Characteristics and prognosis of jejunoileal gastrointestinal stromal tumours (GISTs) in the era of imatinib: a comparative study with gastric GISTs

Backgroung Gastrointestinal stromal tumours (GISTs) located in the jejunum or ileum (JI-GIST) are considered worse prognosis compared to those of gastric (G-GIST) location. It has been suggested that this dogma should be revised. The aim of this study was to describe the characteristics of jejunoileal GISTs and its prognosis and to compare them with G-GISTs in the era of imatinib. Methods We retrospectively reviewed the clinical histories of all the patients diagnosed with GISTs between January 2000 and November 2016: Clinical and pathological data, as recurrence, metastatic state, disease-free survival (DFS) as well as overall survival (OS) rates of patients were reviewed. Results JI-GIST patients comprise 29 cases (37.7%). Compared to G-GIST, JI-GIST patients had undergone emergency surgery more frequently (37.9% vs. 10.4%, p = 0.007). According to the NIH-Fletcher classification, the low or very-low risk group represents 17.2% of JI-GISTs as opposed to 37.6% of G-GISTs (p < 0.005). When the AFIP-Miettinen system was used the low or very-low group represented 17.2% of JI-GISTs vs. 58.4% in the G-GISTs group (p < 0.001). Both local recurrence (24.1% vs. 12.5%, p < 0.05) and metastatic rate (34.5% vs. 22.9%, p < 0.05) were higher in the JI-GIST group than in G-GIST. 5- and 10-year DFS and 10-year OS rate were lower for JI-GIST (54.5% and 39.6% vs. 77.2% and 60.8%, and 57.9% vs. 65%, respectively, p < 0.05). Conclusions The observed differences between both groups in DFS and OS rates at long term could be attributed to the effect of imatinib (AU)

Characteristics and prognosis of jejunoileal gastrointestinal stromal tumours (GISTs) in the era of imatinib: a comparative study with gastric GISTs.

BACKGROUND: Gastrointestinal stromal tumours (GISTs) located in the jejunum or ileum (JI-GIST) are considered worse prognosis compared to those of gastric (G-GIST) location. It has been suggested that this dogma should be revised. The aim of this study was to describe the characteristics of jejunoileal GISTs and its prognosis and to compare them with G-GISTs in the era of imatinib. METHODS: We retrospectively reviewed the clinical histories of all the patients diagnosed with GISTs between January 2000 and November 2016: Clinical and pathological data, as recurrence, metastatic state, disease-free survival (DFS) as well as overall survival (OS) rates of patients were reviewed. RESULTS: JI-GIST patients comprise 29 cases (37.7%). Compared to G-GIST, JI-GIST patients had undergone emergency surgery more frequently (37.9% vs. 10.4%, p = 0.007). According to the NIH-Fletcher classification, the low or very-low risk group represents 17.2% of JI-GISTs as opposed to 37.6% of G-GISTs (p < 0.005). When the AFIP-Miettinen system was used the low or very-low group represented 17.2% of JI-GISTs vs. 58.4% in the G-GISTs group (p < 0.001). Both local recurrence (24.1% vs. 12.5%, p < 0.05) and metastatic rate (34.5% vs. 22.9%, p < 0.05) were higher in the JI-GIST group than in G-GIST. 5- and 10-year DFS and 10-year OS rate were lower for JI-GIST (54.5% and 39.6% vs. 77.2% and 60.8%, and 57.9% vs. 65%, respectively, p < 0.05). CONCLUSIONS: The observed differences between both groups in DFS and OS rates at long term could be attributed to the effect of imatinib.

Early Outcomes of Liver Transplantation Using Donors After Circulatory Death in Patients With Hepatocellular Carcinoma: A Comparative Study.

INTRODUCTION: Donation after circulatory death (DCD) has increased in the last decade, although a slight increase in surgical complications has been reported in liver transplantation (LT). Therefore, DCD is not overall recommended because it entails an added risk. However, DCD in selected patients shows acceptable results. OBJECTIVE: The objective was to analyze the characteristics, early outcomes, and survival at 1 year post-LT from a single institute (January 2015 to May 2017). MATERIALS AND METHODS: We included 18 DCD-LTs and compared them with a control group of 18 donation after brain death (DBD) LTs. We analyzed pre- and posttransplant variables related to donors, recipients, and intraoperative early outcomes within patients transplanted due to hepatocellular carcinoma (HCC). A descriptive analysis, Mann-Whitney U test, χ2, or Fisher test was performed when appropriate, as well as multivariate analysis in case of statistical significance. A variable is considered as statistically significant when it reaches a value of P < .05. RESULTS: In DBD, we found a lower length of stay in the intensive care unit before retrieval and a higher rate of alcoholism and diabetes mellitus, Model for End-Stage Liver Disease score, and Child B and C score (P < .05). Most of the DCD were originally from the same LT recipient center, and a higher donor mean post-LT alanine aminotransferase level was found (P < .05). Survival for the DBD group was 88% and 75% in the DCD group at 1 year post-LT, being not significant (NS). CONCLUSION: HCC recipients who are transplanted with good quality DCD livers do no worse than those transplanted with livers from DBD donors, although a good selection of them is crucial.

