Rodrigo Sánchez Clariá

Management of Nonparasitic Hepatic Cysts

BACKGROUND The optimal management of nonparasitic hepatic cysts (NPHC) is a topic of debate. The purpose of this study was to evaluate our 17-year experience with NPHC. STUDY DESIGN From January 1990 to August 2007, 131 consecutive patients with NPHC were evaluated and treated at our institution. Seventy-eight patients (60%) had simple hepatic cysts (SHC). The remaining 53 (40%) had polycystic liver disease (PLD). Morbidity, mortality, and recurrence rates for each of the two groups were evaluated. RESULTS Thirty-seven patients underwent open deroofing (SHC, 24; PLD,13), 66 had laparoscopic deroofing (SHC, 46; PLD, 20), 19 had percutaneous drainage (SHC, 4; PLD, 15), 3 had major hepatic resections (PLD, 3), 4 had cystojejunostomy (SHC, 4), and 2 had combined hepatorenal transplantation (PLD, 2). Corresponding morbidity, mortality, and recurrence rates were, respectively: conventional deroofing: SHC, 29%, 0%, 8%; PLD, 8%, 0%, 0%; laparoscopic deroofing: SHC, 2%, 0%, 2%; PLD, 25%, 0%, 5%; percutaneous drainage: SHC, 0%, 0%, 75%; PLD, 0%, 0%, 20%; cystojejunostomy: SHC, 75%, 0%, 25%; major hepatic resections: PLD, 66%, 0%, 0%; and hepatorenal transplantation: PLD, 50%, 50%, 0%. CONCLUSIONS Laparoscopic deroofing provided complete relief of symptoms for both SHC and PLD. Percutaneous drainage was our procedure of choice for infected liver cysts and potentially for patients who cannot tolerate general anesthesia. Liver and liver-kidney transplantations were reserved for patients with end-stage PLD alone and in association with end-stage renal disease, respectively.

[Prognostic factors after resection of hepatocellular carcinoma in the non-cirrhotic liver: presentation of 51 cases].

BACKGROUND: Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients. OBJECTIVE: To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival. MATERIAL AND METHODS: Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival. RESULTS: Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis. CONCLUSIONS: Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable.

Laparoscopic resection for liver tumors: initial experience in a single center.

Background Laparoscopic liver resections are 1 of the most complex procedures in hepatobiliary surgery. During the last 20 years, laparoscopic liver surgery has had an important development in specialized centers. Objective To describe the initial experience in laparoscopic liver resection for benign and malignant tumors, to assess its indications and outcomes, and to describe technical aspects of these resections. Methods Review of the records of 28 patients who underwent laparoscopic liver resection between November 2000 and November 2007. Analysis of the data regarding preoperative management and postoperative outcomes. Results Twenty-six liver resections were performed laparoscopically (20 purely laparoscopic, 3 hand assisted, and 3 hybrid technique) and 2 were converted to open surgery. The laparoscopic approach was attempted in 6% (28 out of 459) of the liver resections carried out in the analyzed period. Indications for resection were: benign tumors in 22 patients (78%) and malignant tumors in 6 patients (22%). Resections were minor in 27 patients (96%) and major in 1 patient (4%). Pringle maneuver was performed in 14 patients (50%). Margins were negative in all the cases. Mean operative time was 170 minutes (range 70 to 350), and the mean length of stay was 3 days (range 1 to 6). Mortality rate was 0%. Only 2 patients (7%) had postoperative minor complications (self-limited bile leaks). Conclusions In selected patients with benign and malignant liver tumors, laparoscopic liver resections can be safely performed. This procedure must be carried out by the surgeons trained in both the hepatobiliary and laparoscopic surgery.

Surgical strategies for restoring liver arterial perfusion in pancreatic resections

BackgroundHepatic perfusion failure represents an important risk factor for severe complications and death after pancreatic resections. Arterial reconstruction could be required during pancreatic surgery because of tumor infiltration, benign strictures, or as a consequence of accidental arterial injury during dissection. All these situations can be faced with a certain frequency in high-volume pancreatic centers, where surgeons must be aware of the different alternatives to deal with these intricate scenarios.PurposeWe herein describe the preoperative surgical planning as well as different surgical strategies for the restoration of arterial perfusion of the liver in pancreatic resections.ConclusionA thorough preoperative evaluation is essential for planning pancreatic surgery and preparing the surgeon and patient for potentially high complex procedures. The various therapeutic alternatives presented in this technical report might represent a good solution for selected patients with no other potentially curative option than surgery.

