Gallbladder cancer who is really cured?

BACKGROUND: Although gallbladder cancer (GBCA) is characterized by a dismal prognosis, there is a proportion of patients who are cured. The aim of this study was to analyze the profile of these patients. METHODS: A database was queried for patients who underwent curative resection with a follow-up of at least 5 years. Patients were prospectively treated and registered by the same surgical team. A multivariate regression analysis was used to identify factors associated with long-term survival. RESULTS: From 1988 to 2013, 461 patients were evaluated and 112 who underwent resection were analyzed. Among the patients, five year survival was 57% while lymph node and liver compromise were the only independent factors associated with survival. On the other hand, the elapsed time between the cholecystectomy and the resection, the differentiation grade and the level of wall invasion did not have an independent effect on the prognosis. CONCLUSION: Despite its poor prognosis, a subset of patients can be cured of GBCA. R0 resection of patients without lymph and liver infiltration are key to GBCA survival.

[A proposal of the Chilean Academy of Medicine to improve organ procurement and transplantation in Chile]. / Donación y trasplante de órganos: propuesta desde la Academia Chilena de Medicina.

The Chilean Academy of Medicine designated a group of specialists to evaluate the practice and to propose reforms for organ donation and transplantation, due to the general insufficiencies at the national level with these procedures. In the last six years the mean number of organ transplants in Chile was 340 cases per year while effective cadaveric donors ranged between 6 and 10 per million inhabitants. These averages remained stable during this period and are among the lowest in the region. Our analysis attributed these deficient results mainly to low organ donation and inefficient procurement due to lack of compliance with protocols and little accountability. The committee proposes several measures for improvement. These are a systematic and obligatory report of potential organ donors by all emergency and critical care centers, frequent evaluation of results, empowering of health authorities to correct insufficiencies in organ procurement, education programs for primary, secondary, technical and university students to improve their knowledge about the social significance and solidarity required for transplantation policies and specialized updated training of all health professionals involved. Organ donation and transplantation must be based on clear and fair ethical considerations in order to be accepted by the general public.

Incidental Gallbladder Cancer: How Residual Disease Affects Outcome in Two Referral HPB Centers from South America.

BACKGROUND: Residual disease (RD) has been described as one of the most relevant prognostic factors after radical surgical resection for incidental gallbladder cancer (IGC). The purpose of the present study was to analyze patterns of RD and determinant prognostic factors in patients undergoing re-resection for IGC. METHODS: Patients undergoing re-exploration due to IGC between 1990 and 2014 were identified in two referral centers from different South-American countries. Patients submitted to a radical definitive operation were included in the study. Demographics and tumor-treated related variables were analyzed in correlation with RD and survival. The site of RD, local (gallbladder bed) or regional (lymph nodes and bile duct) was correlated with disease-specific survival (DSS). RESULTS: Of 265 patients with IGC submitted to surgery, 168 underwent a radical re-resection and RD was found in 58 (34.5%). Demographic, clinical and surgical variables were compared between both centers showing differences in type of resection, laparoscopic approach, T stages and disease stage. Location of RD was regional in 34 (20.2%) and local in 24 (14.3%), and no residual disease was found in 110 (65.5%) patients. T stage (T1b = 20%, T2 = 23.8%, T3 = 71.7%, p < 0.001) and disease stage (p < 0.001) were independent predictors of RD. Finding RD at any location reduced the DSS in comparison with non-RD patients (19.6 months vs. 62.7 months p < 0.001). No differences in DSS according to the location of RD were found, and all anatomic sites were equally poor (p = 0.27). RD at any site predicted DSS (p < 0.001), independently of all other IGC variables. CONCLUSIONS: IGC presented similar clinical parameters in two different countries of South America. RD was demonstrated as the most critical prognostic variable in patients with IGC treated by a radical resection. The presence of RD was associated with poor outcome, independently of any anatomic location. Future studies incorporating neoadjuvant chemotherapy in the treatment of patients with prognostic factors for RD are required to improve survival in this entity.

Laparoscopic management of incidental gallbladder cancer.

