Unnoticed biloma due to liver puncture after Veress needle insertion.

Laparoscopic surgery has become more widespread in the last years. Creating the pneumoperitoneum is the first surgical procedure but it is still responsible for many of the adverse events described in this field. Until now, liver puncture producing a delayed biloma has not been described. We present a case where a biloma was developed after liver puncture by the Veress needle, during a laparoscopic procedure, and detected on the 3rd day. It was detected by CT scan and treated by laparoscopy. Biloma due to Veress needle is a new entity in the context of adverse events related to Veress needle insertion, which needs a high suspicious index. We recommend to do Palmer's test and to check the insertion and to look for possible lesions below with the camera in order to minimize incidence of such injuries. Should this happen, laparoscopic or percutaneous drainage are both suitable alternatives to solve this complication.

A multidisciplinary approach for peritoneal carcinomatosis and bilobar liver metastases from colorectal cancer: case report and review of the literature.

BACKGROUND: Peritoneal carcinomatosis develops in 15% of patients with primary colorectal cancer (CRC) and in 25% of those with recurrence. Liver metastases are also frequent and appear at some time in 35-55% of patients with CRC. When both conditions are present and treated palliatively, the expected median survival is 5-6 months. Recent publications suggest survival is improved when R0 resection of both peritoneal and liver diseases is achieved. CASE PRESENTATION: A 36-year-old woman with synchronous peritoneal and liver metastases of colorectal origin was treated with a stepwise approach consisting of initial cytoreductive surgery, minor liver resection, intraperitoneal intraoperative hyperthermic chemotherapy, adjuvant chemotherapy, right portal embolization, and finally, right hepatectomy achieving an R0 resection. The patient is alive and free of disease after 30 months of follow-up. DISCUSSION: Patients with peritoneal carcinomatosis and liver metastases from CRC must be carefully evaluated by multidisciplinary oncological teams in order to offer the possibility of surgery to obtain an R0 resection in selected patients (especially if the peritoneal cancer index is <19 and there is resectable or potentially resectable metastatic liver disease).

Multiple nodal locoregional recurrence of pheochromocytoma.

INTRODUCTION: Malignancy is present in 10% of pheochromocytomas (PCC) and is defined as local/vascular infiltration of surrounding tissues or the presence of chromaffin cells deposits in distant organs. The presence of isolated nodal recurrence is very rare and only 7 cases have been reported in the medical literature. PRESENTATION OF THE CASE: The case of a 32-y male with a symptomatic recurrence of a previously operated (2-years ago) PCC is presented. Radiological and functional imaging studies confirmed the presence of multiple nodules in the surgical site. A radical left nephrectomy with extensive lymphatic clearance in order to get an R0 resection was performed. The pathologist confirmed the diagnosis of massive locoregional nodal invasion. DISCUSSION: A detailed histological report and a thorough genetic study must be considered in every operated PCC in order to identify mutations and profiles of risk for malignancy. When recurrence or metastastic disease is suspected, imaging and functional exams are done in order to obtain a proper staging. Radical surgery for the metastatic disease is the only treatment that may provide prolonged survival. If an R0 resection is not possible, then a debulking surgery is a good option when the benefit/risk ratio is acceptable. CONCLUSION: Isolated lymph nodal recurrence is very rare in malignant PCC, with only 7 cases previously published. The role of surgery is essential to get long-term survival because provides clinical and functional control of the disease.

Thyroid metastasis as initial presentation of clear cell renal carcinoma.

INTRODUCTION: Metastatic tumors account for 1.4-2.5% of thyroid malignancies. About 25-30% of patients with clear cell renal carcinoma (CCRC) have distant metastasis at the time of diagnosis, being the thyroid gland a rare localization [5%]. PRESENTATION OF THE CASE: A 62-year woman who underwent a cervical ultrasonography and a PAAF biopsy reporting atypical follicular proliferation with a few intranuclear vacuoles "suggestive" of thyroid papillary cancer in the context of a multinodular goiter was reported. A total thyroidectomy was performed and the histology of a clear cell renal carcinoma (CCRC) was described in four nodules of the thyroid gland. A CT scan was performed and a renal giant right tumor was found. The patient underwent an eventful radical right nephrectomy and the diagnosis of CCRC was confirmed. DISCUSSION: Thyroid metastasis (TM) from CCRC are usually apparent in a metachronic context during the follow-up of a treated primary (even many years after) but may sometimes be present at the same time than the primary renal tumor. Our case is exceptional because the TM was the first evidence of the CCRC, which was subsequently diagnosed and treated. CONCLUSION: The possibility of finding of an incidental metastatic tumor in the thyroid gland from a previous unknown and non-diganosed primary (as CCRC in our case was) is rare and account only for less than 1% of malignancies. Nonetheless, the thyroid gland is a frequent site of metastasis and the presence of "de novo" thyroid nodules in oncologic patients must be always considered and studied.

