Prognostic Value of Lymph Node Status for Actual Long-Term Survival in Resected Pancreatic Cancer.

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.

Pegylated interferon plus ribavirin in HIV-infected patients with recurrent hepatitis C after liver transplantation: a prospective cohort study.

BACKGROUND & AIMS: The aim of this study was to evaluate the results of treatment with pegylated interferon and ribavirin for the recurrence of hepatitis C after liver transplantation in HCV/HIV-coinfected patients. METHODS: This was a prospective, multicentre cohort study, including 78 HCV/HIV-coinfected liver transplant patients who received treatment for recurrent hepatitis C. For comparison, we included 176 matched HCV-monoinfected patients who underwent liver transplantation during the same period of time at the same centres and were treated for recurrent hepatitis C. RESULTS: Antiviral therapy was discontinued prematurely in 56% and 39% (p = 0.016), mainly because of toxicity (22% and 11%, respectively; p=0.034). Sustained virological response (SVR) was achieved in 21% of the coinfected patients and in 36% of monoinfected patients (p = 0.013). For genotype 1, SVR rates were 10% and 33% (p = 0.002), respectively; no significant differences were observed for the other genotypes. A multivariate analysis based on the whole series identified HIV-coinfection as an independent predictor of lack of SVR (OR, 0.17; 95% CI, 0.06-0.42). Other predictors of SVR were donor age, pretreatment HCV viral load, HCV genotype, and early virological response. SVR was associated with a significant improvement in survival: 5-year survival after antiviral treatment was 79% for HCV/HIV-coinfected patients with SVR vs. 43% for those without (p = 0.02) and 92% vs. 60% in HCV-monoinfected patients (p < 0.001), respectively. CONCLUSIONS: The response to pegylated interferon and ribavirin was poorer in HCV/HIV-coinfected liver recipients, particularly those with genotype 1. However, when SVR was achieved, survival of coinfected patients increased significantly.

Cavoatrial thrombectomy without the use of cardiopulmonary bypass for abdominal tumors. Our experience and state of the art.

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.

Arterial pseudoaneurysms following hepato-pancreato-biliary surgery: a single center experience.

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.

Is arterial infiltration still a criterion for unresectability in pancreatic adenocarcinoma?

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.

Alternative arterial reconstruction after extended pancreatectomy. Case report and some considerations of locally advanced pancreatic cancer.

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.

ALPPS procedure: our experience and state of the art.

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.

Switching to sirolimus monotherapy for de novo tumors after liver transplantation. A preliminary experience.

BACKGROUND/AIMS: Alcoholic cirrhosis, smoking, and use of calcineurin inhibitors (CNI) are associated with the development of de novo tumors in liver transplant (LT) recipients. Sirolimus is an immunosuppressor with antitumoral properties. METHODOLOGY: Between April 1986 and April 2007, we performed 1231 liver transplants in 1084 recipients. A total of 128 de novo tumors were observed in 116 recipients from a sample of 850 adult recipients who survived more than 2 months. This study comprises 16 LT recipients (13 male and 3 female; mean age, 45.1 +/- 11.1 years) who were switched to sirolimus monotherapy who developed de novo tumors and were switched from CNI or mycophenolate mofetil to sirolimus monotherapy. RESULTS: De novo tumors location: 2 lymphomas, 9 upper aerodigestive, 1 skin, 1 parotid, 1 lung, 1 breast, and 1 rectum. Time from LT to sirolimus monotherapy was 86 months; time taking to switching from CNI to sirolimus monotherapy was 48 days, and mean follow-up of patients on sirolimus monotherapy was 15.7 months. Thirteen patients underwent tumor resection, 5 received chemotherapy, and 5 received radiotherapy. Five patients died during the follow-up, and patient survival after diagnosis was 42.8 months. Mean dose of sirolimus was 2.7 mg/day and the mean trough level was 8.9 ng/mL. Total cholesterol and triglycerides values increased after switching. Mean serum creatinine, glucose, AST and ALT values, and haematological parameters were similar before and after switching. No patients developed acute rejection, and adverse effects were observed in 8 patients. CONCLUSIONS: Sirolimus monotherapy can be used safely to improve survival in LT recipients with de novo tumors.