Teenagers in Rural Areas Faced With Organ Donation and Transplantation.

INTRODUCTION: In rural areas it is common to find unfavorable attitudes toward organ donation, and therefore it is important to find out the attitude and profile of new generations for improving predisposition to organ donation in these areas. Our objective was to analyze the attitude toward organ donation and the related variables of teenagers in a rural area. MATERIALS AND METHODS: Students in the final year of compulsory education (mostly 15-16 years of age) were selected from secondary schools in a rural area in southeastern Spain (n = 319; population density <300 inhabitants/km2). The instrument of measurement used was a validated psychosocial questionnaire. Completion was anonymous and self-administered. Descriptive statistical analysis, Student t test, χ2 test, and multivariate analysis were employed. RESULTS: There was a completion rate of 96% (n = 306). Overall, 65% (n = 200) were in favor of donating their organs, 30% (n = 90) were undecided, and 5% (n = 16) were against. Attitude toward the donation of one's own organs was related with sex (P = .015), previous experience of organ donation or transplantation (P = .046), comment on the topic of organ donation within the family (P = .003; odds ratio 2.155), knowing one's mother's opinion about the matter (P = .021), knowing the correct concept of brain death (P = .012; odds ratio 2.076), and religion (P = .014). CONCLUSIONS: A favorable attitude of teenagers in rural areas toward organ donation is slightly higher than in the adult population and is determined by many psychosocial variables, above all family discussion about organ donation and transplantation and correct knowledge of the brain death concept.

Importance for the Elderly of Discussion in the Family and Society About Attitude Toward Organ Donation.

BACKGROUND: The aging of the population has changed some of the approaches to the organ donation and transplant (ODT) process, such as considering elderly people as potential donors. We aimed to assess social and family discussions among the elderly about ODT and its effect on their attitude toward organ donation. METHODS: A study was carried out at 2 publicly-funded social centers for the elderly. Contact was made with individuals >65 years of age (n = 120) to seek their participation in the study. A questionnaire was distributed to them with questions about ODT. A descriptive assessment was performed with the Student t test and χ2 test used for statistical analysis. RESULTS: The completion rate was 87% (n = 104). Of the respondents with a partner and children, 48% had discussed the topic of ODT. It was found that talking about the subject with one's partner, children, or friends had a favorable influence on attitude compared with when this was not done (93%, 86%, and 83% vs 19%, 30%, and 31%, respectively; P < .001). In addition, the opinion of one's partner and children toward ODT also had an influence; if favorable, the respondent's attitude was more favorable, compared with when they did not know their opinion (92% to 88% vs 58% to 37%, respectively; P < .001). Other ODT-related variables did not affect their attitude (P > .05). CONCLUSIONS: Almost half of the elderly people had discussed ODT socially or with their family. This discourse has a favorable influence on their attitude toward organ donation and, therefore, it is important to encourage social and family dialog among this group.

Liver Transplantation in Patients With Hepatocellular Carcinoma Outside the Milan Criteria After Downstaging: Is It Worth It?

BACKGROUND: The outcome of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) is excellent if it is performed within the Milan criteria (ie, single tumor less than 5 cm or 3 tumors less than 3 cm each one and no macrovascular invasion). However, after a few studies, it has become possible to have a similar survival expanding those criteria. The aim of this study is to evaluate the survival of patients with advanced HCC who, after downstaging, did not met the Milan criteria although they were within the "up to seven" benchmark, and were transplanted at our center in the last 5 years. PATIENTS AND METHODS: This is a retrospective study of patients who underwent OLT for HCC in the last 5 years in our center exceeding Milan criteria despite remaining within the "up to seven" benchmark. An observational study of associated factors with overall survival based on patient characteristics after OLT was performed. For the statistical study, the statistical program SPSS v. 17.0 (Chicago, Illinois, United States) was used. RESULTS: We studied 95 patients who had been transplanted for HCC in this period, 11 of whom met the study requirements. There were 10 (91%) males and 1 female. The mean age of the patients was 54.73 ± 8.75 years, with an average waiting list time of 279 days. Nine patients had a Child A status, with a mean Model for End-stage Liver Disease score of 9.64 (range, 6 to 16). The most frequent etiology of cirrhosis was hepatitis C virus infection in 6 patients (50%) followed by hepatitis B virus infection and ethanolic and cryptogenic cirrhosis. Ten patients (91%) had at least one pretransplantation transarterial chemoembolization. The survival of patients after 1 year was 75%, whereas after 4 years that rate decreases to 25%. At this time, we do not have any patients with a 5-year survival rate. The longest survival rate is 55 months. CONCLUSIONS: Although the expanded indication of transplantation in HCC raises controversies, especially after downstaging, it is possible to provide acceptable survival rates for patients within the expanded criteria of "up to seven" after locoregional therapies. The performance of a liver transplant in the patient profile shown in this article should also be evaluated from the perspective of the relative lack of organs for transplantation.