Laparoscopic approach of primary bladder endometriosis.

OBJECTIVE: To report a case of primary bladder endometriosis treated with laparoscopic partial cystectomy. METHODS: We report the case of a 38 year old woman presenting with cyclic catamenial pain and hematuria who was diagnosed of bladder endometriosis by means of cystoscopy and MRI. Partial cystectomy using a laparoscopic approach was performed and symptoms disappeared. RESULTS: We report a well-documented case of primary bladder endometriosis and the laparoscopic approach used for its treatment. A review of the concept and the therapeutic alternatives are presented. CONCLUSIONS: Bladder endometriosis must be in mind when cyclic catamenial symptoms of pain and hematuria are present. When diagnosed, the laparoscopic approach must be considered the preferential option.

[Diverticulectomy and cricopharyngeal myotomy for the treatment of Zenker's diverticulum. a presentation of 33 cases]. / Diverticulectomía y miotomía del cricofarígeo para el tratamiento del divertículo de Zenker. Presentación de una serie de 33 casos.

INTRODUCTION: The classic treatment of Zenker's diverticulum (ZD) has been cricopharyngeal myotomy (CPM), with the need or not to resect it being argued (diverticulectomy versus diverticulopexy). However, the advance of endoscopic techniques requires new treatment strategies to be established. We analyse the complications and clinical results of our series with cricopharyngeal myotomy and diverticulectomy in patients with ZD. METHOD: A retrospective, observational and descriptive study was conducted on 33 patients who, between January 1998 and December 2010, had a diverticulectomy and CPM performed in the university hospitals Virgen del Rocío in Seville and Carlos Haya in Malaga. Demographic and operative variables that might be associated with morbidity were analyzed. RESULTS: Seventeen patients were treated in the Carlos Haya Hospital, Málaga and sixteen in the Virgen del Rocío Hospital, Seville. Although there were no deaths, the morbidity rate of the series was 27% (9 cases), all associated with an oesophageal-cutaneous fistula. None of the variables studied were significantly associated with the appearance of morbidity. None of the patients had a clinical or radiological recurrence of ZD after a mean follow up of 44 months (range, 6 -192). CONCLUSIONS: Diverticulectomy combined with CPM is a good technique for the treatment of ZD, with excellent clinical and functional results in the medium to long term, despite the high morbidity in the form of an oesophageal-cutaneous fistula.

Outpatient laparoscopic adrenalectomy: a new step ahead.

BACKGROUND: The feasibility of performing laparoscopic adrenalectomy (LA) as an outpatient procedure in selected patients in the context of a specialized unit has been assessed in this study. METHODS: Retrospective cohort of 22 patients who underwent LA without hospital admission under strict selection criteria within a specific laparoscopic surgery unit of a tertiary hospital center has been reported. Patient demographics, indications for surgery, operative data, outpatient management, morbidity, and immediate follow-up have been analyzed. RESULTS: The mean age of the patients was 50.9 years (median 52.5, range 28-65) and 13 (59.1%) were women. All patients underwent successful LA and none of them required conversion to laparotomy. The mean length of the procedure was 56.6 min (median 60, range 15-120 min) and no patient required transfusion. The most common indications for surgery were adrenal incidentaloma and primary hyperaldosteronism (36.4% each). Three patients accurately complied with the MAS regimen and the other 19 spent the night on a DC basis and were discharged with the hospital stay being less than 23 h. No patient required readmission and relevant events occurred only in three patients. With regard to postoperative pain management, only six patients (27.27%) required more than 1 week of analgesics. In 68.1% of the cases, resuming physical and professional activity took less than 2 weeks and only three patients required more than 1 month before restoring a "normal life." CONCLUSION: By applying strict protocol and selection criteria, LA can be safely and successfully performed as an outpatient procedure within an experienced laparoscopic unit.

