Tratamiento quirúrgico del colangiocarcinoma extrahepático / Surgical Treatment of Extrahepatic Cholangiocarcinoma

Introducción: El colangiocarcinoma constituye la neoplasia de la vía biliar más frecuente, la cual es responsable de una alta morbimortalidad. Objetivo: Determinar la morbilidad y la mortalidad por colangiocarcinoma extrahepático en el Servicio de Cirugía del Hospital Universitario Manuel Ascunce Domenech. Métodos: Se realizó un estudio descriptivo, prospectivo y observacional de pacientes que ingresaron en el Servicio de Cirugía General con diagnóstico de colangiocarcinoma extrahepático entre septiembre de 2018 y enero del 2022. El universo estuvo conformado por 21 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: La mayor incidencia de los pacientes fueron del sexo masculino y blancos, con el 71,4 por ciento y el 85,7 por ciento respectivamente. Predominó el adenocarcinoma como variedad histológica con un 85,7 por ciento, así como el colangiocarcinoma proximal y la variante esclerosante de su clasificación. El 71,4 por ciento de los pacientes egresaron vivos y con una cirugía con finalidad curativa. Conclusiones: La mayoría de los pacientes fueron masculinos, de color blanco y de procedencia rural. Los hallazgos más frecuentes fueron la localización proximal y la variante esclerosante. A más de la mitad de los pacientes se les realizó procedimiento de Hess y Whipple con finalidad curativa. La fuga biliar, el adenocarcinoma como tipo histológico y el estado al egreso vivo prevaleció en todos los pacientes(AU)

Introduction: Cholangiocarcinoma is the most frequent biliary tract neoplasm responsible for high morbidity and mortality. Objective: To determine morbidity and mortality due to extrahepatic cholangiocarcinoma in the surgery service of Hospital Universitario Manuel Ascunce Domenech. Methods: A descriptive, prospective and observational study was carried out with patients admitted to the general surgery service with a diagnosis of extrahepatic cholangiocarcinoma between September 2018 and January 2022. The study universe consisted of 21 patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: The highest incidence of patients were male and white-skinned, accounting for 71.4 percent and 85.7 percent, respectively. Adenocarcinoma predominated as histological variety, representing 85.7 percent, together with proximal cholangiocarcinoma and the sclerosing variant of its classification. 71.4 percent of the patients were discharged alive and after curative surgery. Conclusions: Most of the patients were male, white-skinned and from rural origin. The most frequent findings were a proximal location and the sclerosing variant. Over half the patients underwent Hess and Whipple procedure with curative purpose. Biliary leakage, adenocarcinoma as histologic type, and the condition of alive at discharge prevailed in all patients(AU)

Urgent liver retransplantation due to transmission of intrahepatic cholangiocarcinoma by donor: the first report in the literature / Retransplante de fígado urgente devido à transmissão de colangiocarcinoma intra-hepático pelo doador: o primeiro relato da literatura

ABSTRACT BACKGROUND: Liver transplantation represents the best therapeutic modality in end-stage chronic liver disease, severe acute hepatitis, and selected cases of liver tumors. AIMS: To describe a double retransplant in a male patient diagnosed with Crohn's disease and complicated with primary sclerosing cholangitis, severe portal hypertension, and cholangiocarcinoma diagnosed in the transplanted liver. METHODS: A 48-year-old male patient diagnosed with Crohn's disease 25 years ago, complicated with primary sclerosing cholangitis and severe portal hypertension. He underwent a liver transplantation in 2018 due to secondary biliary cirrhosis. In 2021, a primary sclerosing cholangitis recurrence was diagnosed and a liver retransplantation was indicated. Recipient's hepatectomy was very difficult by reason of complex portal vein thrombosis requiring extensive thromboendovenectomy. Intraoperative ultrasound with liver doppler evaluation was performed. Two suspicious nodules were incidentally diagnosed in the donor's liver and immediately removed for anatomopathological evaluation. RESULTS: After pathological confirmation of carcinoma, probable cholangiocarcinoma, at frozen section, the patient was re-listed as national priority and a new liver transplantation was performed within 24 hours. The patient was discharged after 2 weeks. CONCLUSIONS: The screening for neoplasms in donated organs should be part of our strict daily diagnostic arsenal. Moreover, we argue that, for the benefit of an adequate diagnosis and the feasibility of a safer procedure, the adoption of imaging tests routine for the liver donor is essential, allowing a reduction of the costs and some potential risks of liver transplant procedure.

RESUMO RACIONAL: O transplante de fígado representa a melhor modalidade terapêutica na doença hepática crônica terminal, hepatite aguda grave e casos selecionados de tumores hepáticos. OBJETIVOS: Descrever um retransplante duplo em paciente do sexo masculino, diagnosticado com doença de Crohn e complicado com colangite esclerosante primária, hipertensão portal grave e colangiocarcinoma diagnosticado no fígado transplantado. MÉTODOS: Paciente do sexo masculino, 48 anos, diagnosticado com doença de Crohn há 25 anos e complicado com colangite esclerosante primária e hipertensão portal grave. Foi submetido a um transplante de fígado em 2018 devido a cirrose biliar secundária. Em 2021, foi diagnosticada recidiva de colangite esclerosante primária e indicado retransplante hepático. A hepatectomia do receptor foi de alta complexidade devido à trombose complexa da veia porta, exigindo extensa tromboendovenectomia. Foi realizada ultrassonografia intraoperatória com doppler hepático. Dois nódulos suspeitos foram diagnosticados incidentalmente no fígado do doador e imediatamente removidos para avaliação anatomopatológica. RESULTADOS: Após confirmação patológica de carcinoma, provável colangiocarcinoma, pela congelação, o paciente foi relistado como prioridade nacional, e novo transplante hepático foi realizado em 24 horas. O paciente teve alta após 2 semanas. CONCLUSÕES: O rastreamento de neoplasias em órgãos doados deve fazer parte de nosso estrito arsenal diagnóstico diário. Além disso, defendemos que, em benefício de um diagnóstico correto e da viabilidade de um procedimento mais seguro, a adoção de uma rotina de exames de imagem é essencial em doadores hepáticos, permitindo a redução dos custos e alguns riscos potenciais do procedimento de transplante hepático.