Robotic Liver Surgery: Early Experience From a Single Surgical Center.

INTRODUCTION: The use of robotic surgery in liver resection is still limited. Our aim is to present our early experience of robotic liver resection. MATERIALS AND METHODS: It is a retrospective review of Sanchinarro University hospital experience of robotic liver resection performed from 2011 to 2014. Clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. RESULTS: Twenty-one procedures have been performed and 13 (65%) of them were for malignancy. There were 2 left hepatectomies, 1 right hepatectomy, 1 associated liver partition and portal vein ligation staged procedure (both steps by robotic approach), 1 bisegmentectomy and 3 segmentectomies, 9 wedge resections, and 3 pericystectomies. The mean operating time was 282 minutes (range, 90 to 540 min). Overall conversion rate and postoperative complication rate were 4.7% and 19%, respectively. The mean length of hospital stay was 13.4 days (range, 4 to 64 d). CONCLUSION: From our early experience, robotic liver surgery is a safe and feasible procedure, especially for major hepatectomies.

An intensive cultural experience in a rural area.

More well-trained mental health professionals serving rural and minority populations are needed. This article describes an intensive clinical experience for psychiatric mental health nursing graduates in the rural, culturally diverse Tri-Cities (Pasco, Richland, and Kennewick) of Washington. Before discussing the short-term learning experience and outcomes, the social history of the area is explained because of its impact on current health needs and the kinds of learning opportunities available. In addition, personal reflections of student participants are included.

Robotic versus laparoscopic rectal resection: is there any real difference? A comparative single center study.

INTRODUCTION: Robotic surgery has gained worldwide acceptance in the past decade, and several studies have shown that this technique is safe and feasible. The aim of this study is to compare main outcomes of laparoscopic and robotic rectal resection. METHODS: In total, 143 consecutive patients treated for rectal cancer in our department with laparoscopic or robotic-assisted surgery from October 2010 to July 2013 were retrospectively analyzed. RESULTS: A total of 87 patients underwent laparoscopic rectal resection, and 56 patients were treated using a robotic approach. The conversion rate was 11.5% in the laparoscopic group and 3.5% in the robotics group (P = 0.09). The low rectal cancer conversion rate was significantly lower in the robotic group (1.8%) than in the laparoscopy group (9.2%) (P = 0.04). Mean operation time was 252 min in the laparoscopic group and 309 min in the robotic group (P = 0.023). CONCLUSIONS: The robotic approach shows a lower conversion rate in low rectal cancer but with a longer operative time compared with the laparoscopic technique.

Does robotic distal pancreatectomy surgery offer similar results as laparoscopic and open approach? A comparative study from a single medical center.

INTRODUCTION: In the field of pancreatic surgery, robotic surgery has yet to be evaluated against open and laparoscopic approaches. The outcomes of robotic surgery for distal pancreatectomy were analysed and the results compared with those of laparoscopic and open procedures. METHODS: Retrospective reviews were made of 47 patients who underwent distal pancreatectomy at our institution between 2008 and 2013 with three different approaches: 16 robotic, 18 laparoscopic and 13 open surgeries. RESULTS: A significant difference was observed in blood loss in the open group (mean 3.44 units) compared with the robotic (mean 0.5 units) and laparoscopic (0 units) technique (P = 0.046). A shorter hospital stay was observed for the robotic group (8.87 days) compared with the laparoscopic (19.16 days) and open groups (20.44 days) (P = 0.035). Morbidity was lower in the robotic group (0%) compared with the Laparoscopic (44%) and Open groups (46%) (P = 0.014). CONCLUSIONS: These findings support the proposition that robotic distal pancreatectomy is as safe as the laparoscopic approach.

