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BACKGROUND: The aims of this narrative review were (i) to describe the current indications of SLKT, (ii) to report evolution of SLKT activity, (iii) to report the outcomes of SLKT, (iv) to explain the immune-protective effect of liver transplant on kidney transplant, (v) to explain the interest of delay kidney transplantation, using hypothermic machine perfusion (HMP), (vi) to report kidney after liver transplantation (KALT) indications and (vii) to describe the value of the increase in the use of extended criteria donors (ECD) and particular controlled donation after circulatory death (cDCD) transplant, thanks to the development of new organ preservation strategies. METHOD: Electronic databases were screened using the keywords "Simultaneous", "Combined", "kidney transplantation" and "liver transplantation". The methodological and clinical heterogeneity of the included studies meant that meta-analysis was inappropriate. RESULTS: A total of 1,917 publications were identified in the literature search. Two reviewers screened all study abstracts independently and 1,107 of these were excluded. Thus, a total of 79 full text articles were assessed for eligibility. Of these, 21 were excluded. In total, 58 studies were included in this systematic review. CONCLUSIONS: Simultaneous liver-kidney transplantation has made a significant contribution for patients with dual-organ disease. The optimization of indication and selection of SLKT patients will reduce futile transplantation. Moreover, increasing the use of transplants from extended criteria donors, in particular cDCD, should be encouraged, thanks to the development of new modalities of organ preservation.
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Trasplante de Riñón , Trasplante de Hígado , Preservación de Órganos , Humanos , Trasplante de Riñón/métodos , Preservación de Órganos/métodos , Predicción , Supervivencia de InjertoRESUMEN
AIMS: Several medicinal treatments for avoiding postoperative ileus (POI) after abdominal surgery have been evaluated in randomized controlled trials (RCTs). This network meta-analysis aimed to explore the relative effectiveness of these different treatments on ileus outcome measures. METHODS: A systematic literature review was performed to identify RCTs comparing treatments for POI following abdominal surgery. A Bayesian network meta-analysis was performed. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis. RESULTS: A total of 38 RCTs were included in this network meta-analysis reporting on 6371 patients. Our network meta-analysis shows that prokinetics significantly reduce the duration of first gas (mean difference [MD] = 16 h; credible interval -30, -3.1; surface under the cumulative ranking curve [SUCRA] 0.418), duration of first bowel movements (MD = 25 h; credible interval -39, -11; SUCRA 0.25) and duration of postoperative hospitalization (MD -1.9 h; credible interval -3.8, -0.040; SUCRA 0.34). Opioid antagonists are the only treatment that significantly improve the duration of food recovery (MD -19 h; credible interval -26, -14; SUCRA 0.163). CONCLUSION: Based on our meta-analysis, the 2 most consistent pharmacological treatments able to effectively reduce POI after abdominal surgery are prokinetics and opioid antagonists. The absence of clear superiority of 1 treatment over another highlights the limits of the pharmacological principles available.
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Ileus , Antagonistas de Narcóticos , Humanos , Metaanálisis en Red , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Ileus/tratamiento farmacológico , Ileus/etiología , Ileus/prevención & controlRESUMEN
BACKGROUND: In the event of symptomatic common bile duct (CBD) stones with dilated CBD, one possible curative treatment option is stone extraction through choledocotomy associated with cholecystectomy. Endoscopic treatment is only reserved for residual stones at 6 weeks. The aim of this study was to evaluate the results from laparoscopic curative surgical treatment of CBD stones with dilated CBD. METHODS: This is a retrospective single-centered cohort study. All consecutive patients admitted for laparoscopic cholecystectomy with evidence of CBD stones with dilated CBD from January 2010 to December 2020 at our center were included. Success was defined by CBD clearance at 6 weeks. Need for additional procedures, such as endoscopic sphincterotomy, immediate, and end-of-procedure morbi-mortality as well as factors associated with procedure failure, were also studied. RESULTS: A total of 246 patients who received curative treatment were included in the study. The success rate for the curative treatment was 93.1% (229 patients). Immediate postoperative morbidity was 24.4% with a 5.3% reintervention rate. Immediate and 6-week postoperative mortality rates were zero and 0.4%, respectively. The mean length of stay was 11.3 days. Factors associated with procedure failure appeared to be the occurrence of an early postoperative complication and the need for readmission during the period between surgery and drain removal. CONCLUSION: This study indicates that laparoscopic curative surgical treatment for symptomatic CBD stones may be performed with acceptable results without routine need for additional procedures.
