RESUMO
BACKGROUND: The watch-and-wait (WW) strategy is a potential option for patients with rectal cancer who obtain a complete clinic response after neoadjuvant therapy. The aim of this study is to analyze the long-term oncological outcomes and perform a cost-effectiveness analysis in patients undergoing this strategy for rectal cancer. MATERIAL AND METHODS: The data of patients treated with the WW strategy were prospectively collected from January 2015 to January 2020. A control group was created, matched 1:1 from a pool of 480 patients undergoing total mesorectal excision. An independent company carried out the financial analysis. Clinical and oncological outcomes were analyzed in both groups. Outcome parameters included surgical and follow-up costs, quality-adjusted life years (QALYs), and the incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). RESULTS: Forty patients were included in the WW group, with 40 patients in the surgical group. During a median follow-up period of 36 months, metastasis-free survival (MFS) and overall survival (OS) were similar in the two groups. In the WW group, nine (22%) local regrowths were detected in the first 2 years. The permanent stoma rate was slightly higher after salvage surgery in the WW group compared to the surgical group (48.5% vs 20%, p < 0.01). The cost-effectiveness analysis was slightly better for the WW group, especially for low rectal cancer compared to medium-high rectal cancer (ICER = - 108,642.1 vs ICER = - 42,423). CONCLUSIONS: The WW strategy in locally advanced rectal cancer offers similar oncological outcomes with respect to the surgical group and excellent results in quality of life and cost outcomes, especially for low rectal cancer. Nonetheless, the complex surgical field during salvage surgery can lead to a high permanent stoma rate; therefore, the careful selection of patients is mandatory.
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Análise de Custo-Efetividade , Neoplasias Retais , Humanos , Qualidade de Vida , Neoplasias Retais/cirurgia , Reto , Indução de Remissão , Terapia Neoadjuvante , Conduta Expectante/métodos , Recidiva Local de Neoplasia , Resultado do Tratamento , QuimiorradioterapiaRESUMO
BACKGROUND: Thanks to the introduction of radiomics, 3d reconstruction can be able to analyse tissues and recognise true hypertrophy from non-functioning tissue in patients treated with major hepatectomies with hepatic modulation.The aim of this study is to evaluate the performance of 3D Imaging Modelling in predict liver failure. METHODS: Patients submitted to major hepatectomies after hepatic modulation at Sanchinarro University Hospital from May 2015 to October 2019 were analysed. Three-dimensional reconstruction was realised before and after surgical treatment. The volumetry of Future Liver Remnant was calculated, distinguishing in Functional Future Liver Remnant (FRFx) i.e. true hypertrophy tissue and Anatomic Future Liver Remnant (FRL) i.e. hypertrophy plus no functional tissue (oedema/congestion) These volumes were analysed in patients with and without post hepatic liver failure. RESULTS: Twenty-four procedures were realised (11 ALPPS and 13 PVE followed by major hepatectomy). Post hepatic liver failure grade B and C occurred in 6 patients. The ROC curve showed a better AUC for FRFxV (74%) with respect to FRLV (54%) in prediction PHLF > B. The increase of anatomical FRL (iFRL) was superior in the ALPPS group (120%) with respect to the PVE group (73%) (p = 0,041), while the increase of functional FRFX (iFRFx) was 35% in the ALLPS group and 46% in the PVE group (p > 0,05), showing no difference in the two groups. CONCLUSION: The 3D reconstruction model can allow optimal surgical planning, and through the use of specific algorithms, can contribute to differential functioning liver parenchyma of the FLR.
