Factores de mal pronóstico en 113 pacientes sometidos a duodenopancreatectomía cefálica por colangiocarcinoma distal / Prognostic risk factors in 113 patients undergoing cephalic duodenopancreatectomy for distal cholangiocarcinoma

Introducción El colangiocarcinoma distal es una neoplasia epitelial maligna que afecta a los conductos biliares extrahepáticos, per debajo del conducto cístico. Existe poca evidencia sobre la relación entre factores perioperatorios y peor evolución a largo plazo tras la resección quirúrgica. Objetivo Analizar los factores de riesgo de mortalidad y recidiva a largo plazo del colangiocarcinoma distal de los pacientes resecados. Material y métodos Se ha analizado una base de datos prospectiva unicéntrica de pacientes intervenidos por colangiocarcinoma distal entre los años 1990 y 2021 con la finalidad de investigar los factores de mortalidad y recidiva. Resultados Se han intervenido 113 pacientes, con una supervivencia actuarial media de 100,2 (76-124) meses tras la resección. El estudio bivariante no evidenció diferencias entre los pacientes dependiendo de la edad o variables preoperatorias estudiadas. La presencia de adenopatías afectadas fue un factor de riesgo de mortalidad a largo plazo en el estudio multivariante. La presencia de adenopatías afectadas, la recidiva tumoral y la fístula biliar durante el postoperatorio implicaron peor supervivencia actuarial al comparar las curvas de Kaplan-Meier. Conclusiones La presencia de adenopatías afectadas influyen en el pronóstico de la enfermedad. La aparición de fístula biliar durante el postoperatorio del colangiocarcinoma distal podría agravar los resultados a largo plazo, hallazgo que debe ser reafirmado en futuros estudios. (AU)

Introduction Distal cholangiocarcinoma is a malignant epithelial neoplasia that affects the extrahepatic bile ducts, below the cystic duct. No relevant relationship between perioperative factors and worse long-term outcome has been proved. Objective To analyze the risk factors for mortality and long-term recurrence of distal cholangiocarcinoma in resected patients. Materials and methods A single-center prospective database of patients operated on for distal cholangiocarcinoma between 1990 and 2021 was analyzed in order to investigate mortality and recurrence factors. Results One hundred and thirteen patients have undergone surgery, with mean actuarial survival of 100.2 (76–124) months after resection. The bivariate study did not show differences between patients depending on age or preoperative variables studied. When multivariate analysis was performed, the presence of affected adenopathy was a risk factor for long-term mortality. The presence of affected lymph nodes, tumor recurrence, and biliary fistula during the postoperative period implied worse actuarial survival when comparing the Kaplan–Meier curves. Conclusions The presence of affected lymph nodes influence the prognosis of the disease. The occurrence of biliary fistula during postoperative cholangiocarcinoma distal could aggravate long-term outcomes, a finding that should be reaffirmed in future studies. (AU)

The involvement of the hepatic artery is a risk factor for unresectability after neoadjuvant treatment in borderline pancreatic adenocarcinoma.

INTRODUCTION: Borderline Resectable Pancreatic Ductal Adenocarcinoma (BR-PDAC) benefits from neoadjuvant treatment (NAT) with the intent of surgical salvage in the absence of disease progression during chemotherapy (CT) or chemoradiotherapy (CRT). Scarce literature exists about prognostic factors of resectability at the time of diagnosis or during neoadjuvant treatment, especially regarding vascular relationships. MATERIALS: We reviewed our prospective BR-PDAC cohort to determine resectability predictors. We collected data about clinical baseline characteristics, vessels' involvement, type of NAT, CA19-9 evolution, and radiological outcome. We performed a descriptive analysis and a logistic regression model to define resectability predictors; we finally compared overall survival (OS) and progression-free survival (PFS) for those predictors. RESULTS: One hundred patients started NAT, with a resection rate of 44 % (40 pancreaticoduodenectomies, 4 distal pancreatectomies). The most frequent vessel relationship was the abutment of the superior mesenteric artery (44 %), and 26 patients had ≥2 vessels involved. Prognostic factors of resectability were CA19-9 response >10 % (OR 3.07, p = 0.016) and Hepatic Artery involvement (OR 0.21, p = 0.026). Median overall survival was better for CA19-9 responders than for non-responders (20.9 months and 11.8 months respectively, p < 0.001), and similar to normalized CA19-9 (25.0 months, p = 0.48). There were no differences in terms of OS or PFS with the involvement of the HA (17.7 vs 17.1 months, p = 0.367; and 8.7 vs 12.0 months, p = 0.267). CONCLUSION: The involvement of the Hepatic Artery seems to confer a worse prognosis regarding resectability. A decrease of only >10 % of CA19-9 is a predictive factor for resectability and better overall and progression-free survival.

