Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence

Objective. Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery. Materials and methods. We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008-March 2015). Data were collected prospectively and analyzed with SPSS 21.0. Results. 12 patients were included. 50 % were male and 50 % were female with a mean age of 59 ± 10 years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75 % of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58 % preoperative portal embolization was performed. Major hepatectomies were performed (66.7 % extended right hepatectomy, 33.3 % left extended hepatectomy). The 83.3 % of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50 % of the patients according to Dindo-Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90 days was 33 % due to hepatic failure and biliary fistula. In December 2015, 33 % of the patients are still alive with a mean survival of 19 months (13-23) with an ECOG Performance Status of 0. Conclusion. Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed (AU)

No disponible

Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence.

OBJECTIVE: Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery. MATERIALS AND METHODS: We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008-March 2015). Data were collected prospectively and analyzed with SPSS 21.0. RESULTS: 12 patients were included. 50 % were male and 50 % were female with a mean age of 59 ± 10 years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75 % of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58 % preoperative portal embolization was performed. Major hepatectomies were performed (66.7 % extended right hepatectomy, 33.3 % left extended hepatectomy). The 83.3 % of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50 % of the patients according to Dindo-Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90 days was 33 % due to hepatic failure and biliary fistula. In December 2015, 33 % of the patients are still alive with a mean survival of 19 months (13-23) with an ECOG Performance Status of 0. CONCLUSION: Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed.

Retrospective analysis of pathological response in colorectal cancer liver metastases following treatment with bevacizumab

AIMS: Pathological response has been shown to be a predictor for survival after preoperative chemotherapy and surgical resection of colorectal cancer liver metastases. This retrospective analysis evaluated the effect on pathological response of adding bevacizumab to standard neoadjuvant chemotherapy in patients with metastatic colorectal cancer (mCRC) and liver metastases. METHODS: Patient records from two Spanish centres were retrospectively examined for this analysis. Patients were included if they had stage IV mCRC with liver metastases, were unresectable or marginally resectable tumour before chemotherapy, and had oxaliplatin- or irinotecan-based chemotherapy, with or without bevacizumab, before resection. Tumour response was evaluated using response evaluation criteria in solid tumours (RECIST). Pathological response was assessed by pathologists blinded to treatment. RESULTS: Ninety-five patients were included. Good pathological responses (PR0/PR1) were observed in 37 patients (39 %). The RECIST response rate was 51 %. Only 42 % of patients with a good pathological response had a complete or partial response according to RECIST, while 57 % of those with a poor pathological response had a complete or partial response according to RECIST. RECIST response rates were similar with and without bevacizumab, although 49 % of bevacizumab-treated patients had a good pathological response versus 27 % of those receiving chemotherapy alone (χ (2) P = 0.0302). CONCLUSION: Pathological response may be a better indicator of treatment efficacy than RECIST for patients with mCRC receiving bevacizumab in the neoadjuvant setting. Adding bevacizumab to chemotherapy has the potential to increase pathological response rates. Well-designed prospective clinical studies are required to establish the efficacy and tolerability of this approach (AU)

No disponible

Retrospective analysis of pathological response in colorectal cancer liver metastases following treatment with bevacizumab.