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Embolização Terapêutica , Falência Hepática , Neoplasias Hepáticas , Humanos , Hepatectomia/métodos , Estudos Retrospectivos , Imageamento Tridimensional , Neoplasias Hepáticas/cirurgia , Veia Porta/cirurgia , Fígado/diagnóstico por imagem , Fígado/cirurgia , Falência Hepática/etiologia , Falência Hepática/cirurgia , Hipertrofia , Embolização Terapêutica/métodos , Resultado do TratamentoRESUMO
Cancer is first a localized tissue disorder, whose soluble and exosomal molecules and invasive cells induce a host response providing the stromal components of the primary tumor microenvironment (TME). Once the TME is developed, cancer-derived molecules and cells can more efficiently spread out and a whole-body response takes place, whose pathophysiological changes may result in a paraneoplastic syndrome. Remote organ-specific prometastatic reactions may also occur at this time, facilitating metastatic activities of circulating tumor cells (CTCs) through premetastatic niche development at targeted organs. However, additional signaling factors from the inter-organ communication network involved in the pathophysiology and comorbidities of cancer patients may also regulate prometastatic reaction-stimulating effects of cancer and non-cancer tissue factors. This article provides a conceptual overview of our ongoing clinical research on the liver prometastatic reaction (LPR) of patients with colorectal cancer (CRC), their portal vein- and hepatic artery-driven LPR-Stimulating Factors (LPR-SF), and their resulting LPR-derived Metastasis-Stimulating Factors (LPR-MSF) acting on liver-invading CRC cells. In addition, we also provide new insights on the molecular subtyping of LPR-responsive cancer phenotypes in patients with CRC and melanoma; and on how to investigate and interpret the prometastatic infrastructure in the real pathophysiological context of patients with cancer undergoing surgical procedures and receiving pharmacological treatments with multiple side effects, including those affecting the LPR, its stimulating factors and responsive cancer phenotypes.
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Neoplasias Hepáticas/secundário , Recidiva Local de Neoplasia/patologia , Células Neoplásicas Circulantes/patologia , Fenótipo , Microambiente Tumoral , Animais , HumanosRESUMO
BACKGROUND: This meta-analysis aims to investigate the role of complete mesocolic excision (CME) in the treatment of right-side colon cancer when compared with standard right-side hemicolectomy, focusing on oncological outcomes, mortality and morbidity rates. MATERIALS AND METHODS: A systematic literature search was performed on MEDLINE and EMBASE archives, including studies on CME in right-side colon cancer. Primary outcomes were five-year disease-free survival and five-year overall survival. Secondary outcomes investigated were mortality and morbidity rates, intraoperative blood loss, anastomotic leakage, postoperative ileus, day of postoperative flatus, pulmonary infection, duration of hospital stay and number of lymph nodes harvested. RESULTS: Seventeen studies have been included in this meta-analysis for a total of 3918 patients. The five-year disease-free survival (DFS) and overall survival (OS) results improved in the CME group with respect to conventional right-side colectomy with an OR 1.88 (95% CI 1.02-3.45) and OR 2.77 (95% CI 1.33-5.74), respectively. The incidence of mortality and morbidity was comparable between the two groups. Moreover, conventional surgery time was faster than CME (MD 33.69 min, 95% CI 12.79-54.59), while no significant differences were reported in mean blood loss and hospital stay. Furthermore, the CME group showed a higher mean number of harvested lymph nodes (MD 7.08 lymph nodes 95% CI 4.90-9.27). CONCLUSION: Complete mesocolic excision of the right-side colectomy improves oncological outcomes without increasing mortality and morbidity rates compared to standard right-side hemicolectomy. CME should therefore be routinely performed in the treatment of right-side colon cancer.
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Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Humanos , Excisão de Linfonodo , Mesocolo/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The prognostic factors for long-term survival after curative resection of pancreatic adenocarcinoma are still poorly understood. The purpose of this study was to identify the prognostic factors of long-term survival after resection of pancreatic adenocarcinoma based on actual 5-year survival including different lymph node status classifications. METHOD: A total of 106 patients who underwent pancreatectomy were enrolled at our institution and retrospectively analyzed according to actual survival (> vs < 5 years), as well as several currently available node classifications: N0/N1, N0/N1/N2, and lymph-node ratio (LNR) including multivariate logistic regression. RESULTS: The actual 5-year overall survival rate of the series was 12.26%. In a univariate analysis, operative blood loss and blood transfusion, completion of adjuvant treatment, histological differentiation, perineural invasion, N0/N1, N0/N1/N2 and LNR were significant predictive factors for actual long-term survival. A multivariate analysis showed that only N0/N1 was an independent predictive factor for actual 5-year survival (OR: 1.593; 0.730-1.325; p= 0.264). CONCLUSION: The nodal involved status is the strongest independent unfavorable factor for actual long-term survival after pancreatic resection for adenocarcinoma.