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Colecistectomía Laparoscópica , Coledocolitiasis , Cálculos Biliares , Humanos , Estudios Retrospectivos , Estudios de Cohortes , Colangiopancreatografia Retrógrada Endoscópica/métodos , Cálculos Biliares/cirugía , Cálculos Biliares/complicaciones , Esfinterotomía Endoscópica/efectos adversos , Esfinterotomía Endoscópica/métodos , Colecistectomía Laparoscópica/métodos , Conducto Colédoco/cirugía , Coledocolitiasis/cirugíaRESUMEN
PURPOSE: A transjugular intrahepatic portosystemic shunt (TIPS) before the liver transplantation (LT) has been considered a contraindication in cases of hepatocellular carcinoma (HCC) because of the risk of tumour growth. We aimed to assess the impact of TIPS on incidental HCC and oncological outcomes in transplanted patients with pre-existing HCC. METHODS: All consecutive transplanted patients for cirrhosis who had a previous TIPS with or without HCC were included. Between 2007 and 2014, 1912 patients were transplanted. We included 122 (6.3%) patients having TIPS before LT. A 1:3 matched cohort of 366 patients (18.9%) having LT without previous TIPS was selected using a propensity score. Incidental HCC rate and risk factor of HCC recurrence were evaluated using multivariate analysis with a competing risk model. RESULTS: Before LT, in the TIPS group, 27 (22.1%) had an HCC vs. 81 (22.1%) in the control group (p = 1). The incidental HCC rate was similar: 10.5% (10/95) in the TIPS group vs. 6.3% (18/285) in the control group (p = 0.17). Recurrence occurred in 1/27 (3.7%) patient in the TIPS group and in 7/81 (8.6%) patients in the control group, without significant difference (p = 0.51). After multivariate regression, patient's gender (p < 0.01) was significantly associated with HCC recurrence while a tumour within Milan criteria (p = 0.01, sHR: 0.17 [0.04; 0.7]) and an incidental HCC (p<0.01) were found to be protector factors against HCC recurrence. CONCLUSION: TIPS did not worsen the prognosis of transplanted patients for HCC. TIPS should no longer be contraindicated for oncological reasons in patients with HCC waiting for an LT.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Trasplante de Hígado , Humanos , Carcinoma Hepatocelular/cirugía , Estudios Retrospectivos , Trasplante de Hígado/efectos adversos , Neoplasias Hepáticas/cirugía , Puntaje de Propensión , Recurrencia Local de Neoplasia/epidemiologíaRESUMEN
Immunohistochemistry (IHC) and/or MSI-PCR (microsatellite instability-polymerase chain reaction) tests are performed routinely to detect mismatch repair deficiency (MMR-D). Classical MMR-D tumors present a loss of MLH1/PMS2 or MSH2/MSH6 with MSI-High. Other profiles of MMR-D tumors have been described but have been rarely studied. In this study, we established a classification of unusual MMR-D tumors and determined their frequency and clinical impact. All MMR-D tumors identified between 2007 and 2017 were selected. Any profile besides the classical MMR-D phenotype was defined as unusual. For patients with unusual MMR-D tumors, IHC, and PCR data were reviewed, the tumor mutation burden (TMB) was evaluated and clinical and genetic features were collected. Of the 4948 cases of MMR testing, 3800 had both the available IHC and MSI-PCR results and 585 of these had MMR-D. After reviewing the IHC and PCR, 21% of the cases initially identified as unusual MMR-D were reclassified, which resulted in a final identification of 89 unusual MMR-D tumors (15%). Unusual MMR-D tumors were more often associated with non-CRC than classical MMR-D tumors. Unusual MMR-D tumors were classified into four sub-groups: i) isolated loss of PMS2 or MSH6, ii) classical loss of MLH1/PMS2 or MSH2/MSH6 without MSI, iii) four MMR proteins retained with MSI and, iv) complex loss of MMR proteins, with clinical characteristics for each sub-group. TMB-high or -intermediate was shown in 96% of the cancers studied (24/25), which confirmed MMR deficiency. Genetic syndromes were identified in 44.9% (40/89) and 21.4% (106/496) of patients with unusual and classical MMR-D tumors, respectively (P < 0.001). Five patients treated with an immune checkpoint inhibitor (ICI) had a prolonged clinical benefit. Our classification of unusual MMR-D phenotype helps to identify MMR deficiency. Unusual MMR-D phenotype occurs in 15% of MMR-D tumors. A high frequency of genetic syndromes was noted in these patients who could benefit from ICI.