BACKGROUND: The laparoscopic cholecystectomy has allowed the detection of an increasing number of incidental gallbladder cancers (IGBC). Although laparoscopy is employed in the management of a variety of abdominal tumors, its use in gallbladder cancer is reduced and controversial. This study analyzes the role of laparoscopy in gallbladder cancer with the focus in IGBC. METHOD: We evaluated our prospective series of 51 patients with an IGBC who were treated by laparoscopy between 2006 and 2016 at the Clinica Alemana in Santiago, Chile. RESULTS: The series comprised 7 men and 44 women. Age ranged from 43 to 76 years (mean age 60). Regarding wall involvement, 29 patients had a T2 tumor, which was the most common. 8 and 14 patients had T1b and T3 tumors, respectively. Of the patients, 17 underwent only laparoscopic exploration. This was due to the presence tumor dissemination not being observed in the preoperative staging. 10 patients had to be converted to complete the resection, whereas 24 patients were laparoscopically resected. The quality of the resected material was not different between those who were converted and those who were treated by laparoscopy. In the laparoscopic group, the average number of harvested lymph nodes was 7.9, not statistically different from the converted group. The mean of hospital stay in the laparoscopic group (4.3 days) was significantly lower than the converted group. CONCLUSIONS: Laparoscopy has been shown to be a safe and feasible method for the management of IGBC. This method not only allows for a complete exploration, identifying a previously unseen residual tumor, but also makes it possible to accomplish the same oncology objectives as the open procedure. Therefore, laparoscopy should be considered a valid alternative in the management of IGBC.

Gallbladder cancer: role of laparoscopy in the management of potentially resectable tumors.

BACKGROUND: The aim of this study was to evaluate the role that laparoscopy plays in the management of gallbladder cancer. METHOD: From August 2005 to March 2009, 23 patients affected by gallbladder cancer detected after the study of a cholecystectomy specimen underwent laparoscopy as part of their management. RESULTS: Among the patients, 5 underwent only an exploratory laparoscopy, while 11 were converted due to the existence of dense adhesions that precluded a complete exploration. Of the patients with adhesions who underwent conversion, three were unresectable. The remainder underwent a lymphadenectomy and liver resection after conversion. Of the seven who underwent a complete laparoscopic exploration, five had a lymphadenectomy and liver resection done completely by laparoscopy while conversion was needed for two. Conversion was required due to lymphatic metastasis at the hepatic pedicle and the presence of a bile leak. Postoperative time was uneventful, with patients discharged within 3 days of the operation. CONCLUSIONS: Laparoscopy may be employed in the management of patients with early forms of gallbladder cancer undergoing reoperation. Although the presence of adhesions may result in inadequate exploration, there is a subset of patients for whom it is possible to perform a complete exam. Furthermore, laparoscopic lymphadenectomy and gallbladder bed resection is a promising technique in well-selected patients.

Early gallbladder cancer: is further treatment necessary?

BACKGROUND AND OBJECTIVES: The goal of this study was to evaluate a series of patients with early gallbladder cancer, focusing on the selection of treatment and the role of Rokitansky Aschoff sinus infiltration. METHODS: We performed a retrospective analysis of a prospective series of 371 patients with gallbladder cancer. Specimens were reviewed by an independent pathologist to confirm the diagnosis and depth of infiltration and to evaluate the presence of Rokitansky Aschoff sinus involvement. RESULTS: Forty-nine and 45 patients with muscular (pT1b) and mucosal (pT1a) infiltration gallbladder cancer tumors were studied respectively. Simple cholecystectomy was the treatment in all patients, with the exception of 11 patients who underwent further surgery. Rokitansky Aschoff sinus invasion was seen in seven patients with mucosa (pT1a) and three with muscular (pT1b) compromise. The 5-year survival rates of patients with muscular (pT1b) and mucosal (pT1a) infiltration were 87.6% and 86.4%, respectively. Patients with Rokitansky Aschoff involvement had a lower survival rate than those with no involvement in both categories. CONCLUSIONS: Early gallbladder cancer is associated with a favorable prognosis and cholecystectomy should be the standard treatment. Despite some patients having a worse prognosis, there are no data to support more aggressive treatment.

Gallbladder cancer: an analysis of a series of 139 patients with invasion restricted to the subserosal layer.

The goal was to study our experience in the management of a series of patients with a potentially curative subserosal gallbladder cancer who were prospectively treated by the authors. Between April 1988 and July 2004, 139 patients were enrolled in our prospective database. Of the above, 120 were operated on with an open procedure and the rest with laparoscopic surgery. In only eight patients was the diagnosis suspected before the cholecystectomy. The majority of tumors were adenocarcinoma. Six patients had an epidermoid tumor, and one had a carcinosarcoma. Of the patients, 74 underwent reoperation, while in 55 (70.2%) it was possible to perform an extended cholecystectomy with a curative aim. Operative mortality was 0%, and operative morbidity was 16%. Lymph node metastases were found in 10 (18.8%), while in 7 (13.2%) the liver was involved. The overall survival rate was 67.7%, while in those who underwent resection, the survival rate was 77%. Through the use of a multivariate analysis, the presence of lymph node metastasis was found to be an independent factor with respect to prognosis. The feasibility of performing an extended cholecystectomy in patients with gallbladder cancer and invasion of the subserosal layer allows for a good survival rate. The presence of lymph node metastases represents the main poor prognosis factor, and some type of adjuvant therapy should be studied in this particular group.