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Adenocarcinoma , Neoplasias Pancreáticas , Adenocarcinoma/cirurgia , Humanos , Linfonodos/cirurgia , Metástase Linfática , Estadiamento de Neoplasias , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
HVH (hepatic vascular hamartoma) is a tumor like malformation arising from the vascular tissue of the liver. HVH has been previously reported in animals and presents distintive features from the most frequent benign tumor like malformation of the liver, the hepatic mesenchymal hamartoma (HMH). Herein we report a case of HVH localized in hepatic segment 4b, involving the gastro hepatic ligament, successfully treated with total excision. We describe the anatomo-pathologic findings focusing on the clinical and radiological presentation, the intraoperative characteristics and the differential diagnosis.
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Hamartoma/diagnóstico , Hepatopatias/diagnóstico , Fígado/irrigação sanguínea , Biópsia , Diagnóstico Diferencial , Feminino , Hamartoma/cirurgia , Hepatectomia , Humanos , Fígado/diagnóstico por imagem , Hepatopatias/cirurgia , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Pancreas divisum is a congenital embryological disease caused by a lack of fusion between the ventral and dorsal pancreatic ducts in the early stages of embryogenesis. Recurrent acute pancreatitis, chronic pancreatitis or chronic abdominal pain are the main clinical syndromes at presentation and occur in only 5% of the patients with pancreas divisum. This review aimed to discuss diagnosis and treatment strategies in patients with symptomatic pancreas divisum. DATA SOURCES: We report a literature review from 1990 up to January 2018 to explore the various diagnostic modalities and surgical techniques and results reported in the surgical treatment of pancreas divisum. RESULTS: There are limited reports available on this topic in the literature. We analyzed and described the main indications in the treatment of pancreas divisum, focusing on surgical treatment and a discussion of the different approaches. Furthermore, we report the results from our experience in two cases of pancreas divisum treated by pancreatic head resection with segmental duodenectomy (the Nakao procedure). CONCLUSIONS: Pancreas divisum is a common pancreatic malformation in which only a few patients develop a symptomatic disease. Surgical treatment is needed in case of endoscopic drainage failure and in cases complicated with chronic pancreatitis and local complications. Many techniques, of greater or lesser complexity, have been proposed.
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Colangiopancreatografia Retrógrada Endoscópica , Anormalidades do Sistema Digestório/diagnóstico por imagem , Anormalidades do Sistema Digestório/cirurgia , Pancreatectomia , Ductos Pancreáticos/diagnóstico por imagem , Ductos Pancreáticos/cirurgia , Pancreaticoduodenectomia , Dor Abdominal/etiologia , Adulto , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Dor Crônica/etiologia , Anormalidades do Sistema Digestório/complicações , Drenagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatectomia/efeitos adversos , Ductos Pancreáticos/anormalidades , Pancreaticoduodenectomia/efeitos adversos , Pancreatite Crônica/etiologia , Recidiva , Resultado do TratamentoRESUMO
INTRODUCTION: Locally advanced pancreatic cancer (LAPC) is a highly malignant carcinoma with an extremely poor prognosis. Vascular venous invasion is a frequent finding in patients with pancreatic cancer. The aim of this study was to investigate the morbidity, mortality, and survival of patients with advanced pancreatic cancer. METHODS: We retrospectively reviewed our experience of 65 consecutive pancreatic surgeries with venous resection for pancreatic cancer in three hospitals: Ramon y Cajal (Madrid, Spain) from 2002 to 2004, Monteprincipe University Hospital (Madrid, Spain) from 2005 to 2006 and Sanchinarro University Hospital (Madrid, Spain) from 2007 to December 2017. Prognostic factors were analyzed by the log-rank test and a multivariate proportional hazard regression analysis. RESULTS: Major venous reconstruction was performed by primary lateral venorrhaphy in 11 patients (17%), primary end-to-end anastomosis in 46 (70.7%) and reconstruction with a Gore-Tex® patch (W.L. Gore & Associates, Inc., Flagstaff, AZ) in 8 (12.3%). In 58% of the patients, the pathological examination showed infiltration of the vascular specimen. About 85% of the procedures performed were R0. The perioperative morbidity rate with Dindo-Clavien classification = III was 21.5%. Tumor size and nodal status were the only prognostic variables, which significantly decreased survival by a multivariate analysis. CONCLUSIONS: Major vascular resection to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. Nevertheless, it is justified only in carefully selected cases.