AIMS: Pathological response has been shown to be a predictor for survival after preoperative chemotherapy and surgical resection of colorectal cancer liver metastases. This retrospective analysis evaluated the effect on pathological response of adding bevacizumab to standard neoadjuvant chemotherapy in patients with metastatic colorectal cancer (mCRC) and liver metastases. METHODS: Patient records from two Spanish centres were retrospectively examined for this analysis. Patients were included if they had stage IV mCRC with liver metastases, were unresectable or marginally resectable tumour before chemotherapy, and had oxaliplatin- or irinotecan-based chemotherapy, with or without bevacizumab, before resection. Tumour response was evaluated using response evaluation criteria in solid tumours (RECIST). Pathological response was assessed by pathologists blinded to treatment. RESULTS: Ninety-five patients were included. Good pathological responses (PR0/PR1) were observed in 37 patients (39 %). The RECIST response rate was 51 %. Only 42 % of patients with a good pathological response had a complete or partial response according to RECIST, while 57 % of those with a poor pathological response had a complete or partial response according to RECIST. RECIST response rates were similar with and without bevacizumab, although 49 % of bevacizumab-treated patients had a good pathological response versus 27 % of those receiving chemotherapy alone (χ (2) P = 0.0302). CONCLUSION: Pathological response may be a better indicator of treatment efficacy than RECIST for patients with mCRC receiving bevacizumab in the neoadjuvant setting. Adding bevacizumab to chemotherapy has the potential to increase pathological response rates. Well-designed prospective clinical studies are required to establish the efficacy and tolerability of this approach.

Preoperative treatment with bevacizumab in combination with chemotherapy in patients with unresectable metastatic colorectal carcinoma

PURPOSE: This prospective observational study assessed the efficacy of bevacizumab in combination with chemotherapy as preoperative treatment to downsize tumours for radical resection in patients with unresectable metastatic colorectal cancer (mCRC). PATIENTS/METHODS: Patients with mCRC initially unresectable according to predefined criteria were included. Preoperative treatment consisted of bevacizumab (5 mg/kg) combined with oxaliplatin- or irinotecan-based chemotherapy, which was followed by surgery in patients showing clinical benefit. Resection rate was the primary endpoint. Response rate (RR) and clinical benefit of preoperative chemotherapy, and overall survival (OS) were secondary endpoints. RESULTS: A total of 120 eligible patients were included and received preoperative treatment. Chemotherapy was irinotecan-based in 73 (61 %) patients, oxaliplatin-based in 25 (21 %) and 22 (18 %) patients received more than one line. A RR of 30 % and a clinical benefit rate of 73 % were observed with preoperative chemotherapy. Metastatic resection was possible in 61 (51 %) patients. Median OS was 33 months (95 % CI 31-NA months) for patients undergoing surgery, and 15 months (95 % CI 11-25 months) in non-operated patients. Thirty-five patients experienced 59 postoperative complications (morbidity rate 57 %). CONCLUSION: Preoperative bevacizumab-based chemotherapy offers a high surgical rescue rate in patients with initially unresectable mCRC (AU)

Preoperative treatment with bevacizumab in combination with chemotherapy in patients with unresectable metastatic colorectal carcinoma.

PURPOSE: This prospective observational study assessed the efficacy of bevacizumab in combination with chemotherapy as preoperative treatment to downsize tumours for radical resection in patients with unresectable metastatic colorectal cancer (mCRC). PATIENTS/METHODS: Patients with mCRC initially unresectable according to predefined criteria were included. Preoperative treatment consisted of bevacizumab (5 mg/kg) combined with oxaliplatin- or irinotecan-based chemotherapy, which was followed by surgery in patients showing clinical benefit. Resection rate was the primary endpoint. Response rate (RR) and clinical benefit of preoperative chemotherapy, and overall survival (OS) were secondary endpoints. RESULTS: A total of 120 eligible patients were included and received preoperative treatment. Chemotherapy was irinotecan-based in 73 (61 %) patients, oxaliplatin-based in 25 (21 %) and 22 (18 %) patients received more than one line. A RR of 30 % and a clinical benefit rate of 73 % were observed with preoperative chemotherapy. Metastatic resection was possible in 61 (51 %) patients. Median OS was 33 months (95 % CI 31-NA months) for patients undergoing surgery, and 15 months (95 % CI 11-25 months) in non-operated patients. Thirty-five patients experienced 59 postoperative complications (morbidity rate 57 %). CONCLUSION: Preoperative bevacizumab-based chemotherapy offers a high surgical rescue rate in patients with initially unresectable mCRC.

Effect of subcentimeter nonpositive resection margin on hepatic recurrence in patients undergoing hepatectomy for colorectal liver metastases. Evidences from 663 liver resections.

