Liver transplantation in colorectal metastases. Is there an indication for this procedure?

Almost 25 % of patients with colorectal cancer present metastases at the time of diagnosis and 50 % go on to develop metastases in the course of the disease. Surgical resection is the only curative treatment although only between 20 % and 30 % of patients present resectable lesions. Although liver transplantation is contraindicated in unresectable metastases of colorectal cancer, ever since the publication of the results of a pilot study there has been renewed interest in transplantation in these patients. In two consecutive trials overall and recurrence-free 5-year survival rates of 83 % and 35 % respectively, have been reported, Currently several trials are ongoing which are expected to allow the patient selection criteria for the indication of liver transplantation to be refined.

Increased Aquaporin-7 Expression Is Associated with Changes in Rat Brown Adipose Tissue Whitening in Obesity: Impact of Cold Exposure and Bariatric Surgery.

Glycerol is a key metabolite for lipid accumulation in insulin-sensitive tissues. We examined the role of aquaporin-7 (AQP7), the main glycerol channel in adipocytes, in the improvement of brown adipose tissue (BAT) whitening, a process whereby brown adipocytes differentiate into white-like unilocular cells, after cold exposure or bariatric surgery in male Wistar rats with diet-induced obesity (DIO) (n = 229). DIO promoted BAT whitening, evidenced by increased BAT hypertrophy, steatosis and upregulation of the lipogenic factors Pparg2, Mogat2 and Dgat1. AQP7 was detected in BAT capillary endothelial cells and brown adipocytes, and its expression was upregulated by DIO. Interestingly, AQP7 gene and protein expressions were downregulated after cold exposure (4 °C) for 1 week or one month after sleeve gastrectomy in parallel to the improvement of BAT whitening. Moreover, Aqp7 mRNA expression was positively associated with transcripts of the lipogenic factors Pparg2, Mogat2 and Dgat1 and regulated by lipogenic (ghrelin) and lipolytic (isoproterenol and leptin) signals. Together, the upregulation of AQP7 in DIO might contribute to glycerol influx used for triacylglycerol synthesis in brown adipocytes, and hence, BAT whitening. This process is reversible by cold exposure and bariatric surgery, thereby suggesting the potential of targeting BAT AQP7 as an anti-obesity therapy.

Delays to surgery following chemoradiotherapy lead to poorer oncologic outcomes in patients with localized pancreatic adenocarcinoma.

BACKGROUND: although neoadjuvant chemoradiotherapy (NCRT) and surgery are accepted as treatments for pancreatic ductal adenocarcinoma (PDAC), some authors have highlighted the risks of delaying surgery. The objective of this study was to analyze the impact of prolonging the time interval between NCRT and surgery (NCRT-TTS) in PDAC. METHODS: patients treated with NCRT and pancreatoduodenectomy (PD) were identified. Clinical, histopathological variables were analyzed about whether NCRT-TTS was greater or less than 50 days. Five- and ten-year overall survival (OS) and disease-free survival (DFS) were analyzed depending on whether the delay was greater than 50 days or not. RESULTS: one hundred (8.3 %) of 120 eligible patients underwent PD (61 male, median age of 63.7 years). In 71 (71 %) patients, the median NCRT-TTS was 39 (24-50) days and in 29 (29 %) 61 days. There were no differences between the two groups except for carbohydrate antigen 19-9 (CA 19-9) levels, the incidence of cholangitis, American Society of Anesthesiologists (ASA) score, intraoperative blood transfusions and degree of histopathologic response (all p < 0.001). Median DFS when the NCRT-TTS was less than 50 days was higher than when the interval exceeded 50 days (51.0 months [95 % CI: 20.3-81.6] vs 17.0 months [95 %: CI 10.9-23.0]; HR [95 % CI 1.08-3.46], p = 0.026). Five-year DFS was higher in the subgroup with NCRT-TTS of less than 50 days compared to the group with an interval of more than 50 days (43.5 % vs 23.65 % [HR 1.812, 95 % CI: 1.001-3.280], p = 0.050). CONCLUSIONS: an increase in the NCRT-TTS > 50 days is associated with poorer OS and DFS in patients with localized PDAC treated with NCRT and PD.