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Pancreatectomia , Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/irrigação sanguínea , Neoplasias Pancreáticas/cirurgia , Prognóstico , Estudos RetrospectivosRESUMO
OBJECTIVE: The aim of this study is to compare the clinical and cost-effective outcomes of the open Lichtenstein repair (OL) and laparoscopic trans-abdominal preperitoneal (TAPP) repair for bilateral inguinal hernias. SUMMARY BACKGROUND DATA: A cost-effective analysis of laparoscopic versus open inguinal hernia repair is still not well addressed, especially regarding bilateral hernia. METHODS: This is a clinical and cost-effectiveness analysis within a randomized prospective study conducted at Sanchinarro University Hospital.Cases of primary, reducible bilateral inguinal hernia were included and randomized using a simple randomization program.The outcome parameters included surgical and postoperative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio. RESULTS: Between March 2013 and January 2017, 165 patients were enrolled in this study (81 of them underwent TAPP and 84 OL).The TAPP procedure had less early postoperative pain (P = 0.037), a shorter length of stay (P = 0.001), and fewer postoperative complications (P = 0.002) when compared with the OL approach. The overall cost of TAPP procedure was higher compared with the OL cost (1,683.93&OV0556; vs 1192.83&OV0556;, P = 0.027). The mean QALYs at 1 year for TAPP (0.8094) was higher than that associated with OL (0.6765) (P = 0.018). At a willingness-to-pay threshold of 20,000 &OV0556; and 30,000 &OV0556;, there was a 95.38% and 97.96% probability that TAPP was more cost-effective relative to OL. CONCLUSIONS: The TAPP procedure for bilateral inguinal hernia appears to be more cost-effective compared with OL.
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Análise Custo-Benefício , Hérnia Inguinal/cirurgia , Herniorrafia/economia , Herniorrafia/métodos , Laparoscopia/economia , Laparoscopia/métodos , Avaliação de Processos e Resultados em Cuidados de Saúde , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Espanha/epidemiologiaRESUMO
BACKGROUND: Hepatic resection of tumors invading the retrohepatic vena cava and hepatic veins are a challenge for surgeons, who consider them unresectable most of the time.1 , 2 Ex situ hepatectomy and liver autotransplantation has developed to improve resectability of these malignancies.3,4 METHODS: The patient was a 51-year-old man who had jaundice secondary to a intrahepatic cholangiocarcinoma 7 cm in diameter in the right lobe of the liver and the caudate lobe. A volumetric scan showed a future liver remnant (segments 2 and 3) not sufficient according to the body weight. The patient was considered to be unresectable by conventional resection due to the critical invasion to the retrohepatic vena cava together with the three hepatic veins. Therefore, an ex vivo extended right hepatectomy and autotransplantation were indicated. RESULTS: The patient underwent biliary decompression through a percutaneous transhepatic catheter and right portal vein embolization for left lobe hypertrophy. During the surgery, the liver was removed with the retrohepatic vena cava, which was replaced by a prosthetic graft without a veno-venous bypass. Ex vivo extended right hepatectomy was performed, and a prosthetic graft was used to replace the vena cava where the remaining left hepatic vein was anastomosed. The surgery duration was 9 h, and the anhepatic time was 4.5 h. The postoperative hospital stay was 19 days, and at this writing, 3 years later, the patient is disease-free. CONCLUSION: Ex vivo hepatectomy without veno-venous bypass should be considered a valid therapeutic option for selected patients with cholangiocarcinoma invading the retrohepatic vena cava.
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Neoplasias dos Ductos Biliares/cirurgia , Colangiocarcinoma/cirurgia , Hepatectomia , Neoplasias Hepáticas/cirurgia , Transplante de Fígado , Neoplasias dos Ductos Biliares/patologia , Colangiocarcinoma/patologia , Humanos , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Transplante AutólogoRESUMO
The radio-guided occult lesion localization (ROLL) technique has been in use since the mid-1990s, mainly in breast surgery. Today, ROLL is used for numerous oncologic pathologies, including parathyroid lesions, melanomas, and colorectal tumors. We report a patient with an 11-mm left mesorectal solitary recurrence of a primary ovarian cancer in whom the ROLL technique was used to identify the implant. A radioisotope was introduced through a 22-gauge needle with endoscopic ultrasound technique using an linear echo endoscope. On the day of surgery, the patient's perianal region was scanned with a gamma probe to identify the area of maximal radioactivity, to determine the optimal placement of the incision over the lesion. After macroscopic excision of the lesion, radioactivity was measured in the lesion bed to ensure complete removal of affected tissues. In our case, the ROLL technique was performed safely for the detection and excision of a recurrent lesion of difficult identification. To our knowledge, this is the first reported case involving use of the ROLL technique to aid the excision of a mesorectal lesion.