Prognostic risk factors in 113 patients undergoing cephalic duodenopancreatectomy for distal cholangiocarcinoma. / Factores de mal pronóstico en 113 pacientes sometidos a duodenopancreatectomía cefálica por colangiocarcinoma distal.

INTRODUCTION: Distal cholangiocarcinoma is a malignant epithelial neoplasia that affects the extrahepatic bile ducts, below the cystic duct. No relevant relationship between perioperative factors and worse long-term outcome has been proved. OBJECTIVE: To analyze the risk factors for mortality and long-term recurrence of distal cholangiocarcinoma in resected patients. MATERIALS AND METHODS: A single-center prospective database of patients operated on for distal cholangiocarcinoma between 1990 and 2021 was analyzed in order to investigate mortality and recurrence factors. RESULTS: One hundred and thirteen patients have undergone surgery, with mean actuarial survival of 100.2 (76-124) months after resection. The bivariate study did not show differences between patients depending on age or preoperative variables studied. When multivariate analysis was performed, the presence of affected adenopathy was a risk factor for long-term mortality. The presence of affected lymph nodes, tumor recurrence, and biliary fistula during the postoperative period implied worse actuarial survival when comparing the Kaplan-Meier curves. CONCLUSIONS: The presence of affected lymph nodes influence the prognosis of the disease. The occurrence of biliary fistula during postoperative cholangiocarcinoma distal could aggravate long-term outcomes, a finding that should be reaffirmed in future studies.

Experiencia en la resección del proceso uncinado del páncreas: indicaciones y resultados. Revisión de la literatura / Experience in the resection of the uncinate process of the pancreas: Indications and results. Literature review

Introducción: El objetivo de nuestro trabajo es evaluar la experiencia acumulada en el empleo de la uncinectomía (UC) como técnica de pancreatectomía conservadora de parénquima. Método: Estudio observacional y descriptivo que incluye retrospectivamente todos los pacientes intervenidos mediante la técnica de UC en Hospital Universitari de Bellvitge (HUB), y revisión exhaustiva de los casos descritos en la literatura inglesa hasta la actualidad. Resultados: Desde el 2003 hasta el 2019 han sido intervenidos siete pacientes mediante UC en el HUB con orientación diagnóstica de lesión pancreática considerada premaligna. Todos los pacientes han presentado morbilidad, fundamentalmente en forma de fístula pancreática postoperatoria y ninguno de ellos ha presentado insuficiencia pancreática endocrina ni exocrina. Actualmente todos los pacientes se encuentran vivos y sin recidiva de enfermedad neoplásica. Otros 29 casos han sido descritos en la literatura. Del total de los casos (36 pacientes), el abordaje ha sido mínimamente invasivo (laparoscópico o robotizado) en seis pacientes (16,7%), conllevando una estancia hospitalaria inferior. La incidencia global de fístula pancreática es del 50% comportando una tasa de reingreso inferior al 10%, pero sin necesitar reintervención. Conclusión: La UC es una técnica infrecuente y poco estandarizada para la resección de lesiones benignas o de bajo potencial de malignidad localizadas en el proceso uncinado del páncreas. Aunque se asocia a una morbilidad igual o superior a las técnicas de resección estandarizadas, ofrece una preservación excelente de la función endocrina y exocrina pancreática, con el consiguiente beneficio en la calidad de vida de los pacientes a largo plazo. (AU)