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Neoplasias Colorrectales , Reparación de la Incompatibilidad de ADN , Neoplasias Colorrectales/genética , Neoplasias Colorrectales/patología , Humanos , Inestabilidad de Microsatélites , Endonucleasa PMS2 de Reparación del Emparejamiento Incorrecto/genética , Endonucleasa PMS2 de Reparación del Emparejamiento Incorrecto/metabolismo , Homólogo 1 de la Proteína MutL/genética , Homólogo 1 de la Proteína MutL/metabolismo , Proteína 2 Homóloga a MutS/genética , Fenotipo , SíndromeRESUMEN
BACKGROUND: Accurate prediction of portal hypertension recurrence after transjugular intrahepatic portosystemic shunt (TIPS) placement will improve clinical decision-making. PURPOSE: To evaluate if perioperative variables could predict disease-free survival (DFS) in cirrhotic patients with portal hypertension (PHT) treated with TIPS. MATERIALS AND METHODS: We recruited 206 cirrhotic patients with PHT treated with TIPS, randomly assigned to training (n = 138) and validation (n = 68) sets. We recorded 7 epidemiological, 4 clinical, and 9 radiological variables. TIPS-distal end positioning (TIPS-DEP) measured the distance between the distal end of the stent and the hepatocaval junction on contrast-enhanced CT scans. In the training set, the signature was defined as the random forest for survival algorithm achieving the lowest error rate for the prediction of DFS which was landmarked 4 weeks after the TIPS procedure. In the training set, a simple to use scoring system was derived from variables selected by the signature. The primary endpoint was to assess if TIPS-DEP was associated with DFS. The secondary endpoint was to validate the scoring system in the validation set. RESULTS: Overall, patients with TIPS-DEP ≥ 6 mm (n = 49) had a median DFS of 24.5 months vs. 72.8 months otherwise (n = 157, p = 0.004). In the training set, the scoring system was calculated by adding age ≥ 60 years old, Child-Pugh B or C, and TIPS-DEP ≥ 6 mm (1 point each) since the signature showed high DFS probability at 6.5 months post-landmark in patients that did not meet these criteria: 86%, 80%, and 78%, respectively. The hazard ratio [95 CI] between patients determined to be low-risk (< 2 points) and high-risk (≥ 2 points) was 2.30 [1.35-3.93] (p = 0.002) in the training set and 2.01 [0.94-4.32] (p = 0.072) in the validation set. CONCLUSION: TIPS-DEP is an actionable radiological biomarker which can be combined with age and Child-Pugh score to predict death or PHT symptom recurrence after TIPS procedure. KEY POINTS: ⢠TIPS-DEP measurement was the third most important but only actionable variable for predicting DFS. ⢠TIPS-DEP < 6 mm was associated with a DFS probability of 78% at 6.5 months post-landmark. ⢠A simple scoring system calculated using age, Child-Pugh score, and TIPS-DEP predicted DFS after TIPS.
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Hipertensión Portal , Derivación Portosistémica Intrahepática Transyugular , Toma de Decisiones Clínicas , Humanos , Hipertensión Portal/cirugía , Cirrosis Hepática/complicaciones , Cirrosis Hepática/cirugía , Persona de Mediana Edad , Estudios Retrospectivos , Stents , Resultado del TratamientoRESUMEN
OBJECTIVE: To compare 2 techniques of remnant liver hypertrophy in candidates for extended hepatectomy: radiological simultaneous portal vein embolization and hepatic vein embolization (HVE); namely LVD, and ALPPS. BACKGROUND: Recent advances in chemotherapy and surgical techniques have widened indications for extended hepatectomy, before which remnant liver augmentation is mandatory. ALPPS and LVD typically show higher hypertrophy rates than portal vein embolization, but their respective places in patient management remain unclear. METHODS: All consecutive ALPPS and LVD procedures performed in 8 French centers between 2011 and 2020 were included. The main endpoint was the successful resection rate (resection rate without 90-day mortality) analyzed according to an intention-to-treat principle. Secondary endpoints were hypertrophy rates, intra and postoperative outcomes. RESULTS: Among 209 patients, 124 had LVD 37 [13,1015] days before surgery, whereas 85 underwent ALPPS with an inter-stages period of 10 [6, 69] days. ALPPS was mostly-performed for colorectal liver metastases (CRLM), LVD for CRLM and perihilar cholangiocarcinoma. Hypertrophy was faster for ALPPS. Successful resection rates were 72.6% for LVD ± rescue ALPPS (n = 6) versus 90.6% for ALPPS (P < 0.001). Operative duration, blood losses and length-of-stay were lower for LVD, whereas 90-day major complications and mortality were comparable. Results were globally unchanged for CRLM patients, or after excluding the early 2âyears of experience (learning-curve effect). CONCLUSIONS: This study is the first 1 comparing LVD versus ALPPS in the largest cohort so far. Despite its retrospective design, it yields original results that may serve as the basis for a prospective study.