[Development and evolution of laparoscopic adrenalectomy in an specialized team: from the beginning to the outpatient setting]. / Desarrollo y evolución de la suprarrenalectomía laparoscópica en una unidad especializada: de los casos iniciales al hospital de día.

BACKGROUND: After the first reports in 1992, laparoscopic adrenalectomy (LA) has evolved technically until becoming the standard approach for the treatment of most of the adrenal gland diseases. MATERIAL AND METHODS: Retrospective and descriptive study of 67 patients who underwent 68 LA between January-1998 and December-2008 in the Laparoscopic Surgery Unit of the General and Digestive Surgery Service in a third level hospital (only one case of bilateral LA). The group was divided in 2 periods, P-1 (1998-2003, 22 cases) and P-2 (2004-2008, 45 cases), which have been compared to evaluate the evolution of the LA technique. RESULTS: Indications for LA were: 19 incidentalomas, 19 primary hyperaldosteronism, 18 pheocromocitoms, 5 cases of symptomatic and non-functioning adrenal masses, 4 Cushing adenomas and 2 metastases. There was no mortality, only 4 patients had minor complications (6%) and conversion rate was only 3% (2 cases). Mean size of adrenal glands resected was 3.83 cm and the mean operative time was 86 minutes. Mean postoperative hospital stay was 3 days and in P-2 seventeen patients were discharged on an outpatient basis (hospital stay less than 23 hours). CONCLUSIONS: In our experience, LA for the treatment of adrenal diseases has shown to be safe, effective and reproducible with low complications and excellent tolerance by patients. When the learning curve is overcome, hospital stay and operative time clearly decrease. As a consequence, LA can be planned in selected cases as outpatient surgery with good results.

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

[Detection of neoplastic lesions in cirrhotic patients waiting for liver transplantation]. / Detección de lesiones neoplásicas en pacientes cirróticos candidatos a trasplante hepático.

INTRODUCTION: Hepatocellular carcinoma is a frequent complication of cirrhosis. Liver transplantation is a valid therapeutic option for this disease providing that certain morphologic selection criteria (Milan criteria) are fulfilled. OBJECTIVE: To evaluate the accuracy of pretransplantation imaging examinations in the detection and characterization of neoplastic lesions in cirrhotic candidates for liver transplantation. PATIENTS AND METHOD: We performed a retrospective study of 250 cirrhotic patients who underwent liver transplantation. The preoperative radiological diagnosis was compared with the definitive pathological diagnosis, allowing the diagnostic sensitivity of the different techniques, as well as the degree of agreement between pre- and postoperative tumoral staging, to be identified. RESULTS: Analysis of 250 specimens from total hepatectomy identified 58 patients with hepatic tumors, with a total of 136 nodules. Fifty-three patients had hepatocarcinoma, nine of which were found incidentally. There were six radiological false positive diagnoses. Sixty-two percent of patients with hepatocarcinoma had multiple lesions. The most sensitive technique for the diagnosis of tumors smaller than 1 cm was magnetic resonance imaging. Agreement between pre- and postoperative staging was found in only 63.6% of cases; consequently, 43% of the patients who exceeded the Milan criteria (20% stage T3 and 23% stage T4a) underwent transplantation. CONCLUSIONS: Currently used imaging techniques lead to a substantial proportion of incorrect stagings in terms of the size and number of lesions in cirrhotic patients.

[Pancreatic transplantation. Results of the Málaga group]. / Trasplante de páncreas: resultados del grupo Málaga.

INTRODUCTION: Pancreatic transplantation is currently the only therapeutic alternative able to restore normal blood glucose levels in diabetic patients. Moreover, this procedure can halt or even reverse diabetes-related complications. The aim of this study was to present our experience and the results of the first 4 years of a pancreatic transplantation program in our center. MATERIAL AND METHOD: From February 2000 to June 2004, 43 pancreatic transplantations were performed in 42 recipients in the Carlos Haya Regional Hospital in Malaga (Spain). In all patients, the technique of enteric drainage of exocrine pancreatic secretions and systemic venous shunting of endocrine secretions (to the inferior vena cava) was used. RESULTS: There were 37 (88.1%) simultaneous pancreas-kidney transplantations, 4 (9.5%) in patients with prior kidney transplantation and 1 retransplantation (2.4%). In all patients, glycosylated hemoglobin and C-peptide levels returned to normal. Patient and pancreatic graft survival were 91% and 84%, respectively, with a median follow-up of 19 months. The reintervation rate was 31%, with an overall rate of graft loss of 16%. CONCLUSIONS: The results obtained in our series are similar to those reported for large series.