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Adenocarcinoma/cirurgia , Procedimentos Cirúrgicos em Ginecologia/métodos , Neoplasias Ovarianas/cirurgia , Traçadores Radioativos , Radiografia Intervencionista/métodos , Neoplasias Retais/cirurgia , Ultrassonografia de Intervenção/métodos , Adenocarcinoma/patologia , Idoso , Procedimentos Cirúrgicos de Citorredução/métodos , Feminino , Humanos , Neoplasias Ovarianas/patologia , Neoplasias Retais/secundário , Agregado de Albumina Marcado com Tecnécio Tc 99mRESUMO
BACKGROUND: Minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. In fact, the indication for robotic surgery in pancreatic disease has been controversial. The present study aimed to assess the safety and feasibility of robotic pancreatic resection. METHODS: We retrospectively reviewed our experience of robotic pancreatic resection done in Sanchinarro University Hospital. Clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. RESULTS: From October 2010 to April 2016, 50 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 50 patients, 26 were male and 24 female. The average age of all patients was 62 years. Operative time was 370 minutes. Among the procedures performed were 16 pancreaticoduodenectomies (PD), 23 distal pan-createctomies (DP), 11 tumor enucleations (TE). The mean hospital stay was 17.6 days in PD group, 9.0 days in DP group and 8.4 days in TE group. Pancreatic fistula occurred in 10 cases (20%), 2 after PD, 3 after DP, and 5 after TE. Four patients had postoperative transfusion in PD group and one in DP group. Conversion to open laparotomy occurred in four patients (8%). No serious intraoperative complications were observed. CONCLUSIONS: From our early experience, robotic pancreatic surgery is a safe and feasible procedure. Further experience and follow-up are required to confirm the role of robotic approach in pancreatic surgery.
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Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Pancreatite Crônica/cirurgia , Procedimentos Cirúrgicos Robóticos , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Hospitais com Alto Volume de Atendimentos , Hospitais Universitários , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/diagnóstico , Pancreaticoduodenectomia/efeitos adversos , Pancreatite Crônica/diagnóstico , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Espanha , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Surgical resection of a tumor with thrombus formation extending from the inferior vena cava (IVC) to the right atrium can be performed without the use of a cardiopulmonary bypass. However, this technique is not widely known or used by general surgeons. Our aim was to present our experience in a general surgical unit setting and to present a literature review. METHODS: Retrospective analysis of 3 cases with successful cavoatrial thrombectomy without the use of cardiopulmonary bypass by a transabdominal, transdiaphragmatic, and transpericardic approach. We also performed a review of the English literature of this procedure. RESULTS: Three cases are presented: right-sided hepatocellular carcinoma, a right renal carcinoma, and a recurrent hepatic hydatid cyst all which required surgery. An approach from the right atrium to the IVC was used, and then, after cavoatrial occlusion, a cavotomy was performed to carry out the thrombectomy. In all cases, a transesophageal echocardiography was performed during surgery. We only found 6 other similar cases that were performed successfully in current medical literature. CONCLUSIONS: Our own experiences and cases identified through a literature review demonstrate that a thrombectomy for IVC thrombus in the setting of abdominal pathology can be performed successfully in selected cases without the support of cardiopulmonary bypass.