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Carcinoma Hepatocelular/terapia , Embolización Terapéutica/métodos , Hepatectomía/métodos , Venas Hepáticas/cirugía , Análisis de Intención de Tratar/métodos , Neoplasias Hepáticas/terapia , Vena Porta/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Femenino , Humanos , Ligadura/métodos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Optimal management of inferior vena cava (IVC) is crucial to ensure safety in late liver retransplantation (ReLT). The aim of this study was to evaluate different surgical strategies with regard to IVC in late ReLT. All consecutive late ReLT (≥90 days from the previous transplant) from 2013 to 2018 in a single center was reviewed (n = 66). Of them, 46 (69.7%) were performed without venovenous bypass (VVB) including 29 with caval preservation (CP) and 17 with caval replacement (CR). The remaining 20 cases (30.3%) required the use of VVB. Among ReLT without VVB, CP was associated with a lower number of packed red blood cells (median 4 vs. 7; P = 0.016) and a lower incidence of post-transplant acute kidney injury (6.9% vs. 47.1%; P = 0.003). The feasibility of CP was 95% (14/15) in patients with previous 3-vein piggyback caval anastomosis versus 48.3% (15/31) after other techniques (P = 0.003). Indirect signs of portal hypertension (PHT) before retransplantation were predictive of VVB requirement. Early and long-term outcomes were similar across the three groups (CP without VVB, CR without VVB, and VVB). Preserving the IVC in late ReLT is associated with better postoperative renal function and is facilitated by a previous 3-vein piggyback. Routine CR is not justified in late ReLT.
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Trasplante de Hígado , Humanos , Hígado , Reoperación , Estudios Retrospectivos , Vena Cava Inferior/cirugíaRESUMEN
BACKGROUND: Portal vein thrombosis (PVT) is a common complication following splenectomy. It affects between 5 and 55% of patients undergoing surgery with no clearly defined pre-operative risk factors. The aim of this study was to determine the pre-operative risk factors of PVT. PATIENTS AND METHOD: Single centre, retrospective study of data compiled for every consecutive patient who underwent splenectomy at Toulouse University Hospital between January 2009 and January 2019. Patients with pre- and post-surgical CT scans have been included. RESULTS: 149 out of 261 patients were enrolled in the study (59% were males, mean age 52 years). The indications for splenectomy were splenic trauma (30.9%), malignant haemopathy (26.8%) and immune thrombocytopenia (8.0%). Twenty-nine cases of PVT (19.5%) were diagnosed based on a post-operative CT scan performed on post-operative day (POD) 5. Univariate analysis identifies three main risk factors associated with post-operative PVT: estimated splenic weight exceeding 500 g with an OR of 8.72 95% CI (3.3-22.9), splenic vein diameter over 10 mm with an OR of 4.92 95% CI (2.1-11.8) and lymphoma with an OR of 7.39 (2.7-20.1). The role of splenic vein diameter with an OR of 3.03 95% CI (1.1-8.6), and splenic weight with an OR of 5.22 (1.8-15.2), as independent risk factors is confirmed by multivariate analysis. A screening test based on a POD 5 CT scan with one or two of these items present could indicate sensitivity of 86.2% and specificity of 86.7%. CONCLUSION: This study suggests that pre-operative CT scan findings could predict post-operative PVT. A CT scan should be performed on POD 5 if a risk factor has been identified prior to surgery.