The effect of prealbumin on the long-term prognosis of hilar cholangiocarcinoma following radical surgery / 中华外科杂志

Objective: To investigate the association between prealbumin and the long-term prognosis of patients with hilar cholangiocarcinoma(HCCA) following radical surgery. Methods: The clinical data of 262 HCCA patients who underwent radical surgery admitted from January 2010 to January 2017 at the First Affiliated Hospital of Army Medical University were collected,retrospectively. There were 158 males and 104 females; aged (57.6±9.9)years old(range:32 to 78 years). According to the preoperative serum prealbumin level(170 mg/L),the patients were divided into low prealbumin group(n=143) and normal prealbumin group(n=119). Follow-up until September 2020,the main research indicator was overall survival(OS), and the secondary research indicator was recurrence-free survival(RFS). The measurement data conforming to the normal distribution adopted the t test,the measurement data not conforming to the normal distribution adopted the Mann-Whitney U test,and the count data adopted the χ2 test. The Kaplan-Meier method was used to calculate the cumulative survival rate. The Log-rank test was used for univariate analysis of the cumulative survival rate. Variables with P<0.10 in univariate analysis were included in the Cox proportional hazards model for multivariate analysis. Results: The 1-, 3-, and 5-year OS rate of the 262 patients was 73.4%, 32.1%, and 24.0%, respectively, and the 1-, 3-, and 5-year RFS rate was 54.6%, 25.2%, and 16.2%, respectively. Median OS and RFS were 21 months and 12 months for patients with low prealbumin and 25 months and 19 months for patients with normal prealbumin. The OS rate and RFS rate of patients in the low prealbumin group were lower than those in the normal prealbumin group, and the difference was statistically significant (both P<0.05). The results of univariate analysis indicated that low prealbumin, CA19-9>150 U/L, tumor infiltration length>3 cm, preoperative jaundice, macrovascular invasion, microvascular invasion, lymph node metastasis, and poor differentiation maybe the risk factors of OS,and low prealbumin,tumor invasion length>3 cm,macrovascular invasion, microvascular invasion,lymph node metastasis,and poor differentiation maybe the risk factors of RFS for postoperative for radical resection in patients with HCCA (all P<0.10). Multivariate results suggested that low prealbumin,tumor invasion length>3 cm,microvascular invasion,lymph node metastasis,and poor differentiation were independent risk factors affecting OS and RFS in patients with HCCA after radical operation (all P<0.05). Conclusion: Preoperative prealbumin level can predict the long-term prognosis of patients with hilar cholangiocarcinoma following radical surgery.

A novel nomogram for individualized preoperative prediction of lymph node metastasis in patients with intrahepatic cholangiocarcinoma / 中华外科杂志

Objective: Constructing and validating a nomogram model for preoperative prediction of intrahepatic cholangiocarcinoma (ICC) lymph node metastasis to assist decision making during surgery. Methods: Retrospectively collecting the clinical and pathological data of 1 031 ICC patients who underwent partial hepatectomy at Eastern Hepatobiliary Surgery Hospital of Naval Military Medical University,General Hospital of Eastern Theater Command,or Zhongda Hospital Southeast University from January 2003 to January 2014. There were 682 males and 349 females; mean age was 54.7 years(range:18 to 82 years). There were 562 patients who underwent lymph node dissection and 469 patients who did not. Among the patients in the dissection group,Lasso regression method was used to filtrate preoperative variables related to lymph node metastasis and establish a nomogram. Bootstrap method was used to internally validate the discrimination of the nomogram,and the accuracy of the nomogram was assessed by using calibration curves. Patients were divided into low-moderate and high-risk groups based on model prediction probability. Propensity score matching(PSM) was used to analyze the overall survival (OS) and recurrence-free survival (RFS) of patients with and without lymph node dissection in the two groups,and to judge the importance of lymph node dissection in the two groups. Results: Six factors related to ICC lymph node metastasis were determined by Lasso regression,including hepatitis B surface antigen,CA19-9,age,lymphadenopathy,carcinoembryo antigen and maximum tumor diameter. These factors were integrated into a nomogram to predict ICC lymph node metastasis. The aera under curve value was 0.764,and the C-index was 0.754. Stratified analysis showed that OS and RFS in the high-risk group of lymph node metastasis were significantly lower than those in the low-medium risk group(median OS:14.6 months vs. 27.0 months,P<0.01; median RFS:9.1 months vs. 15.5 months,P<0.01). In the high-risk group,the median OS was 16.7 months and 6.3 months(Log-rank test: P=0.187;Wilcoxon test:P=0.046),and the median RFS was 11.0 months and 4.8 months(P=0.403),respectively in the lymph node dissection group and undissected group after PSM. In the low-medium-risk group,the median OS was 22.7 months and 26.7 months(P=0.288),and the median RFS was 13.0 months and 14.5 months(P=0.306),respectively in the lymph node dissection group and undissected group after PSM. Conclusions: The nomogram could be used for preoperative prediction of lymph node metastasis and prognostic stratification in patients with ICC. For patients with high risk of lymph node metastasis predicted by the model,active dissection should be performed. For patients predicted to be at low-moderate risk,lymph node dissection might be optional in some specific cases.

