PROGNOSTIC FACTORS IN PATIENTS WITH SURGICAL RESECTION OF PANCREATIC NEUROENDOCRINE TUMOURS.

CONTEXT: Pancreatic neuroendocrine tumours (PanNETs) are rare pancreatic neoplasms. PanNETs can be treated by multimodal approach including surgery, locoregional and systemic therapy. OBJECTIVE: The aim of the present study is to evaluate predictive factors of overall survival in patients with PanNETs surgically treated at a single center. SUBJECTS AND METHODS: The study group consisted of 120 patients with PanNETs who had undergone surgery at the Center of Digestive Diseases and Liver Transplantation of Fundeni Clinical Institute, Bucharest, Romania. Surgical resection of the primary tumor was performed in 110 patients. RESULTS: Tumor size > 2 cm (p=0.048) (90% CI) lymph node involvement (p=0.048), ENET grade (p<0.001), distant metastases (p<0.001), Ki 67 index (<2%, 2-5%, 5-10%, 10-20%, >20%) (p<0.001) were identified as significant prognostic factors for OS on univariate analysis. Using multivariate Cox proportional regression model we found that distant metastases and Ki 67 index were independent risk factors for the survival outcome. CONCLUSIONS: Surgery with curative intent should be considered in all cases if clinically appropriate and technically feasible. High grade (Ki67 index ≥10%) tumours were associated with a 2- fold increase in risk of death as compared to those with a Ki67 <10%.

Multiple visceral resection after locoregional recurrence of signet ring cell gastric cancer -- case report and literature review.

Recurrence is the most important cause of treatment failure in patients with advanced gastric cancer, even after curative surgery. Surgery plays an important role in these patients,even in cases of multivisceral involvement. In selected cases good biological resources - surgery is the only viable choice to prolong survival. This report describes the case of a 41 year-old patient presenting a locoregional recurrence with multiple visceral involvement at 15 months after radical subtotal gastrectomy with D2 lymph node dissection for antral gastric cancer.

A case report of pancreatic transection by blunt abdominal trauma.

Posttraumatic pancreatic rupture is associated with high morbidity and mortality. Various management strategies are described, but due to the relative rarity of this pathology no standards exist. We reported a 21 years old male with post traumatic complete rupture of the pancreatic isthmus,devascularization lesion of descending duodenum, right renal artery posttraumatic thrombosis and left lobe of the liver laceration. Laparotomy for hemostasis was initially performed in a different hospital and the patient was then referred to us.Pancreaticoduodenectomy and right nephrectomy were performed. Postoperatively the patient had a pancreaticojejunal anastomosis fistula spontaneously resolved at 45 days.Pancreaticoduodenectomy can in selected cases be a solution in pancreatic trauma.

Technical aspects of biliary reconstruction correlated with biliary complications in 46 consecutive right lobe liver transplantations from living donors.

INTRODUCTION: Biliary complications contribute to a high morbidity rate in patients with right lobe liver transplant from a living donor. We retrospectively evaluated biliary reconstructions and complications in a number of recipients with liver transplant from a living donor, in a single center. PATIENTS AND METHODS: A number of 46 patients (23 males and 23 females aged 9-63) received a right lobe liver graft between 2009 and 2013, with the following types of biliary reconstruction:duct-to-duct choledochocholedochal anastomosis (n=24)or Roux-en-Y hepaticojejunoanastomosis, with or without an external transanastomotic biliary stent. RESULTS: The rate of biliary complications (leakage 15.21%,anastomotic stenosis 4.34%, overall 17.39%) was not statistically significantly influenced by the demographics of the studied lot, by the etiology of the liver disease or by the characteristics of the biliary reconstruction; the only risk factor which showed a statistically significant influence in terms of biliary complications was MELD. CONCLUSION: The type and technique of the biliary reconstruction in LDLT should be adapted depending on the anatomy of the biliary tree of both the donor and recipient, as well as the clinical and laboratory findings of the recipient.

Living donor liver transplantation with dual grafts -- a case report.