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Vena Esplénica , Trombosis de la Vena , Humanos , Masculino , Persona de Mediana Edad , Vena Porta/diagnóstico por imagen , Estudios Retrospectivos , Factores de Riesgo , Esplenectomía/efectos adversos , Vena Esplénica/diagnóstico por imagen , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/epidemiología , Trombosis de la Vena/etiologíaRESUMEN
BACKGROUND: Anastomotic biliary strictures (AS) is the main surgical complication after liver transplantation. The aims of this study are to investigate the risk factors of AS, its management and its impact on overall survival and survival of the graft. METHODS: All patients who had received a liver transplantation with duct-to-duct anastomosis at Toulouse University Hospital between 2010 and 2016 were included. RESULTS: Of 225 included patients, 56 (24.9%) presented with AS. The median time to discovery of AS was 83 days and 69.6% of the AS appeared within 6 months. Transplantation in critically ill patients, with a liver score >800 points, was an independent predictive factor of survival (P = 0.003). The first-line treatment was endoscopic (87.5%), with a success rate of 79.6% and a median of 4 procedures per patient in 12 months. In cases of failure of endoscopic therapy, percutaneous treatment had a high failure rate (50%). AS had no impact in terms of overall survival or in terms of graft survival. CONCLUSION: AS do not have any repercussions on patient or graft survival, requiring long endoscopic treatment with multiple procedures. In the event of failure of this first-line endoscopic treatment, it seems preferable to turn directly towards surgical repair.
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Colestasis , Trasplante de Hígado , Anastomosis Quirúrgica/efectos adversos , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Colestasis/diagnóstico por imagen , Colestasis/etiología , Constricción Patológica , Humanos , Trasplante de Hígado/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Stents , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVES: To analyze overall survival (OS) rates for the three curative treatments of hepatocellular carcinoma (HCC) on an intention-to-treat (ITT) basis. METHODS: Cohort study based on data from a multidisciplinary team meeting (MDT) dedicated to HCC. From 2006 to 2013, we included every patient with newly diagnosed HCC, for whom curative treatment (liver transplantation (LT), radiofrequency ablation (RFA), surgical resection (SR)) was decided upon. RESULTS: We included 387 consecutive patients. LT was decided in 136 cases, RFA in 131 cases, SR in 120 cases. Sixty-six percent of patients received the planned treatment. Five-year OS on an ITT basis were: 35% for the LT-group, 32% for the RFA-group, 34% for the SR-group (P = 0.77). In multivariate analyses, the main negative prognostic factors were not following the MDT decision (HR: 0.39, CI95% [0.27-0.54], P < 0.001), elevated alpha-fetoprotein level (HR: 0.63, CI95% [0.45-0.87], P = 0.005), being outside the Milan criteria (HR: 0.45, CI95% [0.31-0.65], P < 0.001). When curative treatment was performed, per-protocol 5-year OS were 64% for LT, 34% for RFA, 40% for SR. CONCLUSION: On an ITT basis, OS was similar whatever the type of curative treatment chosen in MDT. Negative prognostic factors were not following the MDT decision, elevated alpha-fetoprotein, being outside the Milan criteria. J. Surg. Oncol. 2017;115:330-336. © 2016 Wiley Periodicals, Inc.
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Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Grupo de Atención al Paciente , Anciano , Ablación por Catéter/métodos , Estudios de Cohortes , Femenino , Humanos , Trasplante de Hígado/métodos , Masculino , Persona de Mediana Edad , Pronóstico , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Transarterial chemoembolization is the most common treatment used for HCC patients on liver transplant waiting list. The aims of this study are to evaluate the radio-histological correlation of the post-chemoembolization HCC response and its influence on overall survival (OS) and recurrence-free survival (RFS). METHODS: Monocentric, retrospective study, including liver transplant patients with HCC who received chemoembolization from 2007 to 2018. The response of the hypervascular nodules was evaluated according to mRECIST, EASL. RESULTS: A total of 70 patients with 122 hypervascular and 28 hypovascular HCCs were included. A complete radiological response concerned 34.3% patients. Concordance rates of hypervascular nodules (mRECIST, EASL and lipiodol uptake) with tumor necrosis ranged from 49% to 57%, with a specificity of 35% and a positive predictive value of 54%. Bilobar involvement was a predictive factor for incomplete radiological response. Major tumor necrosis was significantly correlated with the decrease in αFP level between the first CEL and liver transplantation. OS and RFS at 5 years were 64% and 60%, respectively, and 69% and 66% at complete radiological response. CONCLUSION: Radiological response is significantly related to histological tumor necrosis, but with poor prediction. In case of complete radiological response, OS and RFS seem to be improved.