Impact of adjuvant chemotherapy on prognosis in intrahepatic cholangiocarcinoma patients underwent radical resection / 中华外科杂志

Objectives: To investigate the clinical value of adjuvant chemotherapy(ACT) in patients with intrahepatic cholangiocarcinoma(ICC) who underwent radical resection and to explore the optimal population that can benefit from ACT. Methods: A retrospective cohort study method was adopted. The clinical and pathological data of 685 patients with ICC who underwent curative intent resection in 10 Chinese hepatobiliary surgery centers from January 2010 to December 2018 were collected;There were 355 males and 330 females. The age(M(IQR)) was 58(14) years (range: 22 to 83 years). Propensity score matching(PSM) was applied to balance the differences between the adjuvant and non-adjuvant chemotherapy groups. Log-rank test was used to compare the prognosis of the two groups of patients. A Bayesian network recurrence-free survival(RFS) prediction model was constructed using the median RFS time (14 months) as the target variable, and the importance of the relevant prognostic factors was ranked according to the multistate Birnbaum importance calculation. A survival prognostic prediction table was established to analyze the population benefiting from adjuvant chemotherapy. Results: Among 685 patients,214 received ACT and 471 did not receive ACT. A total of 124 pairs of patients were included after PSM, and patients in the ACT group had better overall survival (OS) and RFS than those in the non-ACT group(OS: 32.2 months vs. 18.0 months,P=0.003;RFS:18.0 months vs. 10.0 months,P=0.001). The area under the curve of the Bayesian network RFS prediction model was 0.7124. The results of the prognostic factors in order of importance were microvascular invasion (0.158 2),perineural invasion (0.158 2),N stage (0.155 8),T stage (0.120 9), hepatic envelope invasion (0.090 3),adjuvant chemotherapy (0.072 1), tumor location (0.057 5), age (0.042 3), pathological differentiation (0.034 0), sex (0.029 3), alpha-fetoprotein (0.028 9) and preoperative jaundice (0.008 5). A survival prediction table based on the variables with importance greater than 0.1 (microvascular invasion,perineural invasion,N stage,T staging) and ACT showed that all patients benefited from ACT (increase in the probability of RFS≥14 months from 2.21% to 7.68%), with a more significant increase in the probability of RFS≥14 months after ACT in early-stage patients. Conclusion: ACT after radical resection in patients with ICC significantly prolongs the OS and RFS of patients, and the benefit of ACT is greater in early patients.

Colangiocarcinoma, diagnóstico, tratamiento y evolución clínica. Presentación de un caso con sobrevida 5 años / Cholangiocarcinoma: diagnosis, treatment and clinical evolution. Presentation of a case with five-year survival

RESUMEN El colangiocarcinoma es un tumor maligno originado en el epitelio de los conductos biliares intra o extrahepáticos. En el cuadro clínico destacan el dolor en hipocondrio derecho, ictericia y baja de peso. Actualmente, el diagnóstico se ha facilitado por la disponibilidad de variados procedimientos imagenológicos y endoscópicos. Se presentó un caso al que se le realizó el diagnóstico de este tipo de tumor. Se sometió a tratamiento endoscópico, quirúrgico y oncológico con Gemcitabina, Cisplatino y Oxaliplatino. Fue seguido por equipo multidisciplinario y evolucionó con sobrevida de 5 años (AU).

ABSTRACT Cholangiocarcinoma is a malignant tumor originated in the epithelium of the intra or extra hepatic biliary ducts. Pain in the right hypochondrium, jaundice and low weight are the main clinical features. Currently, the diagnosis has been facilitated by the availability of different imaging and endoscopic procedures. The authors presented a case diagnosed with this kind of tumor. The patient underwent surgical, endoscopic and oncologic treatment with gemcitabine, cisplatine and oxaliplatine. He was followed up by a multidisciplinary team and evolved with five-year survival (AU).

Protocol for liver transplantation in hilar cholangiocarcinoma / Protocolo de transplante hepático para colangiocarcinoma hilar

ABSTRACT Background: Hilar cholangiocarcinoma represents more than half of all cholangiocarcinoma cases, having poor prognosis and presenting a median overall survival after diagnosis of 12-24 months. In patients who have unresectable tumors with a better prognosis, the proposal to perform liver transplantation emerged for expanding the possibility of free margins by performing total hepatectomy. Aim: To provide a Brazilian protocol for liver transplantation in patients with hilar cholangiocarcinoma. Method: The protocol was carried out by two Brazilian institutions which perform a large volume of resections and liver transplantations, based on the study carried out at the Mayo Clinic. The elaboration of the protocol was conducted in four stages. Result: A protocol proposal for this disease is presented, which needs to be validated for clinical use. Conclusion: The development of a liver transplantation protocol for cholangiocarcinoma aims not only to standardize the treatment, but also enable a better assessment of the surgical results in the future.

RESUMO Racional: O colangiocarcinoma hilar representa mais da metade de todos os casos de colangiocarcinoma; tem prognóstico reservado e sobrevida global mediana de 12- 24 meses após o diagnóstico. A proposta de realizar transplante hepático surgiu para ampliar a possibilidade de margens livres através de hepatectomia total nos portadores de tumoresirressecáveis com melhor prognóstico. Objetivo: Apresentar protocolo brasileiro para realização de transplante hepático em pacientes com colangiocarcinoma hilar. Método: O protocolo foi realizado por duas instituições com grande volume de ressecções e transplantes hepáticos no Brasil, baseado no trabalho realizado pela MayoClinic. A elaboração foi dividida em quatro etapas. Resultado: É apresentada proposta de protocolo para esta doença a ser validada na aplicação clínica. Conclusão: Foi possível elaborar protocolo de transplante hepático para colangiocarcinoma a fim de uniformizar o tratamento e melhor avaliar os resultados cirúrgicos.