Donación y trasplante de órganos: propuesta desde la Academia Chilena de Medicina / A proposal of the Chilean Academy of Medicine to improve organ procurement and transplantation in Chile

The Chilean Academy of Medicine designated a group of specialists to evaluate the practice and to propose reforms for organ donation and transplantation, due to the general insufficiencies at the national level with these procedures. In the last six years the mean number of organ transplants in Chile was 340 cases per year while effective cadaveric donors ranged between 6 and 10 per million inhabitants. These averages remained stable during this period and are among the lowest in the region. Our analysis attributed these deficient results mainly to low organ donation and inefficient procurement due to lack of compliance with protocols and little accountability. The committee proposes several measures for improvement. These are a systematic and obligatory report of potential organ donors by all emergency and critical care centers, frequent evaluation of results, empowering of health authorities to correct insufficiencies in organ procurement, education programs for primary, secondary, technical and university students to improve their knowledge about the social significance and solidarity required for transplantation policies and specialized updated training of all health professionals involved. Organ donation and transplantation must be based on clear and fair ethical considerations in order to be accepted by the general public.

[Porphyria cutanea tarda, hemosiderosis and hepatocellular carcinoma: report of one case]. / Hepatocarcinoma, porfiria y hemosiderosis. Una asociación no reportada en nuestro país: Caso clínico.

Porphyria cutanea tarda (PCT) is a hereditary or acquired disease. It can be unleashed by iron overload, alcohol, estrogens and other conditions. In these patients, hepatic involvement can be associated to cirrhosis, iron overload or C and B viral infections, that are predisposing factors for hepatocellular carcinoma. We report a 69-year-old man with PTC, hemosiderosis and hepatocarcinoma. The tumor was diagnosed during a routine ultrasound examination for early detection of malignant lesions. The patient was subjected to a right hepatic excision. The pathological examination of the surgical piece confirmed the diagnosis and disclosed free surgical margins. After 18 months of follow up, the patient had a relapse and a liver transplantation was performed.

[General considerations, indications and contraindications for liver transplantation in Chile: a multicenter consensus development document]. / Trasplante hepático en Chile: Aspectos generales, indicaciones y contraindicaciones (Documento de consenso).

Liver transplantation is an excellent therapeutic option for terminal liver disease. During the last decades the results of liver transplantation have improved significantly with a patient survival rate of nearly 90% at one year and 80% at 5 years of follow-up. The main indications for liver transplantation include: end-stage liver disease associated to cirrhosis, acute liver failure, and hepatic tumors (mainly hepatocarcinoma). The absolute contraindications for a transplant are less frequent than in the past, and include: severe co-morbidity (cardiac or pulmonary), sepsis, advanced HIV disease and extra-hepatic malignancy. This document presents a Consensus of the main groups performing liver transplantation in Chile, about its indications and contraindications. It also reviews general aspects of liver transplantation, including the selection and referral of liver transplant candidates, allocation of organs and the evaluation of severity of liver disease.

[Pseudotumoral adenomyomatosis of the gallbladder diagnosed by ultrasound. Report of one case]. / Adenomiomatósis vesicular pseudotumoral: Diagnóstico ecográfico. Caso clínico.

Adenomyomatosis of the gallbladder wall is a frequent benign degenerative hyperplasia of unknown etiology. In some cases it looks like a malignant tumor. The diagnosis can be suspected during ultrasound examination. We report a 36 year-old male that presented with nonspecific dyspepsia. The ultrasound showed a gallbladder mass with small cyst and echogenic spot inside that suggested the presence of Rokitansky-Ashoff sinuses, seen in adenomyomatosis. The patient was operated and the tumor was excised. The pathological examination of the surgical specimen confirmed the presence of gallbladder adenomyomatosis.

Chemoradiotherapy in gallbladder cancer.