BACKGROUND: Living donor liver transplantation (LDLT) exposes to risks both the donor, due to a potential small residual liver volume, and the recipient, who faces the risk of small-for-size graft syndrome. In order to overcome these drawbacks, liver grafts from two different donors can be used. This paper presents a case of dual graft LDLT using a right hemiliver and a left lateral section from related donors. CASE PRESENTATION: A 14-year old female diagnosed with chronic hepatic failure due to Wilson's disease with Model-for-End- Stage-Liver-Disease score of 25, underwent a dual graft LDLT, receiving a right hemiliver with a reconstructed middle hepatic vein from her sister, and a left lateral section from her mother. None of the grafts complied with a satisfactory graft-to-recipient weight ratio (GRWR), if they would have been independently transplanted. The combined GRWR was 1.10. The donors and the recipient have been followed-up for over 1 year. RESULTS: The donors had no postoperative complications. The donors and the recipient were discharged 8 and 19 days after surgery, respectively. After 12-month follow-up, both donors and the recipient were alive, with normal graft function. CONCLUSION: Dual graft LDLT can be a feasible solution to overcome the risk of small-for-size graft syndrome. ABBREVIATIONS: BSA = body surface area, GRWR = graft-to-recipient weight ratio, GV SLV = recipient standard liver volume, HA = hepatic artery, HD = hepatic duct, HV = hepatic vein, LDLT = Living donor liver transplantation, LL = left lobe, LLS = left lateral section, MELD = Model for End-Stage Liver Disease, POD = postoperative day, PV = portal vein, RL = right lobe, SFS = small-for-size graft, SLV = standard liver volume, WD = Wilson's disease.

Liver transplantation in a patient with unresectable colorectal liver metastases -- a case report.

BACKGROUND: Due to the lower survival rates achieved, in the early period of liver transplantation era, in patients with colorectal liver metastases, and because of the organ shortage,in the last two decades colorectal liver metastases are considered a contraindication for liver transplantation. However, the increasing number of marginal donors, and the improvements in posttransplant immunossuppresion, chemotherapy and methods to assess the extrahepatic disseminationof colorectal cancer, opened the perspective of liver transplantation to certain patients with malignancies (such as HCC beyond Milan criteria, and selected patients with cholangiocarcinomaor liver metastases from neuroendocrine tumors).Since some of these patients experienced favorable outcomes,in the last years, there were authors that considered a rationalerevisitation of the benefits of liver transplantation in patients with unresectable colorectal liver metastases. Thus, in 2006, a Norwegian group started a study which aims to assess the results of liver transplantation in patients with unresectable colorect alliver metastases. Their results were unexpectedly favorable, revealing that 5-year overall survival rate was 60%, and the quality of life was excellent in the first year following transplantation.However, all the patients presented relapse of the disease in the first two years following transplantation. In the present paper we present the clinico-pathologic characteristics,the pre- and postoperative management and the outcome of a patient with unresectable colorectal liver metastases who underwent liver transplantation in a very advanced state of the disease (when he developed subacute liver failure due to insufficient functional liver parenchyma and toxicity of chemotherapy).We consider useful to present such observations,because collecting the data presented by different centers maybe contributive to identification of a selected group of patients who could benefit from liver transplantation. CASE REPORT: A 42-year old male patient, it was diagnosed with upper rectum cancer and multiple bilobar liver metastases in April 2009. Chemotherapy was started (in another hospital),and because the disease was stable after 7 cycles of FOLFOX and Bevacizumab, the patient was reffered to surgery (for a "two stage" liver resection). In October 2009 it was performed primary tumor resection associated with left lateral section ectomy and segment 4 metastasectomy. Because in November 2009 CT scan re-evaluation revealed progression of liver metastases, the second stage hepatectomy was precluded. Subsequent therapy consisted in radio embolization, multiple lines of chemotherapy,and targeted therapies. After more than 2 years, the liver metastases progressed and the patient developed progressive cholestatic subacute liver failure due to insufficient functional liver parenchyma and chemotherapy toxicity. In this state of the disease, he was admitted in our hospital, being dependant by liver dialysis and plasma exchange procedures. Due to the patients' age, and because the MDCT scan revealed the absence of extrahepatic disease (after almost three years of disease progression), and he could not benefited from any type of antineoplastic treatment due to progressive cholestatic subacute liver failure, liver transplantation with an organ from amarginal donor was considered and performed in January 2012.The postoperative course was uneventful, and the quality of his life improved (being fully reinserted social and professional).The immunosuppressive regimen consisted in Sirolimus and Mycophenolate mofetil, and the adjuvant chemotherapy started two months following liver transplantation. However,the patient developed extrahepatic relapse of the disease (lung metastases and retroperitoneal recurrence), but now, at morethan 20 months following transplantation, he is still alive in agood clinical condition. CONCLUSIONS: In patients with multiple unresectable liver onlycolorectal metastases, liver transplantation may improve overallsurvival and quality of life, by using marginal grafts whichcannot be allocated to the patients with standard indicationsfor liver transplantation. The advent of MDCT and PET CT scan and the use of m-TOR inhibitors may improve the resultsachieved by liver transplantation in patients with CLMs.Further studies could be useful in an attempt to disclosewhether a selected group of patients with unresectable liveronly colorectal metastases could become acceptable candidatesfor liver transplantation.