OBJECTIVE: To elucidate if a nonpositive <1-cm resection margin has any effect on hepatic recurrence in patients undergoing liver resection for colorectal liver metastases. PATIENTS AND METHODS: Six hundred and nine patients underwent 663 liver resections. Patients with positive margin were excluded from the analysis. Two groups were studied: group A, <1-cm resection margin and group B, > or =1-cm resection margin. RESULTS: A total of 545 liver resections in 523 patients were carried out with nonpositive resection margins. With a median follow-up of 25 months, the 5-year cumulative hepatic recurrence reached 54% in group A (n = 206) and 41% in group B (n = 339). Factors associated with hepatic recurrence were synchronic metastases (P = 0.0015), bilobar (P < 0.001), two or more metastases (P < 0.001), margin <1 cm (P = 0.0123) and extrahepatic disease (P = 0.0037). A strong correlation between resection margin and number of metastases was confirmed (P < 0.001). At multivariate analysis only two factors were independent predictors of hepatic recurrence: multinodular disease in the liver specimen [> or =4 metastases hazard ratio (HR) = 3.45; 95% confidence interval (CI): 2.2-5.38; P < 0.001] and extrahepatic disease at hepatectomy (HR = 1.58; 95% CI: 1.58-3.32). CONCLUSION: Subcentimeter nonpositive resection margins do not directly influence hepatic recurrence in patients undergoing hepatectomy for colorectal liver metastases.

Exclusión esofagofúndica temporal en lamediastinitis grave por perforación esofágica / Temporary esophageal-fundic exclusion in severe mediastinitis due to esophageal perforation

La perforación esofágica es una entidad clínica muy grave por sus repercusiones a muy corto plazo.La mayoría de las aportaciones se centran en su terapéutica. La gran variedad de opciones permite prever la ausencia de un tratamiento seguro y eficaz. Los autores presentan una nueva técnica que, carente de una excesiva complejidad, se muestra muy segura para la resolución clínica del proceso. Se desarrolla en dos tiempos quirúrgicos separados por una recuperación de las condiciones locales y generales del paciente. Está inspirada en las técnicas de doble grapado esofágico, pero aporta mayores ventajas. Esta nueva opción técnica estaría indicada en la perforación espontánea por esfuerzos de vómito y en las perforaciones iatrogénicas con instauración de una mediastinitis grave. (AU)

Gangrena de Fournier / Fournier's gangrene

Introducción. La gangrena de Fournier es una infección necrosante subcutánea de origen urogenital o anorrectal, que afecta a la zona genital, perineo y pared anterior del abdomen en la que están implicados gérmenes aerobios y anaerobios. Es una enfermedad poco frecuente, pero potencialmente letal. Pacientes y métodos. Estudiamos de forma retrospectiva 10 casos de gangrena de Fournier, desde 1994 hasta 1999. En la recogida de datos figuran: filiación, edad y sexo, antecedentes patológicos, factores predisponentes, causas, clínica, analítica, tratamiento médico y quirúrgico, gérmenes, antibioterapia, estancia, ingreso en UCI y resultados. Resultados. Todos los pacientes eran varones, con una edad media de 65 años. Todos tenían importante patología orgánica de base y presentaban factores predisponentes, destacando la diabetes mellitus (6 casos) seguida del consumo crónico de alcohol (5 casos). La etiología fue: absceso perianal (3 casos), instrumentación urológica o rectal (2 casos), enfermedades genitourinarias (2 casos), idiopática (2 casos) y traumatismo (un caso). La clínica fue similar, con una zona de celulitis inicial, con dolor local en el escroto y posterior diseminación perineal, con crepitación y cuadro febril. Todos presentaban leucocitosis franca. En todos los pacientes se instauró antibioterapia y se realizó desbridamiento en una o varias sesiones, así como medidas de soporte metabólico y nutricional. En 3 casos se realizó íleo-colostomía derivativa y en 2 casos cistostomía suprapúbica. El germen más aislado fue E. coli, seguido de Bacteroides. En la antibioterapia destaca el uso de piperacilina/tazobactam. La estancia media fue d 27 días. Cinco pacientes requirieron su ingreso en la UCI. Fallecieron 4 pacientes (40 por ciento), con un denominador común de sepsis; de ellos dos llevaban estoma (colostomía).Conclusiones. La gangrena de Fournier es una enfermedad de alta morbimortalidad, especialmente en pacientes mayores, con factores predisponentes como diabetes y alcoholismo y cuya causa desencadenante es una enfermedad perirrectal o urogenital, que no ha sido tratada correctamente. El pronóstico es incierto, llegando nuestra serie a una mortalidad del 40 por ciento, por lo que el diagnóstico precoz y la terapéutica temprana y agresiva son esenciales (desbridamiento quirúrgico, antibióticos de amplio espectro y cuidados intensivos) (AU)