Outcomes of Liver Transplantation Using Older Donors After Circulatory Death and the Super-Rapid Technique: 14 Cases.

INTRODUCTION: Donation after circulatory death (DCD) has increased in the last decade, although a slight increase in surgical complications has been reported in liver transplantation (LT). Therefore, DCD is not recommended with donors aged 60 years or more because it entails an added risk. However, donation after brain death (DBD)-LT with donors aged 70 years or more shows acceptable results. OBJECTIVE: The objective was to analyze the characteristics and complications of DCD-LT with donors aged 70 years or more (DCD-70). MATERIALS AND METHODS: We included 14 DCD-70-LT and compared them with a control group of 28 DBD-LT aged 70 years or more. STATISTICAL ANALYSIS: A descriptive analysis, Mann-Whitney U test, and Pearson chi-square or Fisher test were performed when appropriate. RESULTS: Significant differences were found in aminotransferase peak at 24 hours, with an increase in the DCD-70 group (aspartate aminotransferease [AST] 1038 vs 507, P = .013; alanine aminotransferase [ALT] 750 vs 399, P = .014). The cold ischemia time was lower in DCD-70 although without significant differences (4.8 vs 6.7 hours). Biliary complications (28.6% vs 31.7%) and vascular complications (7.1% vs 7.1%) were similar. A single transplant with DCD-70 required a retransplantation due to arterial thrombosis. Mortality was the same in both cases (14.3%). CONCLUSION: LT results with DCD-70 are similar to those of DBD-70, so the age criteria could also be extended in this type of donation.

Long-term Survival and Evolution of the Kidney Function for Liver Transplant Patients Who Required Postoperative Dialysis.

Patients who underwent orthotopic liver transplantation (OLT) frequently develop chronic kidney disease, with those who present postoperative acute kidney failure and require renal replacement therapy (RRT) at higher risk. The objective of the study was to assess the kidney function and long-term survival of patients who underwent OLT and required RRT during or in the immediate postoperative period. Medical records of OLT and postoperative RRT patients with over 6-month survival were reviewed between January 1, 2005, and December 31, 2015. A variance analysis was carried out for repeated measurements to compare the estimate glomerular filtration rate (eGFR) baseline with the different periods (statistical significance level P < .05). Kaplan-Meier estimator was used to estimate the survival rate. Of 539 patients, 20 (3.7%) met the selection criteria. The basal eGFR at 6 months and 1, 3, 5, and 7 years was 93.41 ± 25, 78.28 ± 33, 73.06 ± 29, 65.96 ± 19, 79.81 ± 28, and 59.06 ± 24 mL/min/1.73 m2, respectively. The comparison of the eGFR baseline within the different periods was statistically significant at 1 year and at 3 years. Four patients died, 3 of them due to sepsis and 1 due to recurrence of hepatitis C virus infection. The average survival was 28 months. The probability of surviving at 1 year was 100%, at 3 years was 84.21% (95% confidence interval: 58.65-94.62), and at 5 and 10 years was 78.6% (95% confidence interval: 52.49-91.39). In conclusion, we have found a progressive worsening of the kidney function in the long term in patients who required postoperative dialysis. However, actuarial survival of these patients was very successful.

Molecular Adsorbent Recirculating System Treatment Can Reduce Blood Levels of N-Acetylcysteine in Patients With Acetaminophen Overdose: Case Reports.

BACKGROUND: Acetaminophen poisoning continues to be a major cause of liver failure that can lead to liver transplantation. N-acetylcysteine (NAC) is the cornerstone of treatment. Some authors use a Molecular Adsorbent Recirculating System (MARS) system in acetaminophen poisoning. It is reported that the MARS system eliminates acetaminophen more efficiently than conventional dialysis. It is theoretically possible that treatment with MARS administered after NAC will increase the effectiveness of treatment. CASE REPORTS: The first patient, a woman of 14 years old, presented blood levels of 112 mg/dL 12 hours after ingestion of 15 g of acetaminophen. Treatment with NAC was initiated. At 17 and 23 hours after ingestion, blood levels were 23.5 µg/mL and 5.9 µg/mL, respectively. The second patient, a woman of 28 years old, presented blood levels of 115 mg/dL 4 hours after ingestion of 40 g of acetaminophen. Treatment with NAC was initiated. At 14 and 23 hours after ingestion, blood levels were 15.8 µg/mL and <2 µg/mL, respectively. In both patients, we performed MARS after completing treatment with NAC, and after the first session, blood levels were below the lower limit of detection (≤2 µg/mL). DISCUSSION: The correct timing of MARS to avoid interactions with the administered dose of NAC in acetaminophen overdose is essential so as to not impair the effectiveness of this treatment. These considerations in the management of this entity help in the resolution of liver failure, thus avoiding the need for a liver transplant.