Giant pancreatic insulinoma. The bigger the worse? Report of two cases and literature review.

INTRODUCTION: Giant pancreatic insulinomas are rare endocrine tumors. We describe 2 cases reviewing the current literature. PRESENTATION OF CASE: We report herein 2 female patients affected by giant insulinomas of 14cm and 6cm, respectively. Symptomatic hypoglycemia episodes occurred during 4 months in first case and 3 years in the second one until diagnosis. Both patients were successfully treated performing a distal pancreatectomy with splenic preservation in the first case and a Whipple's procedure in the second one. DISCUSSION: Up to now only 7 cases have been reported previously. Insulinomas larger than 3cm accounts for less than 5% of all. This literature review shows that despite the size hypoglycemic symptoms varies from 1 day to 3 years and only 1 out of 9 cases reported presented lymph nodes metastases. No recurrences have been described. CONCLUSION: One of the cases here described (14cm) is the largest presented in the literature. Despite the size, giant insulinoma is related apparently neither to metastases nor to the recurrences.

¿Sigue representando la infiltración arterial un criterio de irresecabilidad en el carcinoma de páncreas? / Is arterial infiltration still a criterion for unresectability in pancreatic adenocarcinoma?

La resección quirúrgica representa en la actualidad la única posibilidad terapéutica para pacientes afectos de carcinoma de páncreas (CP). Procedimientos quirúrgicos agresivos han sido descritos en un intento de incrementar la resecabilidad. La resección venosa representa en la actualidad una técnica quirúrgica aceptada en centros con importante experiencia en cirugía pancreática. Por el contrario, la resección arterial en enfermos afectos de CP sigue siendo una técnica muy controvertida. La infiltración arterial en estos pacientes suele ser considerada un criterio de irresecabilidad. En los últimos años, importantes avances en la técnica quirúrgica y en el tratamiento postoperatorio de estos pacientes han permitido reducir la morbimortalidad de las resecciones pancreáticas. Por otra parte, notables mejoras en el tratamiento neoadyuvante y adyuvante así como un mayor conocimiento en la biología del tumor además de nuevas opciones diagnósticas han permitido mejorar la supervivencia. En el presente artículo, destacamos importantes puntos que un cirujano moderno debe de considerar para tratar a afectados de CP con infiltración arterial

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 centres, increasing survival. In contrast, arterial resection is still an issue of debate, continuing to be considered a general contraindication to resection. In the past few 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 tumour 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

Estupor catatónico y reflejos posturales / Catatonic stupor and postural reflexes

Partiendo de un caso en el cual el estupor catatónico puso al descubierto los reflejos posturales, a la vez que durante la kinesiterapia se hizo evidente que la movilización de la enferma era mucho más fácil en el decúbito prono o en el agua, se analiza el papel de estos factores en al confirmación del cuadro clínico catatónico. (Mientras que algunos reflejos posturales facilitan por razones filogenéticas la disposición al movimiento, el efecto antigravitatorio del agua explica, a través de la supresión parcial de la sensación de esfuerzo, la disminución del tono muscular y, con ello, el aumento de la movilidad a pesar del estupor). A continuación se ponen de relieve las consecuencias prácticas de esta observación en la prevención de complicaciones ortopédicas y de amaneramientos motores en la catonía. Finalmente se insinúan algunas consecuencias teóricas de este análisis para una teoría monista de las relaciones entre pensamiento y motórica

Punción y cateterización yugular interna: vía de Daily / Puncture and catheterization of the internal jugular vein

Se estudian en forma prospectiva 250 casos de punción y cateterización de la vena yugular interna. Se realiza una técnica novedosa por el material utilizado obteniéndose buenos resultados y demostrando ser una técnica sencilla, de alta positividad, bajo nivel de complicaciones y gastos