Cytoreductive surgery and intraoperative intraperitoneal hyperthermic chemotherapy in patients with peritoneal carcinomatosis of colorectal origin.

The median survival in patients with peritoneal carcinomatosis from colorectal adenocarcinoma is,with conventional approaches, only about six months. Combined treatment consisting of maxi-mum cytoreductive surgery plus intraoperative intraperitoneal hyperthermic chemotherapy has been shown, albeit in small non-comparative series, to increase disease-free survival and overall survival, compared with previous series. Further, a randomized trial has demonstrated better results (a median survival of 22.4 months) with cytoreduction plus intraperitoneal chemotherapy compared with conventional chemotherapy. Technical considerations, infrastructure requirements and possible complications imply specialized centres and staff. Surgery consists of peritonectomy of affected areas and fulguration of all macroscopic lesions. Intraperitoneal chemotherapy must reach all parts of the peritoneal cavity and the temperature of the hyperthermic procedure must be maintained between 42-44 degrees C. Three prognostic factors associated with this procedure are: pathologic tumour grade, peritoneal carcinomatosis index, and cytoreductive surgery grade.

[Adrenal carcinoma: 7 year disease free survival after complete primary tumor resection and repeated resection of local-regional and distant recurrences. Review after one case with poor initial life expectancy]. / Carcinoma suprarrenal: supervivencia a 7 años libre de enfermedad tras resección completa del tumor primario y resecciones repetidas de recidivas locorregional y a distancia. Revisión a raiz de un caso con una pobre esperanza de vida inicial.

OBJECTIVES: We report the case of a female patient with adrenal carcinoma who had undergone surgery and presented with local-regional and distant recurrences, emphasizing the importance of the aggressive surgical treatment to achieve long-term survival which is unexpected sometimes. Currently, it represents the gold standard and all cases should be reported to stimulate other groups to work in this line. METHODS/RESULTS: We report the case of a 29-year-old female patient who consulted for left flank pain, being diagnosed of an adrenal tumor by radiological tests; she underwent surgical excision of a left adrenal carcinoma (stage II). Later on she presented with local-regional recurrences (2 times) and distant metastases (liver) undergoing excision in three procedures. Currently, the patient is alive and free of disease 7 years after diagnosis. CONCLUSIONS: Adrenal cancer recurrences have been considered lethal in the short-term. Nevertheless, an aggressive surgical approach of local recurrences and metastasic disease may significantly prolong patient's survival and, sometimes, leave the patient disease free several years after the diagnosis of the primary tumor.

Calibrated portacaval H-graft shunt in variceal hemorrhage. Long-term results.

BACKGROUND/AIMS: To analyze the long-term outcome of the calibrated portacaval shunt in the treatment of portal hypertension. METHODOLOGY: Between 1991 and 1996 we undertook a prospective non-randomized study, including 37 cirrhotic patients who underwent small diameter portacaval shunt with polytetrafluoroethylene H-graft, 24 cases with 8 mm and 13 cases with 10 mm. Early and late complications, and survival were analyzed. RESULTS: Overall, 28 corresponded to Child-Pugh class A, 5 to class B and 4 to class C. The cause of cirrhosis was alcoholic in 16 cases, postnecrotic in 12, mixed in 5, primary biliary cirrhosis in 2 and unknown in 1. Postoperative mortality was 10%. Long-term results, after a follow-up of 3-8 years, have shown a rebleeding rate of 12%, mainly after the third postoperative year. Some degree of encephalopathy occurred in 23% of the patients, but in no case was this chronic or incapacitating. The rate of early thrombosis was 5%, but in all cases it was repermeabilized with local thrombolysis. The late thrombosis rate was 6%. The 3-, 5- and 7-year survival rates were 79%, 57%, and 36%, respectively. These rates were not statistically related with the shunt diameter or the etiology of the cirrhosis. CONCLUSIONS: Partial portacaval shunt is a safe option for the treatment of variceal bleeding due to portal hypertension. We consider it to be the treatment of choice in a selected group of cirrhotic patients with well-preserved liver function, after previous failure of medical therapy. Furthermore, it can also be used as a bridge until liver transplantation.