Introduction: The aim of our study is to assess the accumulated experience in the use of uncinatectomy (UC) as a parenchymal-sparing pancreatectomy technique. Method: We have carried out a observational and descriptive study including restrospectively all the patients undergoing UC at Hospital Universitary de Bellvitge (HUB) and an exhaustive review of the cases described in the english literature. Results: From 2003 to 2019, seven patients have been operated by UC in the HUB with a diagnostic orientation of pancreatic lesion considered premalignant. All patients have presented morbidity, mainly in the form of postoperative pancreatic fistula, and none of them have presented endocrine or exocrine pancreatic insufficiency. Currently, all patients are alive and without recurrence of neoplastic disease. Another 29 cases have been described in the literature. Of all the cases (36 patients), the approach was minimally invasive (laparoscopic or robotic) in 6 patients (16.7%), leading to a shorter hospital stay. The global incidence of pancreatic fistula is 50%, with a re-admission rate of less than 10%, but without requiring re-intervention. Conclusion: UC is an infrequent and poorly standardized technique for the resection of benign lesions or those with low potential for malignancy located in the uncinate process of the pancreas. Although it is associated with equal or greater morbidity than standardized resection techniques, it offers excellent preservation of endocrine and exocrine pancreatic function, with the consequent long-term benefit in the patients life quality. (AU)

Experience in the resection of the uncinate process of the pancreas: Indications and results. Literature review.

INTRODUCTION: The aim of our study is to assess the accumulated experience in the use of uncinatectomy (UC) as a parenchymal-sparing pancreatectomy technique. METHOD: We have carried out a observational and descriptive study including restrospectively all the patients undergoing UC at Hospital Universitary de Bellvitge (HUB) and an exhaustive review of the cases described in the english literature. RESULTS: From 2003 to 2019, seven patients have been operated by UC in the HUB with a diagnostic orientation of pancreatic lesion considered premalignant. All patients have presented morbidity, mainly in the form of postoperative pancreatic fistula, and none of them have presented endocrine or exocrine pancreatic insufficiency. Currently, all patients are alive and without recurrence of neoplastic disease. Another 29 cases have been described in the literature. Of all the cases (36 patients), the approach was minimally invasive (laparoscopic or robotic) in 6 patients (16.7%), leading to a shorter hospital stay. The global incidence of pancreatic fistula is 50%, with a re-admission rate of less than 10%, but without requiring re-intervention. CONCLUSIONS: UC is an infrequent and poorly standardized technique for the resection of benign lesions or those with low potential for malignancy located in the uncinate process of the pancreas. Although it is associated with equal or greater morbidity than standardized resection techniques, it offers excellent preservation of endocrine and exocrine pancreatic function, with the consequent long-term benefit in the patients life quality.

Predictive factors for resection and survival in type A borderline resectable pancreatic ductal adenocarcinoma patients after neoadjuvant therapy: A retrospective cohort study.

INTRODUCTION: Pancreatic cancer is the seventh leading cause of cancer-related death worldwide, and surgical resection with radical intent remains the only potentially curative treatment option today. However, borderline resectable pancreatic ductal adenocarcinomas (BR-PDAC) stand in the gray area between the resectable and unresectable disease since they are technically resectable but have a high probability of incomplete exeresis. Neoadjuvant treatment (NAT) plays an important role in ensuring resection success.Different survival prognostic factors for BR-PDAC have been well described, but evidence on the predictive factors associated with resection after NAT is scarce. This study aims to study if CA 19-9 plasmatic levels and the tumor anatomical relationship with neighboring vascular structures are prognostic factors for resection and survival (both Overall Survival and Progression-Free Survival) in patients with type A BR-PDAC. METHODS: This will be a retrospective cohort study using data from type A BR-PDAC patients who received NAT in the Bellvitge University Hospital. The observation period is from January 2010 until December 2019; patients must have a minimum 12-month follow-up. Patients will be classified according to the MD Anderson Cancer Center criteria for BR-PDAC. DISCUSSION: Patients with BR-PDAC have a high risk for a margin-positive resection. Serum Carbohydrate Antigen 19-9 plasmatic levels and vascular involvement stand out as disease-related prognostic factors.This study will provide valuable information on the prognostic factors associated with resection. We will exclude locally advanced tumors and expect this approach to provide more realistic resection rates without selecting those patients that undergo surgical exploration. However, focusing on an anatomical definition may limit the results' generalizability.

Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement.

BACKGROUND: There are no clearly defined indications for pancreas-preserving duodenectomy. The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreas-preserving duodenectomy. METHODS: Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included. We divided the series according to indication: scenario 1, primary duodenal tumors; scenario 2, tumors of another origin with duodenal involvement; and scenario 3, emergency duodenectomy. RESULTS: We included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35). CONCLUSIONS: Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain / Resultados de una encuesta sobre el soporte nutricional perioperatorio en la cirugía pancreática y biliar en España

INTRODUCTION: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. METHODS: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. RESULTS: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (< 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. CONCLUSIONS: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country

INTRODUCCIÓN: realizamos una encuesta sobre soporte nutricional perioperatorio en cirugía pancreática y biliar en hospitales españoles en 2007, que mostró que pocos grupos quirúrgicos seguían las guías de ESPEN 2006. Diez años después enviamos un cuestionario para comprobar la situación actual. MÉTODOS: treinta y ocho centros recibieron un cuestionario con 21 preguntas sobre tiempo de ayunas antes y después de la cirugía, cribado nutricional, duración y tipo de soporte nutricional perioperatorio, y número de procedimientos. RESULTADOS: respondieron 34 grupos. La mediana de pancreatectomías (cabeza/total) fue de 29,5 (IC 95 %: 23,0-35; rango, 5-68) (total, 1002), la de cirugías biliares malignas de 9,8 (IC 95 %: 7,3-12,4; rango, 2-30) y la de resecciones biliares por patología benigna de 10,4 (IC 95 %: 7,6-13,3; rango, 2-33). Solo el 41,2 % de los grupos utilizaban soporte nutricional antes de la cirugía (< 50 % habian efectuado un cribado nutricional). El tiempo medio de ayuno preoperatorio para sólidos fue de 9,3 h (rango, 6-24 h), y de 6,6 h para líquidos (rango, 2-12). Tras la pancreatectomía, el 29,4 % habían intentado administrar una dieta oral precoz, pero el 88,2 % de los grupos usaron algún tipo de soporte nutricional y el 26,5 % usaron NP en el 100 % de los casos. Los demás grupos usaron diferentes porcentajes de NP y NE en sus casos. En la cirugía biliar maligna, el 22,6 % utilizaron NP siempre y NE en el 19,3 % de los casos. CONCLUSIONES: la NP es el soporte nutricional más utilizado tras la cirugía de cabeza pancreática. Solo el 29,4 % de las unidades usan nutrición oral precoz y el 32,3 % emplean la NE tras este tipo de cirugía. El 22,6 % de las instituciones usan NP habitualmente tras la cirugía de tumores biliares malignos. Las guías ESPEN 2006 no se siguen de forma habitual en nuestro país tras más de 10 años desde su publicación

Adenocarcinoma duodenal: resultados del tratamiento quirúrgico de una serie unicéntrica de 27 pacientes / Duodenal adenocarcinoma: Surgical results of 27 patients treated at a single center