Improved Adipose Tissue Function after Single Anastomosis Duodeno-Ileal Bypass with Sleeve-Gastrectomy (SADI-S) in Diet-Induced Obesity.

Bariatric surgery has been recognized as the safest and most effective procedure for controlling type 2 diabetes (T2D) and obesity in carefully selected patients. The aim of the present study was to compare the effects of Sleeve Gastrectomy (SG) and Single Anastomosis Duodenoileal Bypass with SG (SADI-S) on the metabolic profile of diet-induced obese rats. A total of 35 four-week-old male Wistar rats were submitted to surgical interventions (sham operation, SG and SADI-S) after 4 months of being fed a high-fat diet. Body weight, metabolic profile and the expression of molecules involved in the control of subcutaneous white (SCWAT), brown (BAT) and beige (BeAT) adipose tissue function were analyzed. SADI-S surgery was associated with significantly decreased amounts of total fat pads (p < 0.001) as well as better control of lipid and glucose metabolism compared to the SG counterparts. An improved expression of molecules involved in fat browning in SCWAT and in the control of BAT and BeAT differentiation and function was observed following SADI-S. Together, our findings provide evidence that the enhanced metabolic improvement and their continued durability after SADI-S compared to SG rely, at least in part, on the improvement of the BeAT phenotype and function.

Neoadjuvant treatment in localized and resectable cancer of the pancreas: a new therapeutic paradigm.

Ductal carcinoma of the pancreas (DCP) is one of the most devastating tumors and ranks fourth among the causes of death from cancer. It is estimated that by 2030 it will be among the top three "cancer killers", along with lung cancer and hepatocarcinoma. Overall survival at five years from diagnosis is 5-10% in centers with experience. At the time of diagnosis, only 10-15% of patients present tumors localized to the pancreas and which are susceptible to curative resection (R0) (resectable tumors). Fifty percent present with systemic disease (stage IV) and 30-35% present borderline or locally advanced tumors which are generally not resectable due to vascular invasion.

Acute pancreatitis: an opportunity for gastroenterology hospitalists?

Acute pancreatitis (AP) is the third most frequent cause of hospital admissions for digestive disorders in the US and Europe after digestive bleeding and cholelithiasis/cholecystitis. The incidence of AP ranges from 15 to 100 cases per 100,000 inhabitants per year, and has been steadily increasing in recent years. In Spain, the reported incidence is 72 patients per 100,000 inhabitants per year. The most frequent cause is biliary lithiasis (50 %-60 % of cases); fortunately, 80 % of patients have only mild symptoms-as defined by the revised Atlanta Classification-and progress favorably, although mortality rate is 4.2 %. Clinical guidelines explicitly indicate that laparoscopic cholecystectomy should be performed during the first 48-72 hours or at the time of hospital admission in mild cases of biliary origin.

Small pancreatic neuroendocrine tumors: observing and monitoring or prompt surgical resection.

Over recent decades there has been a significant increase in the annual incidence of neuroendocrine tumors of the pancreas (PanNETs), from 0.4 to 0.8 per 100,000 inhabitants, due to a more widespread use of more sensitive imaging techniques (cross-sectional and functional imaging).

Critical stenosis of the celiac trunk by the arcuate ligament, successfully treated by a laparoscopic approach.

A 56-year-old female was referred to our department with a five-month history of progressive abdominal pain related to physical exertion and copious meals. The pain was located in the mesogastric region and the right flank and remitted when the patient lay in the recumbent position with the knees bent. The patient reported nausea and a weight loss of 12 kg over the previous ten years. She had been diagnosed 18 years previously with hereditary leiomyomatosis and renal cancer and had undergone a hysterectomy and partial nephrectomy.

Comparison of phenotypes and outcomes following resection of incidental versus symptomatic pancreatic neuroendocrine tumors.

