Circulating Tumor Cells in Patients Undergoing Resection of Colorectal Cancer Liver Metastases. Clinical Utility for Long-Term Outcome: A Prospective Trial.

BACKGROUND: Patients with resected colorectal cancer liver metastases display heterogeneous clinical behavior. The identification of new prognostic factors would help in making more accurate decisions. OBJECTIVE: The aim of this study was to evaluate the survival impact of circulating tumor cells (CTCs) in this setting. METHODS: We conducted a prospective study of patients with resected liver metastases of colorectal cancer. Patients were included in the study from February 2009 to January 2013. The CellSearch System™ was employed for the detection of pre- and postsurgery CTCs. A positive test was defined as two or more CTCs/7.5 mL of blood. Recurrence rate, disease-free survival, and overall survival were calculated, and univariate and multivariate analyses were performed. RESULTS: Forty-four patients were included in our study. After a median follow-up of 60 months (range 28-74), 32 patients experienced recurrence (72.7%). The CTCs number was determined and the test was positive in 8 patients (18.6%) before surgery and 13 patients (29.5%) after surgery. The postoperative detection of CTCs was not related to any clinical outcome; however, the preoperative detection of CTCs was significantly related to behavior. All patients in the preoperative CTC-positive group relapsed, versus 65% in the CTC-negative group (p = 0.051). Disease-free survival was 19 months in the preoperative CTC-negative group versus 7 months in the CTC-positive group (p = 0.01). Additionally, overall survival was 69 months in the preoperative CTC-negative group versus 17 months in the CTC-positive group (p = 0.004). Preoperative CTC count remained significant in multivariate analysis. CONCLUSIONS: In this cohort of colorectal cancer liver metastases patients, the presence of two or more preoperative CTCs was associated with disease progression and poor survival despite complete resection.

Acute recurrent pancreatitis secondary to hepatocellular carcinoma invading the biliary tree.

Hepatocellular carcinoma rarely invades the biliary tree. Clots or tumor embolus passing though the bile duct can cause pancreatitis by a mechanism similar to gallstone pancreatitis. We present the case of a patient with recurrent acute pancreatitis, initially suspicious of biliary origin. Despite cholecystectomy he had new episodes of acute pancreatitis. Hepatocellular carcinoma was diagnosed after the third episode. ERCP findings suggested the presence of a fistula connecting the tumor and the biliary tree. The patient was operated and the hepatocellular carcinoma was resected. Its pathological analysis confirmed the communication between the tumor and the biliary duct.

[Ectopic retroperitoneal thyroid gland]. / Ectopia tiroidea retroperitoneal.

The presence of subdiaphragmatic thyroid tissue is a very rare finding. We reviewed the literature and found only 15 published cases. The most appropriate management of this entity has not been established, but surgical removal is common to exclude malignancy. We present the case of a 76-year-old woman with an ectopic mesenteric thyroid gland forming a retroperitoneal mass that was surgically removed. Outcome was favorable.

Stent or surgery for incurable obstructive colorectal cancer: an individualized decision.

INTRODUCTION: In the setting of stage-IV obstructive colorectal cancer, self-expanding metallic stents (SEMS) placement and palliative surgery may be appropriate options. The aim of the present study is to evaluate the long-term results of surgery compared with stent implantation and to identify patients in whom one of these options can provide more benefit. MATERIALS AND METHODS: From November 2000 to November 2008, 98 patients with incurable stage-IV colorectal cancer were treated with palliative surgery (n=53) or SEMS (n=45). Data were recorded with respect to age, gender, tumor location, carcinoembryogenic antigen, ASAclass, presence of metastatic disease in one or multiple organs, volume of liver metastases, urgency of the procedure and treatment with chemotherapy. Comparison between surgery and stent placement was performed for all group and for patients who received and did not receive chemotherapy. RESULTS: Both groups were comparable regarding age, ASA-class, chemotherapy treatment, tumor location and presence of metastatic disease in one or multiple organs but not in gender, rate of urgent procedures, abnormal CEA and of volume of liver metastases >25%. Survival in surgical group was significantly higher (11.9 vs 7.3 months; log-rank test, p = 0.002). SEMS group had lower early morbidity, hospital stay and stoma creation. For patients who received chemotherapy, surgery provided benefit in survival (6.8 vs 3.9 months; log-rank test, p = 0.101); in this subgroup, long-term complications from the primary tumour were more common in stented group, and time to chemotherapy was longer in the group of surgery. No differences in survival were shown in patients who did not receive chemotherapy. CONCLUSION: Stent placement offers advantages regarding early morbidity, hospital stay and stoma creation. Surgery offers a benefit in survival in patients who receive chemotherapy but not in non-candidates to chemotherapy.