Introducción: El adenocarcinoma de duodeno es una neoplasia poco frecuente, sobre la que existen pocas experiencias publicadas de los resultados tras su resección. El objetivo es analizar los resultados obtenidos en nuestro centro tras la resección curativa del adenocarcinoma duodenal (AD). Métodos: Estudio retrospectivo de los pacientes intervenidos con resección curativa por AD entre 1990 y 2017 en nuestro hospital. Resultados: Se intervino a 27 pacientes. En 23 casos (85%) se realizó duodenopancreatectomía cefálica (DPC) y en 4 casos (15%) con localización en la 3.ª-4.ª porción duodenal se realizó duodenectomía (DD) segmentaria. La morbilidad postoperatoria global fue del 67% (18 pacientes). La mortalidad postoperatoria global fue 7% (2 pacientes), sin embargo, la mortalidad postoperatoria relacionada con la cirugía fue de 4% (un paciente). El estudio anatomopatológico evidenció resección con márgenes libres en todos los casos intervenidos. La mediana de adenopatías resecadas fue 18 (0 a 38), siendo 1 (0 a 8) las adenopatías afectadas. Tras una mediana de seguimiento de 23 (9-69,7) meses, la supervivencia actuarial fue de 62,2 (25,2 a 99,1) meses y la supervivencia actuarial libre de enfermedad fue de 49 (0 a 133) meses. Conclusiones: La resección quirúrgica del AD comporta una elevada morbilidad postoperatoria, sin embargo, consigue una supervivencia prolongada. Dependiendo de la localización y en ausencia de infiltración pancreática, la DD segmentaria con márgenes libres es una alternativa a la DPC

Introduction: Duodenal adenocarcinoma is a rare malignancy. Given the rarity of the disease, there is limited data related to resection results. The objective is to analyze results at our hospital after the curative resection of duodenal adenocarcinoma (DA). Methods: The variables were retrospectively collected from patients operated on between 1990 and 2017 at our hospital. Results: A total of 27 patients were treated. Twenty-three patients (85%) underwent pancreaticoduodenectomy, and 4 patients (15%) with tumors located in the third and fourth portions of the duodenum underwent segmental duodenal resection. The overall postoperative morbidity was 67% (18 patients). Postoperative mortality was 7% (2 patients); however, postoperative mortality related to surgery was 4% (1 patient). All patients had negative resection margins. A median of 18 lymph nodes (range, 0-38) were retrieved and evaluated, with a median of 1 involved node (range, 0-8). Median follow up was 23 (9-69.7) months. Actuarial overall survival was 62.2 (25.2-99.1) months. Actuarial disease-free survival was 49 (0-133) months. Conclusions: The surgical treatment of duodenal adenocarcinoma is associated with a high morbidity, although it achieves considerable survival. Depending on the tumor location and if there is no pancreatic infiltration, segmental duodenal resection with negative margins is an alternative to cephalic pancreaticoduodenectomy

Duodenal adenocarcinoma: Surgical results of 27 patients treated at a single center. / Adenocarcinoma duodenal: resultados del tratamiento quirúrgico de una serie unicéntrica de 27 pacientes.

INTRODUCTION: Duodenal adenocarcinoma is a rare malignancy. Given the rarity of the disease, there is limited data related to resection results. The objective is to analyze results at our hospital after the curative resection of duodenal adenocarcinoma (DA). METHODS: The variables were retrospectively collected from patients operated on between 1990 and 2017 at our hospital. RESULTS: A total of 27 patients were treated. Twenty-three patients (85%) underwent pancreaticoduodenectomy, and 4 patients (15%) with tumors located in the third and fourth portions of the duodenum underwent segmental duodenal resection. The overall postoperative morbidity was 67% (18 patients). Postoperative mortality was 7% (2 patients); however, postoperative mortality related to surgery was 4% (1 patient). All patients had negative resection margins. A median of 18 lymph nodes (range, 0-38) were retrieved and evaluated, with a median of 1 involved node (range, 0-8). Median follow up was 23 (9-69.7) months. Actuarial overall survival was 62.2 (25.2-99.1) months. Actuarial disease-free survival was 49 (0-133) months. CONCLUSIONS: The surgical treatment of duodenal adenocarcinoma is associated with a high morbidity, although it achieves considerable survival. Depending on the tumor location and if there is no pancreatic infiltration, segmental duodenal resection with negative margins is an alternative to cephalic pancreaticoduodenectomy.

Initial Experience in the Treatment of "Borderline Resectable" Pancreatic Adenocarcinoma. / Experiencia inicial en el tratamiento del adenocarcinoma de páncreas borderline resectable.