Hernia de Richter como causa de obstrucción del intestino delgado / Richter's hernia presenting as small bowel obstruction

El objetivo del trabajo es presentar 4 casos de hernia de Richter que ocasionan problemas mecánicos intestinales, concretamente oclusión del intestino delgado. En todos los casos hubo un grave deterioro del estado general y una deshidratación importante, siendo el cuadro clínico lentamente progresivo con una sintomatología en varios casos de distensión abdominal y en otro caso de diarrea persistente. La demora en su diagnóstico ocasiona una cirugía tardía, con un aumento de la morbimortalidad, por lo que creemos que el adecuado conocimiento de esta rara enfermedad quirúrgica es importante (AU)

Seat belt-induced intestinal perforation.

OBJECTIVE: To determine whether a relationship exists between bowel perforation and seat belt use in patients presenting abdominal trauma after traffic accidents. EXPERIMENTAL DESIGN: We prospectively studied every patient admitted to the emergency room with abdominal trauma after a traffic accident. PATIENTS AND METHODS: We included every patient diagnosed (clinically, by ultrasound or computerized tomography or at laparotomy) as suffering intraabdominal injury. The degree of trauma was classified according to the Injury Severity Score, taking into account the number of abdominal injuries associated with mortality and seat belt use. RESULTS: A total of 146 patients were studied. The spleen was the most frequently injured organ (n = 56). The mean Injury Severity Score was 19. Head injuries were more common among patients not wearing the seat belt. Thirteen cases of bowel perforation in patients who had been using the seat belt (p < 0.0001) were observed. CONCLUSION: Seat belt use can decrease the mortality rate associated with traffic accidents. However, a significant increase exists in the incidence of bowel perforations among seat belt wearers, probably as a result of improper use.

[Low digestive hemorrhage caused by amebic colitis]. / Hemorragia digestiva baja por colitis amebiana.

Amebiasis is an infectious disease produced by Entamoeba histolytica, which has invasion capacity of the colon mucosa. It has different clinical forms, varying from the asymptomatic carrier state to severe, although not frequent, fulminant or necrotizing colitis, with an important necrosis of the colon mucosa. Perforation or intestinal bleeding are possible. We report one case of patient who had a history of recent travel to India. Was admitted with a clinical picture of abdominal pain, diarrhea and fever. Initially he received treatment with Metronidazole and steroids, because of doubts in the endoscopy diagnosis of Crohn's Disease versus Amebic Colitis. The patient developed a fulminant colitis, that required emergency surgery because of lower intestinal massive bleeding. During the operation perforations of the caecum and rectum were found. We performed a total colectomy with ileostomy and closing of the stump rectal. Six months later a second operation was made for the reconstruction of the intestinal continuity by an ileal pouch and rectal anastomosis.

[Usefulness of transrectal echography in the study of rectal cancer]. / Utilidad de la ecografía transrectal en el estudio del cáncer de recto.