BACKGROUND AND AIM: fifty to 70 percent of pancreatic neuroendocrine tumors are diagnosed incidentally. The objective of this study was to compare the phenotype and oncological outcomes of incidental versus symptomatic pancreatic neuroendocrine tumors. METHODS: a retrospective study was performed, identifying all incidental and symptomatic tumors resected between 2000 and 2019. Baseline characteristics, symptoms, operative variables and pathological stage were all recorded. Patterns of recurrence and overall and disease-free survival were analyzed in both groups. RESULTS: fifty-one incidental and 45 symptomatic pancreatic tumor resections were performed. Symptomatic tumors were more frequent in females (29 vs 17; p = 0.005) and younger patients (median years; 50 vs 58; p = 0.012) and were detected at a more advanced stage (p = 0.027). There were no differences in location and most resections (n = 49; 51 %) were performed laparoscopically. There were no operative mortalities and 17 (17.7 %) severe complications (≥ IIIb on the Clavien-Dindo classification) were recorded with no differences between the two groups. With a median follow-up of 64.4 months (range 13.5-90), overall survival at five and ten years was 89.7 % and 72.8 % for the non-incidental tumors and 80.9 % and 54.6 % for the incidental tumors (p = ns), respectively. Disease-free survival in both groups (excluding M1a) was 71.2 % and 47.5 %, and 93.7 % and 78.1 %, respectively (p = ns). CONCLUSIONS: symptomatic tumors are more frequent in females and present at more advanced pathological stages. There were no significant differences in overall and disease-free survival between the two groups. Resection of incidental tumors ≥ 1.5-2 cm seems advisable, although each case should be assessed on an individual basis.

Leading in turbulent times with the aim to serve.

The year 2020 will be remembered for the SARS-CoV-2 pandemic, which has been the greatest ever healthcare crisis for the National Health Service. In Spain there have been more than 1,556,730 cases and 42,619 deaths, as well as 20,268 elderly people who have died in nursing homes and 63,000 healthcare professionals infected (as of November 2020).

COVID-19 and the digestive system: implications for transforming care delivery.

The pandemic caused by SARS-CoV-2 has posed an unprecedented challenge to health systems, leading in many countries to the collapse of health care and a lack of preventive measures both for the most vulnerable sections of the population and among healthcare professionals.

Pancreatic injury and acute pancreatitis in COVID-19 patients.

Apart from pulmonary manifestations, there is an increased incidence of pancreatic involvement and acute pancreatitis (AP) reported in COVID-19 patients. In January 2021, a PubMed search using the terms "Acute Pancreatitis, COVID-19" yielded a result including 94 studies. Most of the studies refer to isolated cases or limited series, with the added difficulty that some authors have considered AP as elevated lipase and/or amylase levels without the diagnostic criteria for AP being met, as highlighted by Chivato et al. in relation to the case they report. Pancreatic involvement has been reported in 17 % of COVID-19 patients and AP in 1.8-2.0 % of these patients.

Hepatic injury and COVID-19: pathogenic mechanisms or epiphenomena?

Ampuero J et al. analyzed the relationship between liver injury and clinical progression of the disease in a meta-analysis of over 5,000 COVID-19 patients. The authors reported an association between increased aspartate aminotransferase (AST), alanine aminotransferase (ALT) and bilirubin levels with mortality, admission to Intensive Care and the development of complications, respectively.

Minimally Invasive Surgical Approach for the Treatment of Superior Mesenteric Artery Syndrome: Long-Term Outcomes.