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Carcinoma Hepatocelular/complicações , Procedimentos Cirúrgicos Cardíacos/métodos , Átrios do Coração/cirurgia , Cardiopatias/cirurgia , Neoplasias Hepáticas/complicações , Trombectomia/métodos , Trombose/cirurgia , Idoso , Carcinoma Hepatocelular/cirurgia , Ponte Cardiopulmonar , Feminino , Cardiopatias/diagnóstico , Cardiopatias/etiologia , Hepatectomia , Humanos , Neoplasias Hepáticas/cirurgia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Trombose/diagnóstico , Trombose/etiologia , Veia Cava Inferior/cirurgiaRESUMO
CONTEXT: Arterial pseudoaneurysm is an uncommon lethal complication following hepato-pancreato-biliary surgery. OBJECTIVE: Aim of this study is to present and discuss the experience of a high volume oncological center. METHODS: Since 2007 all major surgeries performed at Sanchinarro Oncological Center have been included in a prospective database looking for postoperative arterial pseudonaurysm. RESULTS: Until June 2014, among 559 hepato-pancreato-biliary procedures, a total of 14 arterial pseudoaneurysms have been identified (2.5%). Sentinel bleeding was in 57% of cases. Failed arterial embolization occurred in 2 cases. Overall mortality rate was 28.5%. We also identified 3 asymptomatic pseudoaneurysms, one of them managed without embolization, developing a sudden bleeding and died after surgery. CONCLUSIONS: According to our experience, pseudoaneurysm incidence is higher than reported in current literature and it can be successfully managed through arterial embolization. Furthermore, we found 3 asymptomatic pseudoaneurysms, whose management is still controversial.
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As surgical resection remains the only hope for cure in pancreatic cancer (PC), more aggressive surgical approaches have been advocated to increase resection rates. Venous resection demonstrated to be a feasible technique in experienced centers, increasing survival. In contrast, arterial resection is still an issue of debate, continuing to be considered a general contraindication to resection. In the last years there have been significant advances in surgical techniques and postoperative management which have dramatically reduced mortality and morbidity of major pancreatic resections. Furthermore, advances in multimodal neo-adjuvant and adjuvant treatments, as well as the better understanding of tumor biology and new diagnostic options have increased overall survival. In this article we highlight some of the important points that a modern pancreatic surgeon should take into account in the management of PC with arterial involvement in light of the recent advances.
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Adenocarcinoma/patologia , Neoplasias Pancreáticas/patologia , Neoplasias Vasculares/patologia , Adenocarcinoma/cirurgia , Artérias , Artéria Celíaca , Artéria Hepática , Humanos , Artéria Mesentérica Superior , Invasividade Neoplásica , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgiaRESUMO
Cholecystectomy-related iatrogenic biliary injuries cause intricate postoperative complications that can significantly affect a patient's life, often leading to chronic liver disease and biliary stenosis. These patients require a multidisciplinary approach with intervention from radiologists, endoscopists and surgeons experienced in hepatobiliary reconstruction. Symptoms vary from none to jaundice, pruritus and ascending cholangitis. The best strategy for the management of biliary stricture is based on optimal preoperative planning. Our patient presented 1 year after an iatrogenic lesion was induced during a cholecystectomy, and was managed with a complex common bile duct reconstruction through a Roux-en-Y hepaticojejunostomy. The three-dimensional (3D) model reconstruction of the biliary tract was pivotal in the planning of the patient's surgery, providing additional preoperative and intraoperative assistance throughout the procedure. The 3D model's description of detailed spatial relations between the bile duct and the vascular structure in the liver hilum enabled a correct surgical dissection and safe execution of the anastomosis.
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Colecistectomia , Complicações Pós-Operatórias , Humanos , Anastomose em-Y de Roux , Colecistectomia/efeitos adversos , Colecistectomia/métodos , Colestase/cirurgia , Colestase/etiologia , Constrição Patológica/cirurgia , Doença Iatrogênica , Imageamento Tridimensional , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/cirurgiaRESUMO
Introduction: Hepatocellular carcinoma (HCC) is an aggressive solid tumor associated with high mortality. Surgery is the main treatment consideration for early disease, but patients who present with locally advanced or metastatic HCC at diagnosis have limited treatment options. There has been great progress in locoregional, immunotherapy, and targeted treatments for advanced HCC. Standard of care for HCC has changed due to results demonstrating safety and efficacy in phase 3 studies, namely, for atezolizumab concomitant with bevacizumab. Nonetheless, additional therapeutic approaches are still warranted to further increase overall survival in HCC. A first-in-class treatment option investigated in patients with HCC is Tumor Treating Fields (TTFields) therapy, which is delivered locoregionally to the tumor site from a portable medical device. TTFields are electric fields that interfere with critical cancer cell processes, hindering tumor progression. Case Presentation: Here, we report on a case study of a 62-year-old male patient with HCC receiving TTFields concomitant with sorafenib as second-line therapy. Although the patient experienced adverse events with previous nivolumab, they achieved a complete response and continued on treatment for 51 months until disease progression, which led to treatment cessation. We report that during 39 months of subsequent treatment with TTFields therapy and sorafenib, the patient experienced a good quality of life, low systemic toxicity, and stable disease following a partial response. Conclusions: These promising findings, along with those of the pilot phase 2 HEPANOVA clinical study, warrant further investigation of TTFields therapy in HCC.
