Intrahepatic cholangiocarcinoma surgery: the impact of lymphadenectomy.

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignant tumor and its incidence is increasing over the world. At present times, radical liver resection is still the most effective treatment for ICC patients to achieve long term survival. Pathological lymph node metastases (LMN), found in 15% to 45% of the patients, have been recognized as an extremely poor prognostic risk factor, even if curative resection is performed. So, considering this issue, it acquires relevance to determine the validity of surgical resection for LNM cases that are diagnosed in the preoperative setting, or whether a routine lymphadenectomy should be performed systematically in all hepatectomies for ICC. The role of routine lymphadenectomy in the surgical treatment of ICC remains controversial, with some centers considering it standard whereas other surgeons perform lymphadenectomy only as a selective indication. Recently, a growing widespread adoption of lymphadenectomy was demonstrated that nearly doubled its commonly reported execution rate. The newly updated eight edition of the American Joint Committee on Cancer (AJCC) staging system now recommends that six nodes need to be analyzed to stage patients with ICC. In this review, we analyzed and summarized some anatomic considerations of the lymphatic anatomy of the liver and the current knowledge and potential advantages of performing a routine lymphadenectomy in patients with ICC, especially looking at pathological staging, prognosis, prevention of local recurrence and outcome. New areas like lymphadenectomy in cirrhotic patients and laparoscopic lymphadenectomy are also discussed.

Improved waiting-list outcomes in Argentina after the adoption of a model for end-stage liver disease-based liver allocation policy.

In July 2005, Argentina became the first country after the United States to introduce the Model for End-Stage Liver Disease (MELD) for organ allocation. In this study, we investigated waiting-list (WL) outcomes (n = 3272) and post-liver transplantation (LT) survival in 2 consecutive periods of 5 years before and after the implementation of a MELD-based allocation policy. Data were obtained from the database of the national institute for organ allocation in Argentina. After the adoption of the MELD system, there were significant reductions in WL mortality [28.5% versus 21.9%, P < 0.001, hazard ratio (HR) = 1.57, 95% confidence interval (CI) = 1.37-1.81] and total dropout rates (38.6% versus 29.1%, P < 0.001, HR = 1.31, 95% CI = 1.16-1.48) despite significantly less LT accessibility (57.4% versus 50.7%, P < 0.001, HR = 1.53, 95% CI = 1.39-1.68). The annual number of deaths per 1000 patient-years at risk decreased from 273 in 2005 to 173 in 2010, and the number of LT procedures per 1000 patient-years at risk decreased from 564 to 422. MELD and Model for End-Stage Liver Disease-Sodium scores were excellent predictors of 3-month WL mortality with c statistics of 0.828 and 0.857, respectively (P < 0.001). No difference was observed in 1-year posttransplant survival between the 2 periods (81.1% versus 81.3%). Although patients with a MELD score > 30 had lower posttransplant survival, the global accuracy of the score for predicting outcomes was poor, as indicated by a c statistic of only 0.523. Patients with granted MELD exceptions (158 for hepatocellular carcinoma and 52 for other reasons) had significantly higher access to LT (80.4%) in comparison with nonexception patients with equivalent listing priority (MELD score = 18-25; 54.6%, P < 0.001, HR = 0.49, 95% CI = 0.40-0.61). In conclusion, the adoption of the MELD model in Argentina has resulted in improved liver organ allocation without compromising posttransplant survival.

Relevance of residual disease after liver resection for incidental gallbladder cancer.

OBJECTIVES: In patients diagnosed with incidental gallbladder cancer (GC), the benefit and optimal extent of further surgery remain unclear. The aims of this study were to analyse outcomes in patients who underwent liver resection following a diagnosis of incidental GC and to determine factors associated with longterm survival. METHODS: A retrospective analysis of patients diagnosed with incidental GC between June 1999 and June 2010 was performed. Data covering demographics, clinical and surgical characteristics and local pathological stage were analysed. RESULTS: A total of 24 patients were identified. All patients underwent a resection of segments IVb and V and lymphadenectomy. Histological examination revealed residual disease in 10 patients, all of whom presented with recurrent disease at 3-12 months. Overall 5-year survival was 53%. Increasing T-stage (P < 0.001), tumour-node-metastasis (TNM) stage (P= 0.003), and the presence of residual tumour in the resected liver (P < 0.001) were all associated with worse survival. CONCLUSIONS: Aggressive re-resection of incidental GC offers the only chance for cure, but its efficacy depends on the extent of disease found at the time of repeat surgery. The presence of residual disease correlated strongly with T-stage and was the most relevant prognostic factor for survival in patients treated with curative resection.

Caroli's disease: report of surgical options and long-term outcome of patients treated in Argentina. Multicenter study.