[The role of the middle hepatic vein in the living donor liver transplantation with right hemiliver]. / Rolul venei hepatice medii în transplantul hepatic de la donator viu cu hemificat drept.

BACKGROUND: Living donor liver transplantation has appeared and developed as a consequence to the shortage of organs. In case of right hemiliver procurement, the role of the middle hepatic vein is crucial for the prevention of right anterior section congestion and the promotion of liver regeneration. MATERIAL AND METHOD: We performed a retrospective study on a group of 36 adult patients who underwent living donor liver transplantation with right hemiliver in Fundeni Clinical Institute, having as a major indication liver cirrhosis. Concerning the middle hepatic vein, this was procured in 10 cases, not procured nor reconstructed in another 10 cases, and reconstructed on the bench in 16 cases. RESULTS: The immediate postoperative survival was roughly 91%, with 7 cases of "small for size syndrome", 2 cases being retransplanted. CONCLUSIONS: In case of living donor liver transplantation with the right hemiliver, the reconstruction of the middle hepatic vein helps the liver regeneration and prevent the "small for size" syndrome.

[Biliary complications following liver transplantation]. / Complicatiile biliare post transplant hepatic.

The biliary complications (BC) were always considered the "Achilles heel" of liver transplantation, being one of the leading causes of postoperative morbidity. The technique of the biliary reconstruction depends on the surgical procedure and it has a major impact on the patients and the graft evolution. The most frequent types of BC were stenoses, leaks, bilomas, cholangitis, etc. As an incidence, there is a peak of BC in the first 6 months after the transplant, a third of them appearing in the first month. Among the major BC risk factors, the most important are: hepatic artery pathology, the use of partial liver graft, bilioplasty and the number of biliary ducts and anastomoses. The BC management can be conservative, interventional or surgical depending on the type of BC. Along with the improvement of the interventional radiological and endoscopic methods, a large number of BCs are successfully treated non-surgically. There are still a few circumstances in which surgery is mandatory such as important persistent biliary leaks, even more when a partial liver graft was used or in association with hepatic artery pathology when re-transplantation is required. Multiple or serial biliary stenoses can lead to surgical revision. Although BC plays an important role in the patients postoperative morbidity, by early diagnosis and through numerous therapeutic methods promptly applied, there is no major impact on mortality.

[Liver transplantation--indications, surgical technique, results--the analysis of a clinical series of 200 cases]. / Transplantul hepatic--indicati, tehnica, rezultate-analiza unei serii clinice de 200 de cazuri.