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Chronic pancreatitis is one of the main risk factors for pancreatic cancer, but it is a rare event. Inflammation and oncogenes work hand in hand as key promoters of this disease. Tobacco is another co-factor. During alcoholic chronic pancreatitis, the cumulative risk of cancer is estimated at 4% after 15 to 20 years. This cumulative risk is higher in hereditary pancreatitis: 19 and 12% in the case of PRSS1 and SPINK1 mutations, respectively, at an age of 60 years. The diagnosis is difficult due to: (i) clinical symptoms of cancer shared with those of chronic pancreatitis; (ii) the parenchymal and ductal remodeling of chronic pancreatitis rendering imaging analysis difficult; and (iii) differential diagnoses, such as pseudo-tumorous chronic pancreatitis and paraduodenal pancreatitis. Nevertheless, the occurrence of cancer during chronic pancreatitis must be suspected in the case of back pain, weight loss, unbalanced diabetes, and jaundice, despite alcohol withdrawal. Imaging must be systematically reviewed. Endoscopic ultrasound-guided fine-needle biopsy can contribute by targeting suspicious tissue areas with the help of molecular biology (search for KRAS, TP53, CDKN2A, DPC4 mutations). Short-term follow-up of patients is necessary at the clinical and paraclinical levels to try to diagnose cancer at a surgically curable stage. Pancreatic surgery is sometimes necessary if there is any doubt.
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Background: Liver resection and local ablation are the only curative treatment for non-cirrhotic hepatocellular carcinoma (HCC). Few data exist concerning the prognosis of patients resected for non-cirrhotic HCC. The objectives of this study were to determine the prognostic factors of recurrence-free survival (RFS) and overall survival (OS) and to develop a prognostication algorithm for non-cirrhotic HCC. Methods: French multicenter retrospective study including HCC patients with non-cirrhotic liver without underlying viral hepatitis: F0, F1 or F2 fibrosis. Results: A total of 467 patients were included in 11 centers from 2010 to 2018. Non-cirrhotic liver had a fibrosis score of F0 (n=237, 50.7%), F1 (n=127, 27.2%) or F2 (n=103, 22.1%). OS and RFS at 5 years were 59.2% and 34.5%, respectively. In multivariate analysis, microvascular invasion and HCC differentiation were prognostic factors of OS and RFS and the number and size were prognostic factors of RFS (P<0.005). Stratification based on RFS provided an algorithm based on size (P=0.013) and number (P<0.001): 2 HCC with the largest nodule ≤10 cm (n=271, Group 1); 2 HCC with a nodule >10 cm (n=176, Group 2); >2 HCC regardless of size (n=20, Group 3). The 5-year RFS rates were 52.7% (Group 1), 30.1% (Group 2) and 5% (Group 3). Conclusions: We developed a prognostication algorithm based on the number (≤ or >2) and size (≤ or >10 cm), which could be used as a treatment decision support concerning the need for perioperative therapy. In case of bifocal HCC, surgery should not be a contraindication.
