intrahepatic bile duct, although the cause was not able to be identified. Magnetic resonance cholangiography showed a dilated right bile duct with impaired signal in segment 8 at the right bile duct bifurcation, with contrast enhancement and thickening in the bile duct wall (Fig. 1A and B). Given the suspicion of cholangiocarcinoma, the patient was referred to our center. We continued the study by ordering computed tomography (CT) with three-phase multidetector liver study, which demonstrated dilatation of the right intrahepatic bile duct with a change in gauge of the right duct in the bifurcation of the right and left portal branches, with no clearly observed masses or lesions that would justify the stenosis (Fig. 2A). Tumor marker levels (CEA and CA 19.9) were within normal ranges. Due to the radiological findings and not being able to rule out cholangiocarcinoma, we decided to consider the process malignant and scheduled surgery for a radical oncologic resection. The procedure entailed right hepatic trisectionectomy with inclusion of segment 1, resection of the extrahepatic bile duct and lymphadenectomy of the hilar pedicle. Total liver volume was 1310 cc with a calculated remainder (left lateral segment) of 270 cc (21%). With this limited remnant, right percutaneous portal and segment 4 embolizations were used, after which an increased residual liver volume of 30% was achieved in the fourth week after the procedure. During surgery, intraoperative ultrasonography was performed, showing only evidence of the right bile duct dilatation, with good portal flow and no nodular lesions. The planned surgical technique was performed and a sample from the left bile duct margin was sent for intraoperative biopsy, the result of which was absence of malignancy. The reconstruction of biliary continuity was performed with a Roux-en-Y hepaticojejunostomy. The operative time was 325 min and did not require blood transfusion. The patient presented no complications during the postoperative period and was discharged on the 6th postoperative day. The macroscopic examination of the surgical specimen revealed the presence of 2 whitish calculus formations that were hard in consistency and completely obstructed the biliary lumen, with wall thickening. The microscopic study of the right hepatic duct demonstrated fibrous thickening of the wall with areas of erosion in the epithelium and no signs of malignancy (Fig. 2B).