Tumor de Klatskin (colangiocarcinoma hiliar) su morbimortalidad en un servicio de cirugía / Klatskin's tumor (hilar cholangiocarcinoma) his morbi-mortality in a surgery service

RESUMEN Introducción: El tumor de Klatskin es el colangiocarcinoma, más frecuente de la vía biliar siendo responsable de una alta morbimortalidad en los servicios de cirugía. Objetivo: Determinar la morbilidad y la mortalidad por tumor de Klatskin en el Servicio de Cirugía del Hospital Universitario "Manuel Ascunce Domenech". Métodos: Se realizó un estudio descriptivo, prospectivo y observacional de pacientes que ingresaron en el Servicio de Cirugía General con diagnóstico de tumor de Klatskin, entre septiembre de 2018 y enero del 2020. El universo estuvo conformado por 7 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: La mayor incidencia de los pacientes fue de sexo masculino y de raza blanca, con un 71,4 por ciento y 85,7 por ciento respectivamente. Predominó adenocarcinoma como variedad histológica con un 85,7 por ciento. Tipo II de la clasificación topográfica, el procedimiento de Hess como operación realizada y la bilirragia como complicación prevaleció con un 42,8 por ciento respectivamente. El 85,7 por ciento de los pacientes egresaron vivos y con una cirugía con finalidad curativa. Conclusiones: La mayoría de los pacientes eran masculinos y de color blanco. Más de la mitad de los pacientes fueron clasificados como tipo I y II según clasificación de Bismuth-Corlette. El proceder de Hess, el adenocarcinoma como forma histológica y el estado del egreso vivo predominó en el total de pacientes(AU)

ABSTRACT Introduction: Klatskin's tumor is cholangiocarcinoma, most frequent to occur in the bile duct, being responsible for high morbidity and mortality in surgery departments. Objective: To determine the morbidity and mortality of Klatskin's tumor at the surgery service of Manuel Ascunce Domenech University Hospital. Methods: We carried out a descriptive, prospective and observational study of patients admitted to the general surgery service with a diagnosis of Klatskin's tumor, between September 2018 and January 2020. The study population consisted of seven patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: The highest incidence was represented male and white patients, accounting for 71.4 percent and 85.7 percent, respectively. Adenocarcinoma predominated as a histological variety, accounting for 85.7 percent. There was prevalence of type II of topographic classification, the Hess procedure as the performed operation, and bilirrhagia as a complication, accounting for 42.8 percent, respectively. 85.7 percent of the patients were discharged and received surgery for curative purposes. Conclusions: Most of the patients were male and white. More than half of the patients were classified as types I and II, according to the Bismuth-Corlette classification. The Hess procedure, adenocarcinoma as a histological form, and discharge predominated in all patients(AU)

Total laparoscopic vs. open liver resection: comparative study with propensity score matching analysis / Ressecções hepáticas totalmente laparoscópicas vs. abertas: estudo comparativo com pareamento por pontuação de propensão

ABSTRACT Background: There have been an increasing number of articles that demonstrate the potential benefits of minimally invasive liver surgery in recent years. Most of the available evidence, however, comes from retrospective observational studies susceptible to bias, especially selection bias. In addition, in many series, several modalities of minimally invasive surgery are included in the same comparison group. Aim: To compare the perioperative results (up to 90 days) of patients submitted to total laparoscopic liver resection with those submitted to open liver resection, matched by propensity score matching (PSM). Method: Consecutive adult patients submitted to liver resection were included. PSM model was constructed using the following variables: age, gender, diagnosis (benign vs. malignant), type of hepatectomy (minor vs. major), and presence of cirrhosis. After matching, the groups were redefined on a 1:1 ratio, by the nearest method. Results: After matching, 120 patients were included in each group. Those undergoing total laparoscopic surgery had shorter operative time (286.8±133.4 vs. 352.4±141.5 minutes, p<0.001), shorter ICU stay (1.9±1.2 vs. 2.5±2.2days, p=0.031), shorter hospital stay (5.8±3.9 vs. 9.9±9.3 days, p<0.001) and a 45% reduction in perioperative complications (19.2 vs. 35%, p=0.008). Conclusion: Total laparoscopic liver resections are safe, feasible and associated with shorter operative time, shorter ICU and hospital stay, and lower rate of perioperative complications.