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INTRODUCTION: Surgery is the standard treatment for pancreatic neuroendocrine tumors (pNETs), obtaining favorable results but associating high morbidity and mortality rates. This study assesses stereotactic body radiation therapy (SBRT) as a radical approach for small (< 2 cm) nonfunctioning pNETs. MATERIALS AND METHODS: From January 2017 to June 2023, 20 patients with small pNETs underwent SBRT in an IRB-approved study. Endpoints included local control, tolerance, progression-free survival, and overall survival (OS). Diagnostic assessments comprised endoscopy, CT scans, OctreScan or PET-Dotatoc, abdominal MRI, and histological confirmatory samples. RESULTS: In a 30-month follow-up of 20 patients (median age 55.5 years), SBRT was well-tolerated with no grade > 2 toxicity. 40% showed morphological response, 55% remained stable. Metabolically, 50% achieved significant improvement. With a median OS of 41.5 months, all patients were alive without local or distant progression or need for surgical resection. CONCLUSION: SBRT is a feasible and well-tolerated approach for small neuroendocrine pancreatic tumors, demonstrating effective local control. Further investigations are vital for validation and extension of these findings.
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CONTEXT: The clinical benefits of distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer remains controversial and, therefore, declared unresectable in most cases. Appleby first described extended distal pancreatectomy with celiac axis resection for locally advanced gastric cancer. CASE REPORT: We report a case of a 65-year-old female who presented a locally advanced pancreatic carcinoma with infiltration of celiac axis. After radio-chemo neoadjuvant treatment, the patient underwent exploratory laparoscopy and subsequent distal pancreatectomy with en bloc resection of celiac axis. Arterial reconstruction was necessary as hepatic flow was not adequate, determined by intraoperative Doppler ultrasonography. It consisted of end to end anastomosis with prosthetic graft between hepatic artery directly to the aorta, as an atheromatous plaque was at the origin of the celiac axis. The postoperative course was uneventful with a perfect relief of pain. She presents a long term survival of 36 months, very exceptional for this type of disease. CONCLUSION: The particularity of this case is not only the surgical treatment, rarely offered to these patients, but also and especially the subsequent vascular reconstruction. To our knowledge, this is the first report of this type of arterial reconstruction. Besides, we briefly discuss the recent advances in results of extended distal pancreatectomy with arterial resection for locally advanced pancreatic carcinoma.
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Artérias/cirurgia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Idoso , Artéria Celíaca/cirurgia , Feminino , Artéria Hepática/cirurgia , Humanos , Neoplasias Pancreáticas/patologia , Procedimentos de Cirurgia Plástica/métodos , Resultado do TratamentoRESUMO
BACKGROUND/AIMS: The majority of the time extended liver resections cannot be realized because of an insufficient future remnant liver. Baumgart suggests recently combining liver partition and portal vein section for staged hepatectomy, named ALPPS procedure. Our aim is to share our initial experience with ALPPS procedure and to perform the first comprehensive English literature review. METHODOLOGY: From January 2011 until June 2013, 6 patients underwent ALPPS, performing 6 extended right hepatectomies (one with concomitant right colectomy, one with main biliary duct resection). RESULTS: The present series showed a mean of 110% volume hypertrophy of the future remnant liver achieved with a mean of 15.3 days after ALPPS. One patient experienced severe liver failure, one had biliary leak and one died for postoperative respiratory distress syndrome. After a mean followup of 16.2 months (range 2-30 months) one patient had liver recurrence. In an English literature search, we identified 18 publications describing a mean hypertrophy rate of 85%, a mean morbidity and mortality rate of 35% and 6%, respectively. CONCLUSIONS: ALPPS is an effective technique used to induce an increased and rapid growth of the future remnant liver, but at the price of a higher morbidity and mortality compared with other conventional procedures.