Ruptured subcapsular liver hematoma as a rare complication of HELLP syndrome. A therapeutic challenge.

HELLP syndrome (HS), a low-incidence condition of uncertain pathogenesis associated with pregnancy hypertensive syndromes, is characterized by hemolysis, elevated liver enzymes and low platelet count. Ruptured subcapsular liver hematoma complicated with hemoperitoneum is an uncommon but very serious condition where early recognition and multidisciplinary management are key to reduce its associated maternal, infant mortality rate. Symptoms are nonspecific, characterized by por epigastric pain, nausea and vomiting; clinical suspicion and appropriate imaging studies are of crucial importance. We report the case of a 36-year-old primiparous woman at 39 weeks of gestation. She was admitted for early membrane rupture, with delivery complicated by retained placenta. During the immediate puerperium she had blood pressure > 140/90 mmHg, epigastric pain and vomiting, which required respiratory and hemodynamic support. An exploratory laparotomy was performed that revealed a massive hemoperitoneum as well as CR in the RLL with multifocal active bleeding. The left liver lobe was macroscopically normal. The patient underwent hemoperitoneum drainage and hepatic packing (HP); biopsy findings were consistent with necrosis. Polytransfusion was initiated with blood products and antihemorrhagic agents.

Villous adenoma of the choledocho: an infrequent pathology of the main bile duct.

We present the case of a patient with obstructive jaundice due to a polylobulated lesion at the middle common bile duct that is identified as a villous adenoma of the main bile duct. This entity is infrequent with few references in the bibliography. It is a benign pathology but with risk of malignancy, so the diagnosis and resection is essential for adequate treatment.

Lower gastrointestinal bleeding as a form of presentation in an adult case of Abernethy syndrome.

We report the case of a 29-year-old patient who presented with a short history of lower gastrointestinal bleeding. A diagnosis of Abernethy syndrome was made (congenital extrahepatic portosystemic shunt) after this uncommon clinical presentation. The prevalence of this congenital malformation is very low and usually manifests during the pediatric age, according to previously published reports.

Repeated pancreatic resection for pancreatic metastases from renal cell Carcinoma: A Spanish multicenter study (PANMEKID).

BACKGROUND AND OBJECTIVES: Recurrent isolated pancreatic metastasis from Renal Cell Carcinoma (RCC) after pancreatic resection is rare. The purpose of our study is to describe a series of cases of relapse of pancreatic metastasis from renal cancer in the pancreatic remnant and its surgical treatment with a repeated pancreatic resection, and to analyse the results of both overall and disease-free survival. METHODS: Multicenter retrospective study of patients undergoing pancreatic resection for RCC pancreatic metastases, from January 2010 to May 2020. Patients were grouped into two groups depending on whether they received a single pancreatic resection (SPS) or iterative pancreatic resection. Data on short and long-term outcome after pancreatic resection were collected. RESULTS: The study included 131 pancreatic resections performed in 116 patients. Thus, iterative pancreatic surgery (IPS) was performed in 15 patients. The mean length of time between the first pancreatic surgery and the second was 48.9 months (95 % CI: 22.2-56.9). There were no differences in the rate of postoperative complications. The DFS rates at 1, 3 and 5 years were 86 %, 78 % and 78 % vs 75 %, 50 % and 37 % in the IPS and SPS group respectively (p = 0.179). OS rates at 1, 3, 5 and 7 years were 100 %, 100 %, 100 % and 75 % in the IPS group vs 95 %, 85 %, 80 % and 68 % in the SPS group (p = 0.895). CONCLUSION: Repeated pancreatic resection in case of relapse of pancreatic metastasis of RCC in the pancreatic remnant is justified, since it achieves OS results similar to those obtained after the first resection.

[Pancreatic metastasis from undifferentiated pleomorphic sarcoma. An extremely rare entity]. / Metástasis pancreática de sarcoma pleomórfico indiferenciado. Una entidad extremadamente rara.

Undifferentiated pleomorphic sarcoma (UPS) is a very aggressive malignant tumor that originates in bone or soft tissues, being its most frequent location in the extremities. We present the case of a 71-year-old man who, two years of follow-up after a lower right limb UPS excision surgery, presented a single metastasis of sarcomatoid origin in the pancreas that was treated by cephalic pancreaticoduodenectomy. Sarcomatoid metastases to the pancreas are extremely rare. Resection of the metastasis is the only therapeutic alternative that has reported benefit in terms of the survival of these patients.

El sarcoma pleomórfico indiferenciado (SPI) es un tumor maligno muy agresivo que se origina en el hueso o tejidos blandos, siendo su localización más frecuente en las extremidades. Presentamos el caso de un varón de 71 años que a los dos años de seguimiento tras cirugía de exéresis de un SPI presenta una metástasis única de origen sarcomatoide a nivel del páncreas que se trató mediante duodenopancreatectomía cefálica. Las metástasis sarcomatoides a nivel de páncreas son extremadamente raras. La cirugía de exéresis de la metástasis es la única alternativa terapéutica que ha reportado beneficio en cuanto la supervivencia de estos pacientes.

Pancreatic metastases from renal cell carcinoma. Postoperative outcome after surgical treatment in a Spanish multicenter study (PANMEKID).