INTRODUCTION: Initially considered experimental, liver transplantation (LT) has become the treatment of choice for the patients with end-stage liver diseases. MATERIAL AND METHODS: Between April 2000 and October 2009, 200 LTs (10 reLTs) were performed in 190 patients, this study being retrospective. There were transplanted 110 men and 80 women, 159 adults and 31 children with the age between 1 and 64 years old (mean age--39.9). The main indication in the adult group was represented by viral cirrhosis, while the pediatric series the etiology was mainly glycogenosis and biliary atresia. There were performed 143 whole graft LTs, 46 living donor LTs, 6 split LTs, 4 reduced LTs and one domino LT RESULTS: The postoperative survival was 90% (170 patients). The patient and graft one-year and five-year survivals were 76.9%, 73.6% and 71%, 68.2%, respectively. The early complications occurred in 127 patients (67%). The late complications were recorded in 71 patients (37.3%). The intraoperative and early postoperative mortality rate was 9.5% (18 patients). CONCLUSIONS: The Romanian liver transplantation program from Fundeni includes all types of current surgical techniques and the results are comparable with those from other international centers.

Splenic artery used for replaced common hepatic artery reconstruction during pancreatoduodenectomy--a case report.

The arterial anatomy supplying the liver is highly variable. A replaced common hepatic artery originating from superior mesenteric artery is a rare anomaly. We herein present the case of a patient with retro pancreatic lymph nodes recurrence after laparoscopic cholecystectomy for pT2 gallbladder carcinoma, whose replaced common hepatic artery arose from the superior mesenteric artery. It was performed a Whipple operation en bloc with the replaced common hepatic artery resection (enhanced by the tumour). The arterial reconstruction was needed (due to the severe decrease of the arterial flow after clamping the replaced common hepatic artery), using the splenic artery, without any serious complications.

Hepatocellular carcinoma in Riedel's lobe.

We present a rare case of 65-year female with right abdominal mass and abdominal discomfort; a combination of Doppler ultrasonography, computed tomography and laparotomy was utilized to make a diagnosis of tumoral Riedel's lobe. In our case, laparotomy with resection of Riedel's lobe was the proper therapeutical solution.

[Human pancreas procurement for pancreas and islet transplantation]. / Prelevarea pancreasului uman pentru transplantul de pancreas si de insule pancreatice.

Insulin-dependent diabetes mellitus is a disease characterized by a deficiency of insulin secretion by beta islet cells. Integral pancreatic transplantation and islet cell transplantation represent two possibilities of replacing the beta islet cells. The aim of this paper is to analyze the main aspects of selection criteria of the pancreas donor and surgical methods of preservation for integral pancreas or islet cell transplantation. There are described the pancreas procurements realized by the Center of General Surgery and Liver Transplantation team from Fundeni Clinical Institute between December 2005-December 2006 and correlation between the donor's and pancreas features and the quality of islet cell isolation. The selection of pancreas donor and the accomplishment of pancreas procurement represent important factors in the post-transplantation course of the graft. The data from pancreas/islet cell transplantation centers suggest that the factors that influence positively the course of graft are: the donor's age, body mass index, cold ischemia time.

Two-stage hepatectomy: an analysis of a single center's experience.

Hepatic resection remains the only potential curative treatment for either primary or secondary liver tumors. In order to increase the resectability of initially unresectable tumors and to decrease the posthepatectomy morbidity and mortality, ligation and section of a portal branch with consecutive hepatic resection is recommended. Between September 1st 1999 and January 1st 2006, in the Department of General Surgery and Liver Transplantation of Clinical Institute Fundeni (Bucharest), the ligation of a portal branch was performed in 15 patients with gross hepatic tumors: hepatocellular carcinoma (2 cases), peripheral cholangiocarcinoma (6 cases) and hepatic metastases for colorectal cancer (7 cases). Two-stage hepatectomy was performed in 8 cases. The interval between the two operations ranged between 4 weeks and 2 months (except one case that returned to us only after 6 months, when was reevaluated and resected). Hepatic resection could not be performed in 7 cases due to the local and regional progression of the disease (4 cases) or to the absence of the hypertrophy-atrophy process (3 cases). In the 8 resected cases, hepatic failure occurred posthepatectomy in 2 patients, resulting in the death of one patient; that means a mortality of 12.5%. Other two patients died at 4 and 10 months respectively, as a result of distant metastases. The rest of 5 patients are alive, free of recurrence; two of them have more than 5 years from the operation. CONCLUDING: portal vein ligation can be performed in selected cases of unresectable gross hepatic tumors. Two-staged hepatectomy is not always feasible. Moreover, the hypertrophy of the contralateral lobe does not always prevent the postoperative hepatic failure. For the cases that can be resected, both survival and quality of life are significantly improved.