RESUMO Racional: Com a disseminação da cirurgia hepática minimamente invasiva tem-se observado nos últimos anos número crescente de trabalhos que demonstram seus potencias benefícios. No entanto, a maior parte da evidência disponível provém de estudos observacionais retrospectivos sujeitos a vieses, em especial, os de seleção. Além disso, em muitas casuísticas são incluídas no mesmo grupo diversas modalidades de operações minimamente invasivas. Objetivo: Comparar os resultados perioperatórios (até 90 dias) de pacientes submetidos a ressecções hepáticas totalmente laparoscópicas com pacientes contemporâneos por cirurgias abertas, pareados por pontuação de propensão (propensity score matching PSM), submetidos a ressecções hepáticas convencionais. Método: Foram estudados pacientes adultos consecutivos submetidos à ressecção hepática. Para homogeneização dos grupos foi utilizado pareamento por pontuação de propensão, utilizando a variável idade, gênero, tipo de doença (benigna vs. maligna), tipo de hepatectomia (maior vs. menor) e presença de cirrose. A partir disto, os grupos foram redefinidos com proporção 1:1, pelo método nearest. Resultado: Após o pareamento foram incluídos 120 pacientes em cada grupo. Os submetidos à operação totalmente laparoscópica apresentaram menor tempo cirúrgico (286,8±133,4 vs. 352,4±141,5 min, p<0,001), menor tempo de internação em unidade de terapia intensiva (1,9±1,2 vs. 2,5±2,2dias, p=0,031), menor tempo de internação hospitalar (5,8±3,9 vs. 9,9±9,3dias, p<0,001) e redução de 45% nas complicações perioperatórias (19,2 vs. 35%, p=0,008). Conclusão: As ressecções hepáticas totalmente laparoscópicas são exequíveis, seguras e associadas à menor tempo operatório, menor tempo de internação em unidade de terapia intensiva e internação hospitalar, além de diminuição nas complicações perioperatórias.

Resección hepática extendida con vena cava inferior por colangiocarcinoma intrahepático: presentación de 2 casos / Extended hepatic resection with inferior cava vein for intrahepatic cholangiocarcinoma: presentation of two cases

Resumen Introducción: El colangiocarcinoma intrahepático (CIH) corresponde al segundo tumor hepático primario y la resección quirúrgica es la única alternativa válida para el tratamiento curativo de esta enfermedad. Reporte de casos: Describimos 2 paciente portadores de CIH con compromiso de vena cava inferior (VCI) que fueron sometidos a resección en Clínica Alemana de Santiago (CAS). Ambas pacientes son de género femenino de 39 y 47 años de edad. Ambas fueron sometidas a resección mayor hepática izquierda, asociada a resección del segmento I y extendida a VCI. La reconstrucción de la VCI fue realizada con parche pericárdico bovino y cierre primario respectivamente. El período desde el posoperatorio hasta el alta, fue de 13 y 23 días respectivamente. Discusión: Aunque la reseccion quirúrgica es la única vía para la curación en el CIH, el compromiso de estructuras vasculares hacen que esto no sea posible. El manejo multidisciplinario asociado a una técnica meticulosa realizada por un equipo quirúrgico experimentado, hacen posible lograr buenos resultados.

Introduction: Intrahepatic cholangiocarcinoma is the second most common primary liver tumor and surgical resection the only valid curative treatment. Case reports: We describe two patients harboring an intrahepatic cholangiocarcinoma with cava vein involvement who underwent resection at Clinica Alemana of Santiago. Both patients were females with ages of 39 and 47 years old. Both patients underwent left liver resection, associated to resection of segment I and of a portion of cava vein. Reconstruction of resected portion of the cava vein was performed by using a pericardium bovine patch and primary closure respectively. Postoperative period was uneventfully being discharged at 13 and 23 days respectively. Discussion: Although surgical resection is the only way to get curativeness, frequent involvement of large vascular structures make treatment unfeasible. A multidisciplinary approach associated with a meticulous technique performed by an experienced surgical team make possible to accomplish the above objective.

Pancreaticoduodenectomy: impact of the technique on operative outcomes and surgical mortality / Duodenopancreatectomia: impacto da técnica nos resultados operatórios e mortalidade cirúrgica

ABSTRACT Background: Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s. Aim: To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication. Method: Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication. Results: Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001). Conclusion: There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.

RESUMO Racional : A duodenopancreatectomia (DP) é procedimento associado com significativa morbimortalidade. Inicialmente descrita como gastroduodenopancreatectomia (GDP), a possibilidade de preservação do antro gástrico e piloro foi descrita na década de 1970. Objetivo : Avaliar a mortalidade e variáveis operatórias da DP com ou sem preservação pilórica e correlacioná-las com a técnica adotada e indicação cirúrgica. Método: Estudo de coorte histórica, baseado em análise de dados de registros médicos de indivíduos submetidos à DP entre os anos de 2012 a 2017. Foram analisadas variáveis demográficas, antropométricas e operatórias e correlacionadas com a técnica adotada (GDP vs. DP) e a indicação cirúrgica. Resultados : Dos 87 indivíduos avaliados, 38 (43,7%) foram submetidos à GDP e 49 (53,3%) à DP. A frequência de realização da GDP (62,5%) foi significativamente maior entre os pacientes com neoplasia de pâncreas (p=0,04). O tempo de internação total foi significativamente menor entre os indivíduos submetidos à ressecção por neoplasias de comportamento menos agressivo (p=0,04). A mortalidade cirúrgica foi de 10,3%, não havendo diferença entre GDP e DP. A mortalidade foi significativamente maior entre os indivíduos submetidos à ressecção por pancreatite crônica (p=0,001). Conclusão : Não houve diferenças na morbimortalidade, tempo cirúrgico, sangramento ou tempo de internação entre GDP e DP. A neoplasia de cabeça de pâncreas associou-se mais com indicação de GDP. A ressecção de neoplasias menos agressivas associou-se a menor morbimortalidade.