BACKGROUND: Renal Cell Carcinoma (RCC) occasionally spreads to the pancreas. The purpose of our study is to evaluate the short and long-term results of a multicenter series in order to determine the effect of surgical treatment on the prognosis of these patients. METHODS: Multicenter retrospective study of patients undergoing surgery for RCC pancreatic metastases, from January 2010 to May 2020. Variables related to the primary tumor, demographics, clinical characteristics of metastasis, location in the pancreas, type of pancreatic resection performed and data on short and long-term evolution after pancreatic resection were collected. RESULTS: The study included 116 patients. The mean time between nephrectomy and pancreatic metastases' resection was 87.35 months (ICR: 1.51-332.55). Distal pancreatectomy was the most performed technique employed (50 %). Postoperative morbidity was observed in 60.9 % of cases (Clavien-Dindo greater than IIIa in 14 %). The median follow-up time was 43 months (13-78). Overall survival (OS) rates at 1, 3, and 5 years were 96 %, 88 %, and 83 %, respectively. The disease-free survival (DFS) rate at 1, 3, and 5 years was 73 %, 49 %, and 35 %, respectively. Significant prognostic factors of relapse were a disease free interval of less than 10 years (2.05 [1.13-3.72], p 0.02) and a history of previous extrapancreatic metastasis (2.44 [1.22-4.86], p 0.01). CONCLUSIONS: Pancreatic resection if metastatic RCC is found in the pancreas is warranted to achieve higher overall survival and disease-free survival, even if extrapancreatic metastases were previously removed. The existence of intrapancreatic multifocal compromise does not always warrant the performance of a total pancreatectomy in order to improve survival.

Ventral Portal Vein Over Gallbladder and Pancreas---An Exceptional Anatomical Variation Found in a Liver Transplant Patient: A Case Report.

BACKGROUND: Anatomic variations are well known in the liver hilum. A rare precholecystic, preduodenal, prepancreatic portal vein is described as found in a liver transplant candidate. Precholecystic location of portal vein is an exceptional finding and does not seem to have been previously described. It is associated with a preduodenal portal vein. Its position is challenging, as its surface can be mistaken with the gallbladder wall. We present the case of a patient candidate to liver transplantation. In the preoperative studies, a portal thrombosis was suspected, with recanalization by collaterals, but also a malformation was suggested. The patient had a primary biliary cirrhosis. Other findings included agenesis of inferior vena cava on the right side. During operation, the portal vein was found over the gallbladder and fixed to it, making it at first difficult to distinguish one from the other. CONCLUSIONS: A precholecystic portal vein is a rare finding that poses a challenge for the surgeon. It must be ruled out in the preoperative workout.

Villous adenoma of the choledocho: an infrequent pathology of the main bile duct / Adenoma velloso de colédoco: una patología infrecuente de la vía biliar principal

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Overexpression of COL11A1 by cancer-associated fibroblasts: clinical relevance of a stromal marker in pancreatic cancer.

BACKGROUND: The collagen11A1 (COL11A1) gene is overexpressed in pancreatic cancer. The expression of COL11A1 protein could be involved in desmoplastic events in pancreatic cancer, but an antibody that specifically stains the COL11A1 protein is not currently available. METHODS AND FINDINGS: A total of 54 pancreatic ductal adenocarcinomas (PDAC), 23 chronic pancreatitis (CP) samples, and cultured peritumoral stromal cells of PDAC (passages 3-6) were studied. Normal human pancreas tissue samples were obtained through a cadaveric organ donation program. 1) Validation of COL11A1 gene overexpression by q-RT-PCR. FINDINGS: the expression of COL11A1 gene is significantly increased in PDAC samples vs. normal and CP samples. 2) Analysis of COL11A1 by immunohistochemistry using highly specific anti-proCOL11A1 antibodies. FINDINGS: anti-proCOL11A1 stains stromal cells/cancer-associated fibroblasts (CAFs) of PDAC but it does not stain chronic benign condition (chronic pancreatitis) stromal cells, epithelial cells, or normal fibroblasts. 3) Evaluation of the discrimination ability of the antibody. FINDINGS: anti-proCOL11A1 immunostaining accurately discriminates between PDAC and CP (AUC 0.936, 95% CI 0.851, 0.981). 4) Phenotypic characterization of proCOL11A1+ stromal cells co-staining with mesenchymal, epithelial and stellate cell markers on pancreatic tissue samples and cultured peritumoral pancreatic cancer stromal cells. FINDINGS: ProCOL11A1+ cells present co-staining with mesenchymal, stellate and epithelial markers (EMT phenotype) in different proportions. CONCLUSIONS/SIGNIFICANCE: Detection of proCOL11A1 through immunostaining with this newly-developed antibody allows for a highly accurate distinction between PDAC and CP. Unlike other available antibodies commonly used to detect CAFs, anti-proCOL11A1 is negative in stromal cells of the normal pancreas and almost absent in benign inflammation. These results strongly suggest that proCOL11A1 is a specific marker for CAFs, and thus, anti-proCOL11A1 is a powerful new tool for cancer research and clinical diagnostics.

Rectorragia como forma de presentación de un caso de síndrome de Abernethy en el adulto / Lower gastrointestinal bleeding as a form of presentation in an adult case of Abernethy syndrome

Presentamos el caso de una paciente de 29 años que consultó por rectorragias autolimitadas que fue diagnosticada de síndrome de Abernethy (shunt portosistémico congénito). Se trata de un debut clínico poco habitual en este tipo de síndrome congénito muy poco prevalente. La gran mayoría de los casos descritos en la literatura se manifiestan clínicamente en la edad pediátrica

We report the case of a 29-year-old patient who presented with a short history of lower gastrointestinal bleeding. A diagnosis of Abernethy syndrome was made (congenital extrahepatic portosystemic shunt) after this uncommon clinical presentation. The prevalence of this congenital malformation is very low and usually manifests during the pediatric age, according to previously published reports