INTRODUCTION: A borderline resectable group (APBR) has recently been defined in adenocarcinoma of the pancreas. The objective of the study is to evaluate the results in the surgical treatment after neoadjuvancy of the APBR. METHOD: Between 2010 and 2014, we included patients with APBR in a neoadjuvant and surgery protocol, staged by multidetector computed tomography (MDCT). Treatment with chemotherapy was based on gemcitabine and oxaliplatin. Subsequently, MDCT was performed to rule out progression, and 5-FU infusion and concomitant radiotherapy were given. MDCT and resection were performed in absence of progression. A descriptive statistical study was performed, dividing the series into: surgery group (GR group) and progression group (PROG group). RESULTS: We indicated neoadjuvant treatment to 22 patients, 11 of them were operated, 9 pancreatoduodenectomies, and 2 distal pancreatectomies. Of the 11 patients, 7 required some type of vascular resection; 5 venous resections, one arterial and one both. No postoperative mortality was recorded, 7 (63%) had any complications, and 4 were reoperated. The median postoperative stay was 17 (7-75) days. The pathological study showed complete response (ypT0) in 27%, and free microscopic margins (R0) in 63%. At study clossure, all patients had died, with a median actuarial survival of 13 months (9,6-16,3). The median actuarial survival of the GR group was higher than the PROG group (25 vs. 9 months; p < 0.0001). CONCLUSION: The neoadjuvant treatment of APBR allows us to select a group of patients in whom resection achieves a longer survival to the group in which progression is observed. Post-adjuvant pancreatic resection requires vascular resection in most cases.

Experiencia inicial en el tratamiento del adenocarcinoma de páncreas borderline resectable / Initial Experience in the Treatment of "Borderline Resectable" Pancreatic Adenocarcinoma

Introducción: Se ha definido un grupo de resecabilidad borderline resectable (APBR) en el adenocarcinoma de páncreas. El objetivo del estudio es evaluar los resultados en el tratamiento quirúrgico tras neoadyuvancia del APBR. Método: Entre 2010 y 2014 incluimos pacientes afectos de APBR en un protocolo de neoadyuvancia y cirugía, estadificados mediante tomografía computarizada multidetector (TCMD). El tratamiento con quimioterapia se basó en gemcitabina y oxaliplatino (GEMOX). Posteriormente, se realizó TCMD para descartar progresión, y se administró 5-FU en infusión y radioterapia concomitante. Se practicó TCMD y resección en ausencia de progresión. Se realizó un estudio estadístico descriptivo, dividiendo la serie en grupo resección (grupo GR) y grupo progresión (grupo PROG). El seguimiento finalizó en febrero de 2016. Resultados: Indicamos tratamiento neoadyuvante a 22 pacientes, 11 de ellos fueron finalmente intervenidos. Se realizaron 9 duodenopancreatectomías cefálicas, una duodenopancreatectomía total y una pancreatectomía corporocaudal. De los 11 pacientes, 7 requirieron algún tipo de resección vascular; 5 resecciones venosas, uno arterial y otro ambas. No hubo mortalidad postoperatoria, 7 (63%) tuvieron alguna complicación y 4 fueron reintervenidos. La estancia hospitalaria postoperatoria mediana fue 17 días (7-75). El estudio patológico evidenció márgenes microscópicos libres (R0) en el 63% de los pacientes y ausencia de afectación adenopática en 10 pacientes (ypN0). Al cierre del estudio, todos los pacientes habían fallecido, con una supervivencia actuarial mediana de 13 meses (9,6-16,3). La supervivencia actuarial mediana del grupo GR fue superior al grupo PROG (25 vs. 9 meses; p<0,0001). Conclusión: El tratamiento neoadyuvante del APBR permite seleccionar un grupo de pacientes en el que la resección consigue una supervivencia superior al grupo en el que se observa progresión. La resección pancreática posneoadyuvancia requiere resecciones vasculares en la mayoría de los casos (AU)