Gallbladder cancer (GC) is considered a rare disease associated with a poor prognosis. Unfortunately, the low number of cases makes the performance of trials addressing the role of adjuvant, neoadjuvant, and/or palliative therapy difficult. For a long time, the majority of trials were 5-fluorouracil (5 FU)-based, and results were uniformly poor. Since the introduction of Gemcitabine, response rates of approximately 30% have been observed through the use of this drug and new approaches have been tested. In this sense, drugs such as Cisplatin and Capecitabine have been employed concurrently with gemcitabine and/or radiation. Since a recurrence pattern is both distant and local, chernoradiation seems a logical option to deal with the disease. However, at the present time, the lack of valid and scientific evidence means that most of the recommendations originate from trials dealing with other tumors, such as pancreas cancer and biliary tract cancer (BTC). The aforementioned treatment alternatives warrant further evaluation focusing on GC.

Hepatocarcinoma, porfiria y hemosiderosis. Una asociación no reportada en nuestro país: caso clínico / Porphyria cutanea tarda, hemosiderosis and hepatocellular carcinoma: report of one case

Porphyria cutanea tarda (PCT) is a hereditary or acquired disease. It can be unleashed by iron overload, alcohol, estrogens and other conditions. In these patients, hepatic involvement can be associated to cirrhosis, iron overload or C and B viral infections, that are predisposing factors for hepatocellular carcinoma. We report a 69-year-old man with PTC, hemosiderosis and hepatocarcinoma. The tumor was diagnosed during a routine ultrasound examination for early detection of malignant lesions. The patient was subjected to a right hepatic excision. The pathological examination of the surgical piece confrmed the diagnosis and disclosed free surgical margins. After 18 months of follow up, the patient had a relapse and a liver transplantation was performed.

[Sirolimus for rescue of recurrent acute rejection and diabetes mellitus after liver transplantation: report of one case]. / Rescate con Sirolimus por rechazo agudo recurrente y diabetes mellitus en trasplante hepático. Caso clínico pediátrico.

Sirolimus (SRL) is a new immunosuppressive drug approved for renal transplantation, but is being used increasingly in orthotopic liver transplantation (OLT). Compared with the calcineurin inhibitors, SRL has different mechanisms of action and side effects profile. Thus, this drug offers significant potential advantages over other immunosuppressive agents. SRL does not cause glucose intolerance, hypertension or renal failure, but it may cause dyslipidemia, hepatic artery thrombosis, thrombocytopenia, anemia, leukopenia, oral mucosa ulcers, edema, arthralgias and wound complications. SRL inhibits the signal of interleukin 2 at a post-receptor level, inhibiting lymphocyte proliferation and fibroblast proliferation. It also has antineoplastic and antifungal effects. We report a 10 years old girl who underwent OLT, experiencing a biopsy-proven recurrent acute rejection (AR) in spite of using three immunosuppressive agents (tacrolimus, mofetil micofenolate and steroids). She developed diabetes mellitus as a consequence of the immunosuppressive therapy. She was rescued with SRL, not experiencing AR again. Mofetil micofenolate, steroids and insulin could be discontinued and tacrolimus doses were reduced, without experiencing severe complications. SRL is a new and safe immunosuppressive agent for rescue in patients with OLT and recurrent AR.

[Combined liver-kidney transplantation: report of a case]. / Trasplante combinado hepato-renal: a propósito de un caso.

End stage renal disease is not an absolute contraindication for liver transplantation (LT) in patients with end stage liver disease. Actuarial patient and graft survival are comparable for children and adults who undergo LT alone and liver-kidney transplantation (LKT). The most common indications for LKT are the primary hyperoxaluria type I (PH1) and the liver and renal polycystic disease. We report a 12 years old boy with congenital hepatic fibrosis with severe portal hypertension, encephalopathy and polycystic kidney disease with end stage renal disease on dialysis that underwent LKT. During the second postoperative week, he had a biopsy-proven acute liver and renal rejection, that had a good response to corticosteroids. Thirty days after surgery, the liver biopsy was without rejection. No other complications were observed.

[Liver transplantation in adults: a caseload from Clínica Alemana de Santiago, Chile]. / Trasplante hepático en adultos: casuística de Clínica Alemana de Santiago.