Feasibility and morbidity and mortality in two hundred consecutive cases of pancreaticogastrostomy after pancreaticoduodenectomy. / Factibilidad y morbimortalidad en doscientos casos consecutivos de pancreaticogastrostomía después de duodenopancreatectomía.

BACKGROUND: Postoperative mortality associated with pancreaticoduodenectomy (PD) in high-volume hospitals is below 5%, yet morbidity rates range between 45% and 60%. Recent studies show a lower incidence of complications and postoperative pancreatic fistula (POPF) in pancreaticogastrostomy (PG). The primary objective was to assess the incidence and predictive factors for complications: POPF, post-pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE) following the criteria of the ISGPS and Clavien-Dindo classifications. METHODS: A prospective observational study that included all patients who underwent PD between 2008 and 2016. PG was the surgical procedure of choice for PD reconstruction. RESULTS: Two hundred forty-nine patients underwent surgery with intention of performing a PD. The feasibility of PG was 90.5%. One hundred and six (53%) patients had complications, 36 (18%) were severe (Clavien-Dindo grade ≥III). Death within 90 postoperative days was 4%. DGE was the most frequent complication (22.5%), followed by PPH (21%). The clinical POPF rate was 15% (6% Clavien-Dindo grade ≥III). The primary risk factors associated with complications were age >70 years (1.9 [1-3.55]), being male (1.89 [1; 3.6]) and soft pancreatic texture (3.38 [1.5; 7.37]). CONCLUSIONS: In this paper, we report a feasibility study for PG (90.5%). The primary risk factors associated with complications were age >70 years, being male and soft pancreatic texture. Soft pancreatic texture is also associated with the development and severity of POPF.

[Surgical site infection in general surgery: 5-year analysis and assessment of the National Nosocomial Infection Surveillance (NNIS) index]. / Infección de sitio quirúrgico en un servicio de cirugía general. Análisis de cinco años y valoración del índice National Nosocomial Infection Surveillance (NNIS).

INTRODUCTION: The aim of this study was to describe the rate of surgical site infections (SSI), classified according to the NNIS index and its components, as well as to evaluate this scale and assess the importance of several factors that influence the development of an SSI. PATIENTS AND METHOD: All episodes of SSI were prospectively registered over a 5-year period. All patients (infected or not) were given an NNIS index and an NNIS category. Postoperative hospital stay and bacteria cultured from the surgical site were also analyzed. Chi2 test, Student's t-test and multiple logistic regression were used. RESULTS: There were 6,218 patients and 513 SSI (8.25%). The infection rate was 2.27% for clean surgery, 9.17% for clean-contaminated surgery, 11.40% for contaminated surgery, and 19.14% for dirty surgery; 4% for ASA I, 8.23% for ASA II, 13.54% for ASA III, 19.55% for ASA IV, and 33.33% for ASA V; 6.97% for length of procedure = 75th percentile, and 23.01% for > 75th percentile; 3.95% for NNIS 0, 8.17% for NNIS 1, 22.08% for NNIS 2, and 37.23% for NNIS 3. Among the components of the NNIS index, the length of the surgical procedure had the greatest influence on the rate of SSI (OR = 3.43 versus OR = 2.60 for the grade of contamination and OR = 2.20 for ASA index). The infection rates according to the type of intervention were: 30.9% in hepatobiliopancreatic surgery, 24.3% in small bowel surgery, 16.1% in colorectal surgery, 15.4% in gastroduodenal surgery; 8.5% in other soft tissue interventions, 7.7% in exploratory laparotomies, 6.4% in appendicectomies for appendicitis, 5.0% in cholecystectomy, 5.0% in other interventions of the digestive tract, 3.3% in breast surgery, 1.5% in herniorrhaphies, and 0.7% in endocrine surgery. CONCLUSIONS: The NNIS index is a valid instrument for classifying surgical patients according to the risk of developing an SSI. Of the three components, the length of the intervention has the greatest influence on increasing the risk of infection. The NNIS categories also distinguish different levels of risk of infection.