Resultados del tratamiento quirúrgico del colangiocarcinoma intrahepático / Intrahepatic cholangiocarcinoma: experience in 30 operated patients

background: Intrahepatic cholangiocarcinoma (ICC) corresponds to 10% of liver primary malignant tumors. Aim: To show the results of surgical treatment of ICC in a biliary surgery center. material and methods: Review of a prospective database of operated patients at a surgical service of a clinical hospital. Thirty operated patients with an ICC, aged 25 to 83 years (20 women), were identified. Results: Twenty six patients had symptoms, 12 of 19 had high levels of CA19-9 and in four the tumor was non resectable. Twenty four patients underwent major hepatectomy and two, a minor hepatectomy. Combined resections were performed in three patients. Lymphadenectomy was performed in 14 patients and five had lymph node metastases. Surgical time was 272 minutes, mean intensive care unit stay was 10 days and mean ventilatory support use was five days. Surgical mortality was 19% and complications appeared in 53% of patients. Tumors were stage I, II, III and IV in 11, 5, 3 and 11 patients respectively. Overall survival was 16 months. Survival in tumors stage I and II was 50% at five years. In stages III and IV, it was 11.2 months. Conclusions: Surgery for ICC has an acceptable mortality and complications rate with a five years survival of 25%.

Introducción: El colangiocarcinoma intrahepático (CCIH), corresponde al segundo cáncer primario hepático, representando alrededor del 10% de los cánceres primarios del hígado; el tratamiento es la hepatectomía. Objetivo: Mostrar los resultados del tratamiento quirúrgico de pacientes con CCIH en Chile en un centro de cirugía hepatobiliar. Pacientes y métodos: Análisis prospectivo de los pacientes con CCIH operados en nuestro centro entre 2005 y 2015. Resultados: 30 pacientes, 20 mujeres (67%), 10 hombres (33%). Edad promedio: 60 años (rango 25-83 ), 26 pacientes sintomáticos (87%), CA19-9 elevado en 12 (63,2%), 4 pacientes (13%) irresecables, 24 pacientes (80%) hepatectomías mayores y 2 resecciones menores. Resecciones combinadas en 3, linfadenectomía en 14 pacientes (47%), metástasis linfonodales en 5 (17%). Tiempo promedio quirúrgico 272 min (rango 45-480). UCI, mediana 10 días, ventilación mecánica mediana 5 días. Hospitalización, mediana 10 días y 7 días postoperatorio. Morbilidad 53%, mortalidad 19%. R0 en 19 pacientes (64%), R1 en 7 pacientes (23%) y R2 en 4 pacientes (13%). Estadio I en 11 pacientes, estadio II en 5 pacientes, estadio III en 3 pacientes, estadio IV en 11 pacientes. Sobrevida general de 16 meses. Sobrevida estadio I 58,4 meses, estadio II 31,1 meses, estadio III 5,9 meses y estadio IV 11,8 meses, p = 0,06. Sobrevida R0 16 meses, R1: 31,1 meses y R2: 9,25 meses, p = 0,53. Sobrevida estadios I y II 50% a 5 años, estadios III-IV 11,2 meses, p < 0,01. Discusión: Este es el primer reporte nacional de una serie importante de pacientes con CCIH, con morbilidad y mortalidad aceptables. Sobrevida de 25% a 5 años.

Seleccionando candidatos para tratamiento quirúrgico de las neoplasias hepáticas primarias malignas, riesgos y resultados / Selecting candidates for surgical treatment of malignant primary liver tumors: risks and results

Surgical resection is the treatment of choice in patients with primary liver neoplasm, both hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Results for surgical morbidity, mortality, overall survival and recurrence are better if the correct protocols are implemented for the selection of patients. The surgical goal of this modality of treatment is based in a complete excision of the tumor with free resection margins, associated with a preservation of liver functionality. Due to the association between HCC and liver cirrhosis, is critical to establish surveillance protocols in those patients who are at high risk of developing HCC. Once the diagnosis of HCC is confirmed, patient selection is made according to the characteristics of the tumor, hepatic function and performance status. In patients who are not candidates for hepatic resection, liver transplantation offers a treatment alternative. Selection criteria are based principally on size and number of lesions. ICC is a bad prognosis disease, due to late diagnosis. Surgical resection represents the main therapeutic option. Patient selection is based on imaging findings. ICC staging is made based on the number of lesions and the presence of vascular invasion, but not tumor size. In contrast with HCC, liver transplantation in patients with ICC is a controversial alternative.

El tratamiento quirúrgico es actualmente la modalidad terapéutica de elección para las neoplasias primarias hepáticas, tanto para el carcinoma hepatocelular (CHC) como para el colangiocarcinoma intrahepático (CCI). Los resultados en cuanto a morbilidad quirúrgica, sobrevida global y recidiva tumoral mejoran cuando se establecen correctos protocolos de selección de pacientes. El objetivo quirúrgico en el tratamiento de estas neoplasias se basa en la erradicación completa de la masa tumoral, con márgenes quirúrgicos adecuados, asociado a la preservación de la funcionalidad hepática. En el caso del CHC, debido a su asociación con cirrosis hepática es fundamental establecer protocolos de vigilancia en pacientes susceptibles. Una vez que se establece el diagnóstico, la selección de los pacientes se realiza en base a las características del tumor, la funcionalidad hepática y la capacidad funcional. En aquellos pacientes que no son candidatos a resección quirúrgica, el trasplante hepático representa una alternativa de tratamiento, para lo que se han establecido criterios que se basan principalmente en el tamaño y número de lesiones. El CCI es una enfermedad de mal pronóstico, debido a que el diagnóstico se realiza generalmente en etapas avanzadas. El tratamiento quirúrgico es la principal alternativa terapéutica. La selección de los pacientes se basa en los hallazgos imagenológicos. La etapificación se realiza de acuerdo al número de lesiones y la invasión vascular, pero no el tamaño tumoral. A diferencia del CHC, el trasplante hepático en pacientes con CCI es una alternativa controversial.