BACKGROUND: Latero-lateral duodenojejunostomy is the treatment of choice for superior mesenteric artery syndrome (SMAS). The present study analyzes the long-term outcomes in 13 patients undergoing laparoscopic surgery for SMAS. MATERIALS AND METHODS: A retrospective study of 10 females and three males undergoing surgery between 2001 and 2013 was performed. Demographic, clinical and radiologic data and long-term surgical outcomes were recorded. In 12 patients latero-lateral duodenojejunostomy and in one patient distal laparoscopic gastrectomy with Roux-en-Y reconstruction were performed. The median age was 24 years (20-28), and the median duration of symptoms was 24 months (5-24). The most frequent symptoms were abdominal pain (n = 11; 92.3%), nausea and vomiting (n = 10; 77%) and weight loss (n = 9; 69.2%). The median operating time was 98 min (86-138) and hospital stay was 3 days (1-14). RESULTS: No reconversions occurred, and one patient experienced gastric emptying delay in the immediate postoperative period with spontaneous resolution. In four patients, SMAS was associated with severe stenosis of the celiac trunk which was treated in the same operation, and four patients presented stenosis of the left renal vein (the "nutcracker" phenomenon). With a median follow-up of 94 months (SD 65.3), eight patients (61.5%) had excellent results. One patient had a relapse of symptoms 4 years after surgery requiring distal gastrectomy, two patients presented delay in gastric emptying following temporary improvement and one patient experienced no improvement. CONCLUSIONS: Latero-lateral duodenojejunostomy yields good results in SMAS although it requires other gastric motility disorders to be ruled out for appropriate treatment to be established.

Defining authorship and contributorship criteria: transparency and visibility.

The complexity and research publications have expanded exponentially.The role of authors and collaborators need to be clarified according with the standards of the International Committee of medical Journal Editors (ICMJE). New projects as Contributor Role Taxonomy (CRediT), has been launched in order to provide credit and transparency to the authors, readers and evaluation agencies.

Small but great steps.

At the beginning of 2020 it is our pleasure to inform our readers about the changes in structure and future projects this journal will undertake. First of all, we wish to thank The National and International Editorial Committee, as well as the journal reviewers, for their enthusiasm, dedication, and scientific rigor in their silent and behind-the-scenes task of improving the quality of the published materials.

Co-occurrence of compression syndromes: celiac axis stenosis, superior mesenteric artery and nutcracker syndrome.

Moreno Márquez et al. report an association between arcuate ligament syndrome (ALS) and the "nutcracker" phenomenon (compression of the left renal vein). The case illustrates the association between several syndromes, which all involve compression of vascular or gastrointestinal structures: arcuate ligament syndrome, superior mesenteric artery syndrome (SMAS) or Wilkie's syndrome, the "nutcracker" syndrome and May-Thurner syndrome (compression of the left iliac vein).

Pancreatic injury in COVID-19: pathogenesis and challenges.

Apart from the mechanisms reported by Fernandes et al, the thromboembolic pathogenesis should also be taken into account in patients with severe COVID-19 and prophylaxis with low molecular weight heparin should be implemented.

Mechanism of bariatric and metabolic surgery: beyond surgeons, gastroenterologists and endocrinologists.

Bariatric-metabolic surgery is the safest, most effective and long-lasting treatment for obesity and its associated co-morbidities, whether they be metabolic (type 2 diabetes, hyperlipidemia non-alcoholic fatty liver disease) or cardiovascular (myocardial infarction, stroke). Due to the obesity pandemic, bariatric-metabolic surgery is the second most frequent intra-abdominal procedure and the gastroenterologist and the surgeon must be aware of the physiologic changes caused by the anatomic reconfiguration following surgery. Among the mechanisms of action, independent of the loss of weight and fat tissue, surgery leads to the release of gut hormones related to carbohydrate metabolism (the rapid and continuous release of insulin), appetite and degree of satiety (glucagon-like peptide 1, peptide Y-Y, grhelin). As a result, indications for surgery have been extended to earlier disease stages. Apart from the neurohormonal effects, changes in the metabolism of biliary acids and the microbiota have also been reported. The aim of this review is to describe the physiologic changes caused by bariatric-metabolic surgery.

COVID-19. Immunothrombosis and the gastrointestinal tract.

Mönkemüller et al. brilliantly describe the pathogenesis of SARS-CoV-2 (COVID-19) in the gastrointestinal tract. Their findings highlight the local and systemic inflammatory response generated by the coronavirus. After having the opportunity to observe three cases of severe colonic ischemia and elevation of D-dimer levels in patients with COVID-19 and severe acute respiratory distress syndrome (SARS) due to SARS-CoV-2, we would like to highlight the thromboembolic complications in COVID-19, which are related to those reported by Mönkemüller and which have been mentioned by other authors.