Introduction: A borderline resectable group (APBR) has recently been defined in adenocarcinoma of the pancreas. The objective of the study is to evaluate the results in the surgical treatment after neoadjuvancy of the APBR. Method: Between 2010 and 2014, we included patients with APBR in a neoadjuvant and surgery protocol, staged by multidetector computed tomography (MDCT). Treatment with chemotherapy was based on gemcitabine and oxaliplatin. Subsequently, MDCT was performed to rule out progression, and 5-FU infusion and concomitant radiotherapy were given. MDCT and resection were performed in absence of progression. A descriptive statistical study was performed, dividing the series into: surgery group (GR group) and progression group (PROG group). Results: We indicated neoadjuvant treatment to 22 patients, 11 of them were operated, 9 pancreatoduodenectomies, and 2 distal pancreatectomies. Of the 11 patients, 7 required some type of vascular resection; 5 venous resections, one arterial and one both. No postoperative mortality was recorded, 7 (63%) had any complications, and 4 were reoperated. The median postoperative stay was 17 (7-75) days. The pathological study showed complete response (ypT0) in 27%, and free microscopic margins (R0) in 63%. At study clossure, all patients had died, with a median actuarial survival of 13 months (9,6-16,3). The median actuarial survival of the GR group was higher than the PROG group (25 vs. 9 months; p < 0.0001). Conclusion: The neoadjuvant treatment of APBR allows us to select a group of patients in whom resection achieves a longer survival to the group in which progression is observed. Post-adjuvant pancreatic resection requires vascular resection in most cases (AU)

Human immunodeficiency virus-infected liver transplant recipients with incidental hepatocellular carcinoma: A prospective multicenter nationwide cohort study.

There is a lack of data on incidental hepatocellular carcinoma (iHCC) in the setting of liver transplantation (LT) in human immunodeficiency virus (HIV)-infected patients. This study aims to describe the frequency, histopathological characteristics, and outcomes of HIV+ LT recipients with iHCC from a Spanish multicenter cohort in comparison with a matched cohort of LT patients without HIV infection. A total of 15 (6%) out of 271 patients with HIV infection who received LT in Spain from 2002 to 2012 and 38 (5%) out of the 811 HIV- counterparts presented iHCC in liver explants (P = 0.58). Patients with iHCC constitute the present study population. All patients also had hepatitis C virus (HCV)-related cirrhosis. There were no significant differences in histopathological features of iHCC between the 2 groups. Most patients showed a small number and size of tumoral nodules, and few patients had satellite nodules, microvascular invasion, or poorly differentiated tumors. After a median follow-up of 49 months, no patient developed hepatocellular carcinoma (HCC) recurrence after LT. HIV+ LT recipients tended to have lower survival than their HIV- counterparts at 1 (73% versus 92%), 3 (67% versus 84%), and 5 years (50% versus 80%; P = 0.06). There was also a trend to a higher frequency of HCV recurrence as a cause of death in the former (33% versus 10%; P = 0.097). In conclusion, among LT recipients for HCV-related cirrhosis, the incidence and histopathological features of iHCC in HIV+ and HIV- patients were similar. However, post-LT survival was lower in HIV+ patients probably because of a more aggressive HCV recurrence. Liver Transplantation 23 645-651 2017 AASLD.

Tratamiento quirúrgico de los tumores neuroendocrinos no funcionantes de páncreas basado en 3 escenarios clínicos / Surgical treatment of non-functioning pancreatic neuroendocrine tumours based on three clinical scenarios