Endoscopic drainage in patients with inoperable hilar cholangiocarcinoma

Hilar cholangiocarcinoma has an extremely poor prognosis and is usually diagnosed at an advanced stage. Palliative management plays an important role in the treatment of patients with inoperable hilar cholangiocarcinoma. Surgical, percutaneous, and endoscopic biliary drainage are three modalities available to resolve obstructive jaundice. Plastic stents were widely used in the past; however, self-expanding metal stents (SEMS) have become popular recently due to their long patency and reduced risk of side branch obstruction, and SEMS are now the accepted treatment of choice for hilar cholangiocarcinoma. Bilateral drainage provides more normal and physiological biliary flow through the biliary ductal system than that of unilateral drainage. Unilateral drainage was preferred until recently because of its technical simplicity. But, with advancements in technology, bilateral drainage now achieves a high success rate and is the preferred treatment modality in many centers. However, the choice of unilateral or bilateral drainage is still controversial, and more studies are needed. This review focuses on the endoscopic method and discusses stent materials and types of procedures for patients with a hilar cholangiocarcinoma.

Colangiocarcinoma hilar (tumor de klatskin) / Colangiocarcinoma hilar (Klatskin tumor)

Os adenocarcinomas constituem quase a totalidade de todas as malignidades encontradas no intestino grosso, sendo a maioria originada a partir de pólipos adenomatosos. Por isso é muito importante a realização de exames de rastreamento com intuito de um diagnóstico precoce, proporcionando um tratamento curativo.

Percutaneous endoscopic gastrostomy/jejunostomy combined with percutaneous transhepatic biliary drainage in treating malignant biliary obstruction

To investigate the safety and efficacy of percutaneous endoscopic gastrostomy/jejunostomy [PEG/PEJ] combined with percutaneous transhepatic biliary drainage [PTCD] in treating malignant biliary obstruction. Nine patients [6 males and 3 females, average age 71.3 +/- 5.5 years] with complete obstruction of the biliary tract were treated with PEG/PEJ after PTCD. The PEG/PEJ and PTCD tubes were linked outside of the abdominal wall to direct the externally drained bile back to the jejunum through the PEG/PEJ intestinal tube. Clinical symptoms and liver function were assessed following the treatment. The operations were successfully completed in the 9 patients within 40 min [average 35 +/- 2.9 min]. Clinical symptoms such as jaundice, abdominal distension, stomachache and diarrhea appeared but improved within 7 days of the operation. Serum levels of bilirubin, aspartate aminotransferase and alanine aminotransferase were reduced [p < 0.01] 4 weeks following the treatment. There were no procedural complications. Combined PEG/PEJ and PTCD appeared to be safe and effective in the management of malignant biliary obstruction. Further, larger-scale studies will be needed to verify findings of this report

Quistes de colédoco en adultos / Choledochal cysts in adults

Introducción: Los quistes de colédoco en adulto son muy raros ya que la mayoría se diagnostica antes de los 10 años de edad. Los síntomas más frecuentes son dolor abdominal e ictericia, principalmente en mujeres. El objetivo de esta investigación fue informar la experiencia en el manejo de quistes de colédoco en adultos en un hospital de tercer nivel. Material y métodos: Estudio retrospectivo, descriptivo, observacional y transversal de la evolución posoperatoria de pacientes adultos con diagnóstico de quistes de colédoco tratados en un servicio de cirugía general en un periodo de 17 años. Resultados: Fueron en total 23 pacientes, de los cuales 16 fueron mujeres, con una mediana de edad de 26 años. Los síntomas principales fueron dolor abdominal (87 %) e ictericia (57 %). Solo cuatro pacientes (17 %) tuvieron además de estos síntomas tumor abdominal. El método diagnóstico más utilizado fue ultrasonido (100 %) seguido de colangiografía endoscópica (78 %) y tomografía computarizada de abdomen (74 %). De acuerdo con la clasificación de Todani, el tipo de quiste fue I en 17 pacientes, II en dos pacientes, III en tres pacientes y IV-A en un paciente. Todos fueron intervenidos quirúrgicamente, a 18 se les realizó resección del quiste y hepatoyeyuno anastomosis, a dos resección del quiste y a tres esfinteroplastia transduodenal. Hubo complicaciones posoperatorias en siete pacientes (35 %) y no hubo mortalidad operatoria. Solo en uno se informó colangiocarcinoma. Conclusiones: La cirugía de elección para el manejo de los quistes de colédoco es la resección del mismo, con morbilidad y mortalidad aceptables.

BACKGROUND: Choledochal cysts are usually diagnosed during childhood. They mainly affect females. Abdominal pain and jaundice are the two most common symptoms. Our objective was to report the experience of a third-level referral center in the management of choledochal cysts in adults. METHODS: We performed a 17-year retrospective review of patients with choledochal cysts who underwent surgical interventions in a gastrointestinal surgery department. RESULTS: There were 23 patients with a median age of 26 years; 16 were females. The most frequent symptoms were abdominal pain and jaundice. Only four patients had an abdominal mass. The most frequently used diagnostic studies were abdominal sonography and endoscopic retrograde cholangiopancreatography. According to the classification of Todani, most cysts were type I and were found in 17 patients, two patients had type II, three patients had type III (choledocele) and one patient had type IVA. Eighteen patients underwent complete removal of the cyst with a concomitant hepatic-jejunostomy, three patients had transduodenal sphincteroplasty and two patients had only cystectomy. Seven patients developed postoperative complications, representing a morbidity rate of 35%. None of the patients died during the first 30 postoperative days. Cholangiocarcinoma was found in the resected specimen in only one case. CONCLUSIONS: The surgery of choice for choledochal cysts in the adult is hepatojejunostomy, which has a low surgical morbidity and mortality.