BACKGROUND: The success of orthotopic liver transplantation (OLT) has resulted in its widespread use for different liver diseases. AIM: To report our 8 years experience with adult OLT at Clinica Alemana de Santiago. PATIENTS AND METHODS: In all transplantations done at the center, we recorded patient's overall data and survival, postoperative medical and surgical complications and causes of death. RESULTS: Between November 1993 and September 2001, 51 consecutive OLT were performed in 44 patients (22 females, median age 45 years old). Thirty eight patients presented with chronic and 6 with acute or sub-acute liver failure. Cryptogenic cirrhosis and hepatitis C infection were the most common causes for OLT. Postoperative bleeding and extrahepatic biliary complications were seen in 17.6 and 21.5% of cases respectively. Acute rejection, bacterial infections, CMV infection or disease and post OLT hemodialysis were the most common medical complications (51, 31, 19.6 and 19.6% of cases respectively). The overall 1 and 5 years survival rates were 80% and 73% respectively. Considering exclusively the last 22 OLT performed since January 1999, the 1 year survival rate has improved to 91%. CONCLUSIONS: Liver transplantation in Chile provides a good long term survival with acceptable morbidity, due to a multidisciplinary approach management. The survival rates have improved over the last few years probably due to better surgical techniques, ICU care and immunosuppression. These overall results are comparable with those from other Centers in developed countries.

Trasplante hepático en Chile: Aspectos generales, indicaciones y contraindicaciones (Documento de consenso) / General considerations, indications and contraindications for liver transplantation in Chile: A multicenter consensus development document

Liver transplantation is an excellent therapeutic option for terminal liver disease. During the last decades the results of liver transplantation have improved significantly with a patient survival rate of nearly 90 percent at one year and 80 percent at 5 years of follow-up. The main indications for liver transplantation include: end-stage liver disease associated to cirrhosis, acute liver failure, and hepatic tumors (mainly hepatocarcinoma). The absolute contraindications for a transplant are less frequent than in the past, and include: severe co-morbidity (cardiac or pulmonary), sepsis, advanced HIV disease and extra-hepatic malignancy. This document presents a Consensus of the main groups performing liver transplantation in Chile, about its indications and contraindications. It also reviews general aspects of liver transplantation, including the selection and referral of liver transplant candidates, allocation of organs and the evaluation of severity of liver disease.

Adenomiomatósis vesicular pseudotumoral: Diagnóstico ecográfico. Caso clínico / Pseudotumoral adenomyomatosis of the gallbladder diagnosed by ultrasound. Report of one case

Adenomyomatosis of the gallbladder wall is a frequent benign degenerative hyperplasia of unknown etiology. In some cases it looks like a malignant tumor. The diagnosis can be suspected during ultrasound examination. We report a 36 year-old male that presented with nonspecific dyspepsia. The ultrasound showed a gallbladder mass with small cyst and echogenic spot inside that suggested the presence of Rokitansky-Ashoff sinuses, seen in adenomyomatosis. The patient was operated and the tumor was excised. The pathological examination of the surgical specimen confirmed the presence of gallbladder adenomyomatosis.

Extracción multiple de órganos para trasplante / Multiple organ procurement

Se describe la técnica clásica de extracción múltiple de corazón, hígado y riñones para trasplantes, la cual permite un mejor aprovechamiento de los donantes frente a la creciente necesidad de órganos. También se presenta la técnica rápida que ha permitido que la intervención de extracción de órganos se realice en un tiempo más breve, no demorando al equipo que realiza la cardiectomía, con esta técnica se puede además utilizar donantes homodinámicamente inestable que antiguamente se perdían

Colecistectomía laparoscópica: casuística del Hospital Militar / Laparoscopic cholecystectomy: casuistic from the Military Hospital

Se presenta la casuística de la colecistectomía laparoscópica (CL) del Hospital Militar en la patología vesicular, revisando los resultados obtenidos en 1.102 pacientes en un lapso de 23 meses. El 22 por ciento de los pacientes son portadores de un cuadro vesicular agudo. El 10 por ciento de las CL recibieron una colangiografía endoscópica retrógrada (CER) preoperatoria en búsqueda de coledocolitiasis, encontrándola en un tercio de ellos. Durante la intervención se detecta un 1,8 por ciento de coledocolitiasis, llegando a un 5,3 por ciento de cálculos coledocianos en toda la serie. En el 1,6 por ciento de la serie se realizó exploración coledociana trancística, lo que permite resolver el 40 por ciento de los hallazgos de coledocolitiasis intraopereratoria. Se convirtió la técnica en el 6 por ciento de las CL, existiendo 3,8 por ciento de complicaciones médicas, 3,5 por ciento de complicaciones quirúrgicas, con 0,7 por ciento de reoperaciones, 06 por ciento rehospitalizaciones 0,18 por ciento de sección del colédoco y 0,09 por ciento de mortalidad. Las cifras refuerzan sólidamente el concepto de que la CL es la técnica quirúrgica para tratar la patología vesicular no neoplásica, con un adecuado margen de seguridad, buena recuperación postoperatoria y rápida rehabilitación