[A rare cause of lower digestive hemorrhage--jejunal diverticulosis]. / Hemoragie digestiva inferioara de cauza rara--diverticuloza jejunala.

Small bowel diverticula are usually asymptomatic and rare. Digestive bleeding is a rare complication of jejunal diverticulum whose diagnosis and treatment are difficult. We report a rare case of hematochezia whose origin was a proximal jejunal diverticulum and not determined by endoscopic investigations. Bowel resection with primary anastomosis was the chosen surgical procedure. There was no complication until discharge nor was any recurrent bleeding or functional disorder of the bowel reported during follow-up. The clinical presentation, the different value of diagnostic tools and the therapy are discussed.

A rare indication for liver resection.

We present the rare case of a young female with a right upper abdomen tumoral mass and suffering abdominal discomfort. A combination of ultrasonography, computed tomography, magnetic resonance imaging and laparotomy was utilized to conclude a diagnosis of Riedel's lobe. Laparotomy and a resection of Riedel's lobe were selected as the correct therapeutic solutions.

[Double localization of pancreatic insulinoma. Diagnostic and therapeutic difficulties]. / Insulinom pancreatic cu dubla localizare. Dificultati de diagnostic si atitudine terapeutica.

Insulinomas are the most common cause of hypoglycemia resulting from endogenous hyperinsulinism. Because most of insulinomas are less than 2 cm in size and rarely they not may be visible by CT scan or transabdominal ultrasonography. Intraoperative ultrasonography may be a solution. Although as surgical method is preferred enucleation because operative time is shorter and easier and the low frequency postoperative complications, pancreaticoduodenectomy Whipple is indicated in selected cases. We report a case of double insulinoma located in the head of the pancreas in which the diagnosis and surgical treatment presented difficulties which determined a particular clinical evolution.

[Current treatment of hepatocellular carcinoma. Analysis of a series of 123 cases over a 5-year period]. / Tratamentul multimodal al carcinomului hepatocelular. Analiza unei experiente clinice de 123 de cazuri în 5 ani.

We analyze a 123-cases experience over a 5-year period in the treatment of hepatocellular carcinoma (HCC). Liver resection, transplantation and hyperthermic ablation of the tumor were used according to the indication and patient selection. Systemic chemotherapy followed resection in 18 cases and hyperthermic ablation in 5 cases. Chemo-embolisation was performed in patients to be transplanted and in other two patients with tumor destruction. A number of 86 liver resections were performed in 84 patients (2 re- resections in 1 patient, subsequently transplanted) - 43 on normal liver and 41 on cirrhotic liver. Postoperative mortality was 4.7% in non-cirrhotic and 4.9% in cirrhotic patients. Survival in non-cirrhotic patients was 77% at 1 year, 65% at 2 years, and constant - 45% at 3 and 4 years, whereas in cirrhotic patients it was 60%, 56%, 56% and 36% (Kaplan-Meyer actuarial survival rates). Nine patients underwent liver transplantation (4 OLTs, 3 living donor LT, 1 split LT and 1 "domino" LT); postoperative mortality was 11% (1 patient). At present five patients are alive and well. One patient died by peritoneal carcinomatosis at 10 months; another patient died at 6 months by severe cholestatic recurrent C virus hepatitis and one patient was discharged with permanent severe neurologic disturbances. In 31 patients hyperthermic ablation of the tumor was used with zero mortality. Actuarial survival rates were 75% at one year and 67% at 2 years. In conclusion, in non-cirrhotic patients with HCC resection is the treatment of choice. In cirrhotic patients limited resections should be preferred and liver transplantation is the best solution in selected cases; local ablative methods may be used for some unresectable tumors. The role of adjuvant chemotherapy has to be determined in future comparative studies.