BACKGROUND: Caroli's disease (CD) management is still controversial. AIM: The purpose of this study is to report the most frequent clinical features, treatment options, and outcome obtained after surgical management of CD. METHODS: A voluntary survey was conducted. Demographic, clinical, surgical, and pathological variables were analyzed. RESULTS: Six centers included 24 patients having received surgical treatment from 1991 to 2009. Seventeen (70.8%) patients were female, with average age of 48.7 years old (20-71), and 95.5% were symptomatic. There was left hemiliver involvement in 75% of the patients. Surgical procedures included nine left lateral sectionectomies, eight left hepatectomies, and four right hepatectomies for those with hemiliver disease, while for patients with bilateral disease, one right hepatectomy and two Roux-en-Y hepaticojejunostomies were performed. The average length of hospitalization was 7 days. For perioperative complications (25%), three patients presented minor complications (types 1-2), while major complications occurred in three patients (type 3a). No mortality was reported. After a median follow-up of 166 months, all patients are alive and free of symptoms. CD diagnosis was confirmed by histology. Congenital hepatic fibrosis was present in two patients (8.3%) and cholangiocarcinoma in one (4.2%). CONCLUSIONS: CD in Argentina is more common in females with left hemiliver involvement. Surgical resection is the best curative option in unilateral disease, providing long-term survival free of symptoms and complications. In selected cases of bilateral disease without parenchymal involvement, hepaticojejunostomy should be proposed. However, a close follow-up is mandatory because patients might progress and a transplant should be indicated.

Evidence of oxidative stress in familial amyloidotic polyneuropathy type 1.

OBJECTIVE: To evaluate the oxidative state in patients with familial amyloidotic polyneuropathy type 1 (FAP1). DESIGN: From 3 unrelated families, patients with FAP1 carrying a transthyretin Met-30 mutation were studied. The diagnosis was confirmed by genetic analysis. Eleven of 21 patients carried the mutation; all were symptomatic and were clinically assessed using a clinical score. All of the patients were evaluated for copper-zinc superoxide dismutase type 1 activity in red blood cells using spectrophotometry. Plasma total reactive antioxidant potential was studied using a chemiluminescent method. The results were compared with those obtained from an age-matched control group. SETTING: A public and academic multidisciplinary research clinic. RESULTS: Six of the 11 FAP1-positive patients disclosed superoxide dismutase type 1 activity values greater than 55 U/mg of protein (upper control limit), whereas 9 of 10 patients in whom total reactive antioxidant potential was measured had values below the lower limit of the control group. No relationship was found between the levels of superoxide dismutase type 1 activity and the severity of the clinical involvement. CONCLUSIONS: Oxidative stress may be part of the mechanisms leading to tissue damage in patients with FAP1. The lack of correlation between the laboratory findings and the severity of clinical involvement may signal that oxidative processes are at work throughout the natural history of the disease.

Trasplante hepático en el hospital público / Liver transplantation in public hospital

Objetivo: Analizar la factibilidad de desarrollo de un Programa de Trasplante con los medios disponibles en un hospital público y mostrar los resultados obtenidos tras la evaluación de 1244 pacientes y la realización de 423 trasplantes de hígado, señalando las dificultades existentes en el momento actual. Lugar de aplicación: Hospitales públicos de alta complejidad. Diseño: Estudio longitudinal, retrospectivo, descriptivo, clínico. Población: Pacientes adultos y pediátricos tratados con trasplante hepático. Método: Tras una primera etapa de cirugía experimental, de estructuración edilicia y de incorporación y capacitación profesional se inició la etapa clínica. Hasta mayo del 2001 se evaluaron 1244 pacientes (688 adultos y 556 pediátricos). Resultados: Se realizaron 423 trasplantes hepáticos en 385 pacientes. El tipo de injerto utilizado fue hígado entero en 257 (61 por ciento), hígado reducido en 101 (24 por ciento), bipartición hepática "split" en 28 (6 por ciento) y donante vivo relacionado en 37 (9 por ciento). El índice de retrasplante fue del 8,9 por ciento, la falla primaria del injerto del 2,1 por ciento y la supervivencia global al año del 79,2 por ciento. Conclusiones: Se ha demostrado la factibilidad de la inserción de dos programas de trasplante hepático en hospitales públicos de distintas características. La necesidad de su existencia queda demostrada en el alto número de pacientes evaluados. Su operatividad, actividad y resultados no difieren con los de otras instituciones de referencia. El crecimiento de los programas de trasplante debe acompañarse de las modificaciones institucionales, estructurales y administrativas necesarias que permitan su total desarrollo

Variantes anatómicas de la arteria hepática: la importancia de su reconocimiento en la cirugía digestiva / Anatomic variants of the hepatic artery: importance for the digestive surgery