This paper presents the initial results of a study designed to measure the ability of transrectal ultrasonography (TU) in determining the degree of local invasion of rectal cancer, comparing the preoperative radiographic diagnosis with the histological one. The series consists of 30 patients. In 24 cases preoperative TU was performed--following confirmation of the histological diagnosis--and in six cases UT was used after surgery to study the anastomosis. The postoperative group consists of eight males and 16 females, with a mean age of 70; in 14 cases the tumors were located in the lower third of the rectum, and in 10 cases in the middle third. In 12 of these 24 cases, pelvic CAT was also performed. TU showed the correct stage in 17 of the 24 (70.8%), with two false positives and five false negatives. CAT showed the correct diagnosis in 10 out of 12 (83%), with one false positive and one false negative. In the follow-up of the surgical patients, TU was normal in five cases and local recurrence was diagnosed. On the basis of our results, we consider that TU is a method with a high degree of diagnostic reliability in preoperative staging of rectal cancer; it can be associated with CAT; furthermore, it is an important screening method for early diagnosis of local recurrence at the suture line. Its main drawbacks are in studying high and stenosing lesions.

[Appendicular diverticulitis: a review of 5 cases]. / Diverticulitis apendicular: revisión de cinco casos.

Of a total of 3,669 appendectomies, five corresponded to appendicular diverticulosis (0.13%), all of which had an inflammatory pathology. Four patients underwent emergency surgery with a diagnosis of acute appendicitis, and in only one was a correct preoperative diagnosis made. There were three cases of acute primary diverticulitis and one appendicitis with secondary diverticular affectacion. Another patient was operated electively for a history of long evolution; during the surgical act an appendicular inflammatory mass was found that the pathological report described as diverticulitis with subacute periappendicitis. Certain aspects of this entity are remarked and the bibliography is reviewed.

[Descriptive analysis of 660 cases of upper digestive hemorrhage: relation of emergency endoscopy and mortality]. / Análisis descriptivo de 660 casos de hemorragia digestiva alta: relación con la endoscopia de urgencia y la mortalidad.

A study was made of 660 patients admitted for upper gastrointestinal bleeding in which the endoscopic findings were analyzed, excluding patients with esophageal varices and cases in which the lesions responsible for bleeding were not appreciated (5.7% diagnostic failure). 71.7% were males and 38.3% females, average age was 59.9 +/- 17.5 years and average hematocrit on admission was 27.4 +/- 8.2. 58.3% were over 60 years-old. There was a history of ingestion of gastro-erosive drugs in 56.8%. Gastroscopy was performed within 24 hours of admission in 77.4%, the first clinical symptom of bleeding being melenas in 50%. Peptic ulcer was the most common cause of upper gastrointestinal bleeding. Eighty-one patients required surgery, 30 early and 51 delayed. The global mortality was 3.6% and surgical mortality, 13.5%. After relating the endoscopic groups of upper gastrointestinal bleeding and individual risk with mortality rates, emphasis is placed on the need for early endoscopy as a diagnostic tool of prognostic value.

[Immunoglobulins and the complement system in colorectal cancer]. / Inmunoglobulinas y sistema del complemento en el cáncer colorrectal.

In the present paper is studied the concentration in peripheral blood of immunoglobulins IgG, IgA, IgM and factors C3 and C4 of the complement system in a group of 120 patients with colorectal cancer operated on with radical intention. Preoperative values are compared to postoperative results and the values obtained on diagnosis of tumoral recurrence with the object of describing possible immunologic alterations existent in the patient with colorectal carcinoma. It is concluded that there are no significant relations between the biochemical parameters studied and age, sex, tumoral localization and Duke's clinical stages. Patients with pre and postoperative IgA values above normal present a poor prognosis, with an associated recurrence of 60% (p = 0.001) and 80% (p = 0.000), respectively; postoperative C3 levels above normal also represent a factor of poor prognosis, recurrence appearing in 80% (p = 0.001) and metastases in 85% (p = 0.000).