[Orthotopic liver transplantation in adult patients with cadaveric grafts. Experience of the Fundeni Center of General Surgery and Liver Transplantation]. / Transplantul hepatic ortotopic de la donator cadavru la adult. Experienta Centrului de Chirurgie Generalai si Transplant Hepatic Fundeni.

We analyze the experience of the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest, Romania) regarding orthotopic liver transplantation (OLT) in adult recipients, with whole liver grafts from cadaveric donors, between April 2000 (when the first successful LT was performed in Romania) and December 2004. This series includes 37 OLTs in adult recipients (16 women and 21 men, aged between 29-57 years--average 46 years). Other two LT with whole liver cadaveric grafts and two reduced-size LT were performed in children; also, in the same period, due to the acute organ shortage, other methods of LT were performed in 28 patients (21 living donor LT, 6 split LT and one "do mino" LT), that were not included in the present series. The indications for OLT were HBV cirrhosis--10, HBV+HDV cirrhosis--4, HCV cirrhosis--11, HBV+HCV cirrhosis--2, biliary cirrhosis--5, Wilson disease--2, alcoholic cirrhosis--1, non-alcoholic liver disease--1, autoimmune cirrhosis--1. With three exceptions, in which the classical transplantation technique was used, the liver was grafted following the technique described by Belghiti. Local postoperative complications occurred in 15 patients (41%) and general complications in 17 (46%); late complications were registered in 18 patients (49%) and recurrence of the initial disease in 6 patients (16%). Intrao- and postoperative mortality was 8% (3/37). There were two patients (5%) who died because of immunosuppressive drug neurotoxicity at more than 30 days following LT. Four patients (11%) died lately because of PTLD, liver venoocclusive disease, recurrent autoimmune hepatitis and liver venoocclusive disease, myocardial infarction, respectively. Thirty-four patients survived the postoperative period (92%); according to Kaplan-Meier analysis, actuarial patient-survival rate at month 31 was 75%.

Liver hemangioma revisited: current surgical indications, technical aspects, results.

BACKGROUND/AIMS: New developments regarding the diagnosis of liver hemangiomas, surgical indication and therapeutic options emerged recently. We reviewed our experience from the point of view of these modern developments. METHODOLOGY: Fifty-seven patients with liver hemangiomas were retrospectively studied. The relationship between size, symptoms and treatment was assessed. RESULTS: Indication for surgery was the size of the lesion in 5 patients, symptomatology in 48 and uncertain diagnosis in 4. Increase in size was noted in four patients. Six patients had associated intraabdominal benign or malignant pathology. The treatment of choice was enucleation. Postoperative complications were noted in 6 patients and mortality was nil. In 3 patients the hemangiomas recurred and were reresected in 2. CONCLUSIONS: Hemangiomas should be resected when larger than 10 cm and when they become symptomatic. With the modern diagnostic work-up, uncertainty of diagnosis as an indication for surgery should be rare. Surgery remains the main treatment, with a low morbidity and mortality if performed in a specialized hepatobiliary unit. Enucleation is the surgical option of choice. In selected cases laparoscopic enucleation can be performed with good results.

[Couinard's technics of liver resection]. / Consideratii asupra tehnicii Couinaud de rezectie hepatica.

Six cases of major liver resections (five right lobectomies and one left lobectomy) are reported. In all these cases the technique described by Couinaud (of suprahilar intrahepatic ligation of the portal pedicle) was used. Although the technique could be simple and rapid, it may produce severe accidents, especially in patients with biliary anomalies. Five of the six cases had an uneventful postoperative course, while in the sixth case, obstructive jaundice developed postoperatively. The case was solved through reoperation and a Roux-en-Y anastomosis. The main conclusion is that the Couinaud technique could be used, because of its advantages (speed, less blood loss) but special precautions are necessary when biliovascular anomalies of the liver are present.