Role of multidetector CT [MDCT] in preoperative resectability assessment of central cholangiocarcinoma

CT is an excellent imaging technique for evaluating the soft-tissue extent of hilar cholangiocarcinoma and the relation between the tumor and the hepatic vasculature. To assess the role of multidetector CT [MDCT] in preoperative resectability assessment of hilar cholangiocarcinoma. The study included 20 patients presenting with hilar cholangiocarcinoma. Informed consent signed by the patients. All patients subjected to proper history taking, clinical examination as well as routine laboratory investigations. Triphasic abdominal MDCT. Post-processing techniques including multi-planner reformation [MPR], maximum intensity projection [MIP] and minimum intensity projection [MinIP]. 11 patients with portal vein invasion, 10 patients with hepatic artery invasion. Four patients had type I obstruction; four patients, type II obstruction; two patients, type IIIa obstruction; four patients, type IIIb obstruction; and six patients, type IV obstruction. The tumors were considered resectable in 12 patients in the preoperative assessment. Multidetector CT provides important information on the preoperative assessment of central cholangiocarcinoma resectability and the extent of surgery

Hepatectomía derecha extendida por colangiocarcinoma intrahepático en un paciente con síndrome de Dubin-Johnson / Hepatectomy for cholangiocarcinoma in one patient with Dubin Johnson syndrome

Dubin-Johnson syndrome (SDJ) is a rare benign autosomal recessive congenital disease that causes jaundice. We report a 71 years old male with a Dubin Jonson syndrome diagnosed at the age of 40. On a ultrasound examination and magnetic resonance imaging, a liver tumor was found, that was excised. The pathology report showed a cholangiocarcinoma. During the postoperative period, the patient had a hyperbilirubinemia that subsided slowly. There are reports of hyperbilirubinemia of difficult management after hepatectomy in patients with Dubin-Johnson syndrome.

El síndrome de Dubin-Johnson (SDJ) es una patología benigna, familiar, con carácter autosómico recesivo y de aparición poco frecuente. Consiste en un defecto en la excreción hepática de la bilirrubina conjugada que permite su entrada al canalículo biliar, manifestando un cuadro clínico de ictericia silente. La asociación de esta enfermedad con colangiocarcinoma intrahepático es excepcional, siendo difícil la sospecha precoz de este diagnóstico y también el manejo de la ictericia postoperatoria. El objetivo de este trabajo es describir un caso clínico con estas características y revisión de la literatura existente. Se presenta a un paciente de sexo masculino de 71 años de edad, con antecedente de síndrome de Dubin-Johnson diagnosticado a los 40 años. Asintomático, en exámenes de rutina se encuentra un tumor hepático en la ecotomografía abdominal, que luego se corrobora en la TAC y RNM, mide aproximadamente 10 cm de diámetro, de ubicación central y derecho. Resto de estudio no muestra diseminación. Se realiza laparoscopia diagnóstica y ecografía intraoperatoria confirmando lo visto por imágenes, y se decide convertir a laparotomía para efectuar hepatectomía derecha extendida. Biopsia rápida y diferida informan colangiocarcinoma. Evoluciona favorablemente en el postoperatorio, con hiperbilirrubinemia sostenida de lenta resolución. La asociación de hepatectomía con síndrome de Dubin-Johnson es de muy baja frecuencia, existiendo poca literatura al respecto. Se ha descrito que la hiperbilirrubinemia en el postoperatorio es de difícil manejo, sin embargo, en este caso el paciente evolucionó favorablemente sin necesidad de alguna terapia específica.

Pancreaticoyeyunostomía ducto-seromuscular término-lateral en la operación whipple: experiencia en 27 casos / Seromuscular end pancreaticojejunostomy-duct-side in the whipple operation: experience with 27 cases

Presentar la experiencia con la anastomosis ductoserosa termino-lateral en la pancreaticoyeyunostomía del Whipple, en el Servicio de Cirugía General del Instituto Autónomo Hospital Universitario de Los Andes, Mérida-Venezuela. Estudio prospectivo, descriptivo en pacientes sometidos a duodenopancreatectomía por patología maligna a nivel pancreático y región periampular entre los años 2003 a 2007. En todos los casos se realizó preservación pilórica con anastomosis ducto-serosa termino-lateral del remanente pancreático, con colocación de stent intraductal, excepto en un caso donde se realizó la técnica invaginante término-terminal. Se evaluaron las complicaciones postoperatorias inherentes a la técnica quirúrgica, haciendo especial énfasis en la fístula pancreática. Un total de 27 pacientes durante el período 2003 a 2007 fueron sometidos a duodenopancreatectomía cefálica en forma electiva por etiología maligna tales como: ampuloma II casos, colangiocarcinoma distal 2 casos, cáncer de páncreas 12 casos, tumor neuroendocrino 1 caso, adenoma velloso malignizado de colédoco 1 caso. Las edades estuvieron comprendidas entre 42-81 años con promedio de 61 años, predominantemente del sexo femenino en una proporción 4:1. Entre las complicaciones posquirúrgicas relacionadas con la técnica encontramos 4 casos (14.8 por ciento) dado por: 2 fístulas pancreáticas (una de ellas por la ligadura accidental del stent intraductal), 1 dehiscencia de la duodenopancreatectomía, siendo la causa de muerte, y finalmente un caso de atonía gástrica manejado médicamente en forma satisfactoria. La anastomosis ducto-serosa en el manejo del remanente pancreático del Whipple constituye una técnica de fácil ejecución y con buenos resultados, ya que ofrece menos morbimortalidad.