Objetivo: describir las variantes anatómicas de la arteria hepática, resaltar su importancia en la cirugía digestiva y sugerir pautas para su reconocimiento tanto pre como intraoperatorio. Lugar de aplicación: dos hospitales públicos de alta complejidad. Diseño: longitudinal, retrospectivo, descriptivo. Población: 414 hígados para ser implantados en receptores de Trasplante Hepático, 374 fueron obtenidos de donante cadavéricos y 40 segmentados laterales izquierdo de donante vivo relacionado. Método: se disecaron y clasificaron de acuerdo a su disposición anatómica (según la clasificación propuesta por Michels y modificada por Hiatt) todas las arterias hepáticas de 374 hígados obtenidos de donante cadavérico y 40 de donante vivo relacionado. Resultados: encontramos un 70,7 por ciento de variantes tipo I (distribución normal), 10,6 por ciento tipo II (rama izquierda de la coronaria estomáquica), 7 por ciento tipo III (rama derecha de la Mesentérica superior), 4,8 por ciento tipo IV (triple arteria), 2 por ciento tipo V (hepática común de Mesentérica), 0,8 por ciento tipo VI (hepática común directa de aorta) y 4 por ciento otras variantes no clasificadas. Conclusión: las variantes anatómicas de la arteria hepática son más frecuentes de lo que uno puede esperar y rondan entre el 25 y 40 por ciento. Es importante su estudio preoperatorio y su reconocimiento intraquirúrgico para evitar lesiones de alguna de sus ramas que deriven en consecuencias graves e irreversibles tanto sobre la vía biliar como el hígado

Efecto sobre el hígado del bloqueo linfático durante la peritonitis experimental / Histologycal lesions in the liver with a lymphatic blockade during experimental peritonitis

Se analizan las lesiones histológicas del hígado durante la fase temprana de la peritonitis experimental en ratas, empleando un modelo de lenta progresión consistente en la punción cecal. Se compararon las lesiones degenerativas hepáticas en dos grupos con y sin bloqueo del drenaje linfático de la cavidad peritoneal. Se observó un incremento de las lesiones degenerativas (acumulación lipídica intracitoplasmática) en el grupo de animales con bloqueo linfático

Trasplante de hígado con donantes de 50 o más años de edad / Liver transplantation fron donors fiftieth years

Se presenta un estudio comparativo entre higados de donantes mayores y menores de 50 años de edad, realizado desde el 1 de enero al 31 de diciembre de 1989. Se estudio la función hepática, la sobrevida del injerto, del paciente y el porcentaje de retrasplante en ambos grupos. Los resultados indican que no debe usarse la edad como único criterio de exclusión de donantes de hígado.

Evaluación de la vía de absorción linfática durante peritonitis experimentales / Evaluation of lymphatic absortion during experimental peritonitis

Se evaluó la vía linfática de absorción de toxinas durante peritonitis experimentales. Durante la 1a parte de la investigación se controló la cantidad de absorción por vía linfática del Tc 99 en ratas con y sin bloqueo del peritoneo subdiafragmático. En la 2a parte se comprobó la absorción linfática con y sin bloqueo subdiafragmático bajo condiciones de sepsis abdominal en un modelo de asa ileal aislada y desvascularizada. En la 1a parte se observó una disminución significativa de la absorción del radioisótopo en los animales con bloqueo, poniendo de manifiesto la importancia de esta vía. En la 2a parte las diferencias de absorción no fueron significativas probablemente debidos a la hipovalemia en la 1a etapa de la sepsis abdominal. Se destaca el importante rol de la vía linfática subdiafragmática y del conducto torácico en la absorción y transporte de endotoxinas en la sepsis.

Evaluación por gammagrafía de la permeabilidad peritoneal durante peritonitis experimentales / Evaluation by scintigraphy of peritoneal absortion during experimental peritonitis

Se evalúan las variaciones de la permeabilidad del peritoneo de la rata durante las primeras horas de una peritonitis y se determina la función de la heparina en la absorción peritoneal, inyectando Tc 99 en la cavidad y midiendo con gamma cámara la reactividad residual a las 12 hs. No se observaron diferencias estadísticamente significativas entre el grupo control y los con peritonitis y con peritonitis más heparina. La distribución y captación del Tc 99 fue uniforme, excepto en 3 animales del grupo de peritonitis sin heparina que mostraron menor captación en un área de la región inferior del abdómen. Se observó una importante exudación en la cavidad peritoneal al parecer superior a la absorción. Se puede deducir que las endotoxinas bacterianas se incorporarían lenta y progresivamente a través de la membrana, cumpliendo en la sepsis un rol secundario durante las primeras horas de una peritonitis.