Primary Hepatic Lymphoma: Features of a Puzzling Disease

Primary hepatic lymphoma (PHL) is a very rare liver tumor. It is described as a lymphoma localized and limited to the liver without extrahepatic involvement [1], and represents about 0.016 % of all non-Hodgkin lymphoma cases [2]. Clinical presentation is nonspecific. As other lymphoproliferative diseases usually presents with constitutional symptoms, and B symptoms often appear (fever, weight loss, and night sweats). It frequently mimics other hepatic tumors, there so diagnosis becomes difficult and is often made intraor postoperatively. Treatment is controversial regarding surgical and chemotherapy indications [3, 4]. Due to its prevalence, there are no controlled studies, and the recommendations made are based on case reports or series of limited amount of patients. We present a case of a PHL, which despite the multiple diagnostic methods implemented, definitive diagnosis was made after surgery and histological analysis of the lesion.

Protocol for extended antibiotic therapy after laparoscopic cholecystectomy for acute calculous cholecystitis (Cholecystectomy Antibiotic Randomised Trial, CHART)

Introduction Acute calculous cholecystitis represents one of the most common complications of cholelithiasis. While laparoscopic cholecystectomy is the standard treatment in mild and moderate forms, the need for antibiotic therapy after surgery remains undefined. The aim of the randomised controlled Cholecystectomy Antibiotic Randomised Trial (CHART) is therefore to assess if there are benefits in the use of postoperative antibiotics in patients with mild or moderate acute cholecystitis in whom a laparoscopic cholecystectomy is performed. Methods and analysis A single-centre, double-blind, randomised trial. After screening for eligibility and informed consent, 300 patients admitted for acute calculus cholecystitis will be randomised into two groups of treatment, either receiving amoxicillin/clavulanic acid or placebo for 5 consecutive days. Postoperative evaluation will take place during the first 30 days. Postoperative infectious complications are the primary end point. Secondary end points are length of hospital stay, readmissions, need of reintervention (percutaneous or surgical reinterventions) and overall mortality. The results of this trial will provide strong evidence to either support or abandon the use of antibiotics after surgery, impacting directly in the incidence of adverse events associated with the use of antibiotics, the emergence of bacterial resistance and treatment costs. Ethics and dissemination This study and informed consent sheets have been approved by the Research Projects Evaluating Committee (CEPI) of Hospital Italiano de Buenos Aires (protocol N° 2111). Results The results of the trial will be reported in a peer-reviewed publication. Trial registration number NCT02057679.

Extended antibiotic therapy versus placebo after laparoscopic cholecystectomy for mild and moderate acute calculous cholecystitis: A randomized double-blind clinical trial

Background: Acute calculous cholecystitis (ACC) is the most common complication of cholelithiasis. Laparoscopic cholecystectomy (LC) is the gold standard treatment in mild and moderate forms. Currently there is consensus for the use of antibiotics in the preoperative phase of ACC. However, the need for antibiotic therapy after surgery remains undefined with a low level of scientific evidence. Methods: The CHART (Cholecystectomy Antibiotic Randomised Trial) study is a single‐center, prospective, double blind, and randomized trial. Patients with mild to moderate ACC operated by LC were randomly assigned to receive antibiotic (amoxicillin/clavulanic acid) or placebo treatment for 5 consecutive days. The primary endpoint was postoperative infectious complications. Secondary endpoints were as follows: (1) duration of hospital stay, (2) readmissions, (3) reintervention, and (4) overall mortality. Results: In the per‐protocol analysis, 6 of 104 patients (5.8%) in the placebo arm and 6 of 91 patients (6.6%) in the antibiotic arm developed postoperative infectious complications (absolute difference 0.82 (95% confidence interval, −5.96 to 7.61, P = .81). The median hospital stay was 3 days. There was no mortality. There were no differences regarding readmissions and reoperations between the 2 groups. Conclusion: Although this trial failed to show noninferiority of postoperative placebo compared to antibiotic treatment after LC for mild and moderate ACC within a noninferiority margin of 5%, the use of antibiotics in the postoperative period does not seem justified, because it was not associated with a decrease in the incidence of infectious and other types of morbidity in the present study.