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BACKGROUND: The Mayo protocol for liver transplantation in patients with unresectable perihilar cholangiocarcinoma is based on strict selection and neoadjuvant chemoradiotherapy. The role of neoadjuvant chemoradiotherapy in this scenario remains unclear. The aim of this study was to compare outcomes after transplantation for perihilar cholangiocarcinoma using strict selection criteria, either with or without neoadjuvant chemoradiotherapy. METHODS: This was an international, multicentre, retrospective cohort study of patients who underwent transplantation between 2011 and 2020 for unresectable perihilar cholangiocarcinoma using the Mayo selection criteria and receiving neoadjuvant chemoradiotherapy or not receiving neoadjuvant chemoradiotherapy. Endpoints were post-transplant survival, post-transplant morbidity rate, and time to recurrence. RESULTS: Of 49 patients who underwent liver transplantation for perihilar cholangiocarcinoma, 27 received neoadjuvant chemoradiotherapy and 22 did not. Overall 1-, 3-, and 5-year post-transplantation survival rates were 65 per cent, 51 per cent and 41 per cent respectively in the group receiving neoadjuvant chemoradiotherapy and 91 per cent, 68 per cent and 53 per cent respectively in the group not receiving neoadjuvant chemoradiotherapy (1-year hazards ratio (HR) 4.55 (95 per cent c.i. 0.98 to 21.13), P = 0.053; 3-year HR 2.07 (95 per cent c.i. 0.78 to 5.54), P = 0.146; 5-year HR 1.71 (95 per cent c.i. 0.71 to 4.09), P = 0.229). Hepatic vascular complications were more frequent in the group receiving neoadjuvant chemoradiotherapy compared with the group not receiving neoadjuvant chemoradiotherapy (nine of 27 versus two of 22, P = 0.045). In multivariable analysis, tumour recurrence occurred less frequently in the group receiving neoadjuvant chemoradiotherapy (HR 0.30 (95 per cent c.i. 0.09 to 0.97), P = 0.044). CONCLUSION: In selected patients undergoing liver transplantation for perihilar cholangiocarcinoma, neoadjuvant chemoradiotherapy resulted in a lower risk of tumour recurrence, but was associated with a higher rate of early hepatic vascular complications. Adjustments in neoadjuvant chemoradiotherapy reducing the risk of hepatic vascular complications, such as omitting radiotherapy, may further improve the outcome in patients undergoing liver transplantation for perihilar cholangiocarcinoma.
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Neoplasias de los Conductos Biliares , Colangiocarcinoma , Tumor de Klatskin , Trasplante de Hígado , Humanos , Tumor de Klatskin/cirugía , Tumor de Klatskin/patología , Terapia Neoadyuvante , Recurrencia Local de Neoplasia/patología , Estudios Retrospectivos , Conductos Biliares Intrahepáticos/patologíaRESUMEN
BACKGROUND: In the current setting of organ shortage, brain-dead liver donors with recent liver trauma (RLT) represent a potential pool of donors. Yet, data on feasibility and safety of liver transplantation (LT) using grafts with RLT are lacking. METHODS: All liver grafts from brain-dead donors with RLT proposed for LT between 2010 and 2018 were identified from the nationwide CRISTAL registry of the Biomedicine Agency. The current study aimed at evaluating 1-y survival as the primary endpoint. RESULTS: Among 11 073 LTs, 142 LTs (1.3%) using grafts with RLT were performed. These 142 LTs, including 23 split LTs, were performed from 131 donors (46.1%) of 284 donors with RLT proposed for LT. Transplanted grafts were procured from donors with lower liver enzymes levels ( P < 0.001) and less advanced liver trauma according to the American Association for the Surgery of Trauma liver grading system ( P < 0.001) compared with not transplanted grafts. Before allocation procedures, 20 (7%) of 284 donors underwent damage control intervention. During transplantation, specific liver trauma management was needed in 19 patients (13%), consisting of local hemostatic control (n = 15), partial hepatic resection on back-table (n = 3), or perihepatic packing (n = 1). Ninety-day mortality and severe morbidity rates were 8.5% (n = 12) and 29.5% (n = 42), respectively. One-year overall and graft survival rates were 85% and 81%, and corresponding 5-y rates were 77% and 72%, respectively. CONCLUSIONS: Using liver grafts from donors with RLT seems safe with acceptable long-term outcomes. All brain-dead patients with multiorgan trauma, including liver injury, should be considered for organ allocation.