Use of radiotherapy in patients with palliative double bypass for locally advanced pancreatic adenocarcinoma

Purpose Pancreatic cancer (PC) has not changed overall survival in recent years despite therapeutic efforts. Surgery with curative intent has shown the best long-term oncological results. However, 80%–85% of patients with these tumors are unresectable at the time of diagnosis. In those patients, first therapeutic attempts are minimally invasive or surgical procedures to alleviate symptoms. The addition of radiotherapy (RT) to standard chemotherapy, ergo chemoradiation, in patients with locally advanced pancreatic cancer (LAPC) is still controversial. The study aims to compare outcomes in patients with a double bypass surgery due to LAPC treated or not with RT. Materials and Methods A retrospective cohort study of patients with double bypass for LAPC were registered and divided into two groups: treated or not with postoperative RT. Baseline characteristics, postoperative complications, those related to RT and their relation to the main event (mortality) were compared. Results Seventy-four patients were included. Surgical complications between the groups did not offer significant differences. Complications related to RT were mostly mild, and 86% of patients completed the treatment. Overall survival at 1 and 2 years for patients in the exposed group was 64% and 35% vs. 50% and 28% in the non-exposed group, respectively (p = 0.11; power 72%; hazard ratio = 0.53; 95% confidence interval, 0.24–1.18). Conclusion We observed a tendency for survival improvement in patients with postoperative RT. However, we’ve not had enough power to demonstrate this difference, possibly due to the small sample size. It is indispensable to develop randomized and prospective trials to guide more specific treatment lines in this patients.

Intraductal Papillary Neoplasm of the Bile Duct (IPNB): Case Report and Literature Review of a Challenging Disease to Diagnose

Intraductal papillary neoplasm of the bile duct (IPNB) is defined as a bile duct epithelial tumor characterized by papillary proliferation within the bile duct lumen [1, 2]. It has been established as a precursor lesion towards cholangiocarcinoma and includes previous categories of premalignant biliary lesions. There are certain morphological features of these tumors, especially intraductal papillary growth pattern, that are similar to IPMN of the páncreas. Opposed to cystic mucinous tumors, the IPNB shows communication with the biliary tract and no ovarian like stroma (OLS) in the pathology findings [3]. IPNB develops through the adenoma-carcinoma sequence and usually progresses slowly compared to classic intrahepatic bile duct carcinoma [1, 3, 4]. An invasive component is present in approximately 40–80% of reported cases [5]. These tumors can originate from anywhere along the biliary tree, including intrahepatic and extrahepatic bile ducts. The main clinical features are intermittent abdominal pain, acute cholangitis, and jaundice but in some patients IPNB remain asymptomatic for a long period of time [3–5]. Due to the unusual presentation of IPNB, its identification represents a diagnostic challenge. Given the malignant potencial, surgical resection with adequate margins is the standard treatment. In this case report, we describe the cytologic, histopathologic, clinical features, and surgical treatment of IPNB with invasive adenocarcinoma in a 72-year old male patient.

Intrahepatic cholangiojejunostomy for complex biliary stenosis after pediatric living‐donor liver transplantation

The treatment of biliary stenosis after pediatric LDLT is challenging. We describe an innovative technique of peripheral IHCJ for the treatment of patients with complex biliary stenosis after pediatric LDLT in whom percutaneous treatment failed. During surgery, the percutaneous biliary drainage is removed and a flexible metal stylet is introduced trough the tract. Subsequently, the most superficial aspect of the biliary tree is recognized by palpation of the stylets round tip in the liver surface. The liver parenchyma is then transected until the bile duct is reached. A side‐to‐side anastomosis to the previous Roux‐en‐Y limb is performed over a silicone stent. Among 328 pediatric liver transplants performed between 1988 and 2015, 26 patients developed biliary stenosis. From nine patients requiring surgery, three patients who had received left lateral grafts from living‐related donors due to biliary atresia were successfully treated with IHCJ. After a mean of 45.6 months, all patients are alive with normal liver morphological and function tests. The presented technique was a feasible and safe surgical option to treat selected pediatric recipients with complex biliary stenosis in whom percutaneous procedures or rehepaticojejunostomy were not possible, allowing complete resolution of cholestasis and thus avoiding liver retransplantation.