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Trasplante de Hígado , Obtención de Tejidos y Órganos , Heridas no Penetrantes , Humanos , Trasplante de Hígado/efectos adversos , Hígado , Donantes de Tejidos , Heridas no Penetrantes/etiología , Aloinjertos , Supervivencia de Injerto , Estudios RetrospectivosRESUMEN
BACKGROUND: The ABO blood group system may influence tumorigenesis, but its prognostic value in liver transplantation (LT) for hepatocellular carcinoma (HCC) has never been assessed. METHODS: All consecutive patients who underwent LT for HCC between 2013 and 2017 at 9 centers were analyzed. Predictors of tumor recurrence were identified using multivariable analysis, while comparison between group A and non-A recipients was performed after propensity score matching. RESULTS: Among 925 LT recipients, 406 were blood group A, 94 group B, 380 group O, and 45 group AB. On multivariable analysis, group A was associated with tumor recurrence (hazard ratio [HR] = 1.574 [95% confidence interval; 95% CI = 1.034-2.394] P = 0.034). After propensity score matching, 1- and 5-y recurrence rates were 7.4% and 20.1% in group A recipients versus 3.3% and 13.2% in non-A recipients (HR = 1.66 [95% CI = 1.12-2.45], P = 0.011). One and 5-y recurrence-free survivals were 85.2% and 66.8% in group A recipients versus 88.5% and 71.3% in non-A recipients (HR = 1.38 [95% CI = 1.01-1.90], P = 0.045). Among recipients within Milan criteria (n = 604), 1- and 5-y recurrence rates were 5.8% and 12.7% in group A recipients versus 3.1% and 12.2% in non-A recipients (HR = 1.197 [95% CI = 0.721-1.987], P = 0.485). Among recipients outside Milan criteria (n = 182), 1- and 5-y recurrence rates were 12.1% and 43.8% in group A recipients versus 3.9% and 15.6% in non-A recipients (HR = 3.175 [95% CI = 1.526-6.608], P = 0.002). CONCLUSIONS: ABO blood system influences the oncological outcome of recipients undergoing LT for HCC. Its incorporation in the prognostication model of LT for HCC may allow improving the management of LT candidates.
Asunto(s)
Carcinoma Hepatocelular , Neoplasias Hepáticas , Trasplante de Hígado , Sistema del Grupo Sanguíneo ABO , Carcinoma Hepatocelular/patología , Humanos , Neoplasias Hepáticas/patología , Trasplante de Hígado/efectos adversos , Recurrencia Local de Neoplasia/patología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
INTRODUCTION: Renal cell carcinoma (RCC) represents above 3 % of all cancers. At diagnosis, above 25 % of patients with RCC present an advanced disease. Gastric metastasis of RCC is associated with poor outcome. We report the case of a patient treated for a gastric metastasis of RCC and we conducted a systematic review of the literature to report all published cases of RCC patients with gastric metastasis. CASE PRESENTATION: In December 2010, a 61-year-old man was treated by open partial nephrectomy for a localized right clear cell RCC. In September 2018, a metachronous gastric metastasis was found on CT scan. The lesion was located on the lesser curvature of the stomach, measuring 4.5 cm long axis. No other secondary lesions were identified. A laparoscopic wedge resection, converted to laparotomy was performed. Two years later, in September 2020, a CT scan was performed, revealing a 17 mm adenopathy behind the hepatic hilum and a surgical management was performed, including a lymph node dissection of the hepatic hilum and the hepatic artery. Actually, he remains healthy. CLINICAL DISCUSSION AND CONCLUSION: Our systematic review suggests that solitary gastric metastasis of RCC are scarce. In comparison of patients with multiple metastatic sites, the median survival of patients with solitary gastric metastasis is longer.
RESUMEN
PURPOSE: To evaluate the impact of blended learning using a combination of educational resources (flipped classroom and short videos) on medical students' (MSs) for radiology learning. MATERIAL AND METHODS: A cohort of 353 MSs from 2015 to 2018 was prospectively evaluated. MSs were assigned to four groups (high, high-intermediate, low-intermediate, and low achievers) based on their results to a 20-MCQs performance evaluation referred to as the pretest. MSs had then free access to a self-paced course totalizing 61 videos based on abdominal imaging over a period of 3 months. Performance was evaluated using the change between posttest (the same 20 MCQs as pretest) and pretest results. Satisfaction was measured using a satisfaction survey with directed and spontaneous feedbacks. Engagement was graded according to audience retention and attendance on a web content management system. RESULTS: Performance change between pre and posttest was significantly different between the four categories (ANOVA, P = 10-9): low pretest achievers demonstrated the highest improvement (mean ± SD, + 11.3 ± 22.8 points) while high pretest achievers showed a decrease in their posttest score (mean ± SD, - 3.6 ± 19 points). Directed feedback collected from 73.3% of participants showed a 99% of overall satisfaction. Spontaneous feedback showed that the concept of "pleasure in learning" was the most cited advantage, followed by "flexibility." Engagement increased over years and the number of views increased of 2.47-fold in 2 years. CONCLUSION: Learning formats including new pedagogical concepts as blended learning, and current technologies allow improvement in medical student's performance, satisfaction, and engagement.