INTRODUCCIÓN: El tratamiento de los tumores neuroendocrinos pancreáticos no funcionantes (TNEPNF) es la resección en caso de enfermedad localizada o metástasis hepáticas resecables. Existe controversia en metástasis hepáticas irresecables. MÉTODOS: Analizamos los datos perioperatorios y de supervivencia de 63 pacientes resecados por TNEPNF entre 1993 y 2012, dividiéndolos en 3 escenarios: A, resección pancreática (44 pacientes); B, resección pancreática y hepática por metástasis hepáticas sincrónicas (12 pacientes), y C, resección pancreática en presencia de metástasis hepáticas irresecables (6 pacientes). Se estudiaron factores pronósticos de supervivencia y recidiva. RESULTADOS: Las cirugías más frecuentes fueron, pancreatectomía corporocaudal (51%) y duodenopancreatectomía cefálica (38%). El 44% de los pacientes requirieron una cirugía asociada, resecando sincrónicamente páncreas e hígado en 9. Dos pacientes recibieron un trasplante hepático durante el seguimiento. Según la clasificación de la OMS, se distribuyeron en G1: 10 (16%), G2: 45 (71%) y G3: 8 (13%). La morbimortalidad postoperatoria fue del 49 y del 1,6%, respectivamente. Al cierre del estudio, 43 (68%) seguían vivos, con una supervivencia actuarial media de 9,6 años. La clasificación de la OMS y la recidiva fueron factores de riesgo de mortalidad en el estudio multivariante. La supervivencia actuarial mediana por escenarios fue de 131 meses (A), 102 meses (B) y 75 meses (C), sin diferencias estadísticamente significativas. CONCLUSIONES: El tratamiento del TNEPNF sin enfermedad a distancia es la resección. Las metástasis hepáticas resecables en los tumores bien diferenciados deben resecarse. La resección del tumor pancreático con metástasis hepáticas sincrónicas irresecables debe considerarse en TNEPNF bien diferenciados. El grado de clasificación de la OMS y la recidiva son factores de riesgo de mortalidad a largo plazo

INTRODUCTION: The treatment of patients with non-functioning pancreatic neuroendocrine tumours (NFPNET) is resection in locally pancreatic disease, or with resectable liver metastases. There is controversy about unresectable liver disease. METHODS: We analysed the perioperative data and survival outcome of 63 patients who underwent resection of NFPNET between 1993 and 2012. They were divided into 3 scenarios: A, pancreatic resection (44 patients); B, pancreatic and liver resection in synchronous resectable liver metastases (12 patients); and C, pancreatic resection in synchronous unresectable liver metastases (6 patients). The prognostic factors for survival and recurrence were studied. RESULTS: Distal pancreatectomy (51%) and pancreaticoduodenectomy (38%) were more frequently performed. Associated surgery was required in 44% of patients, including synchronous liver resections in 9 patients. Two patients received a liver transplant during follow-up. According to the WHO classification they were distributed into G1: 10 (16%), G2: 45 (71%), and G3: 8 (13%). The median hospital stay was 11 days. Postoperative morbidity and mortality were 49% and 1.6%, respectively. At the closure of the study, 43 (68%) patients were still alive, with a mean actuarial survival of 9.6 years. The WHO classification and tumour recurrence were risk factors of mortality in the multivariate analysis. The median actuarial survival by scenarios was 131 months (A), 102 months (B), and 75 months (C) without statistically significant differences. CONCLUSIONS: Surgical resection is the treatment for NFPNET without distant disease. Resectable liver metastases in well-differentiated tumours must be resected. The resection of the pancreatic tumour with unresectable synchronous liver metastasis must be considered in well-differentiated NFPNET. The WHO classification grade and recurrence are risk factors of long-term mortality

Surgical treatment of non-functioning pancreatic neuroendocrine tumours based on three clinical scenarios. / Tratamiento quirúrgico de los tumores neuroendocrinos no funcionantes de páncreas basado en 3 escenarios clínicos.

INTRODUCTION: The treatment of patients with non-functioning pancreatic neuroendocrine tumours (NFPNET) is resection in locally pancreatic disease, or with resectable liver metastases. There is controversy about unresectable liver disease. METHODS: We analysed the perioperative data and survival outcome of 63 patients who underwent resection of NFPNET between 1993 and 2012. They were divided into 3 scenarios: A, pancreatic resection (44patients); B, pancreatic and liver resection in synchronous resectable liver metastases (12patients); and C, pancreatic resection in synchronous unresectable liver metastases (6patients). The prognostic factors for survival and recurrence were studied. RESULTS: Distal pancreatectomy (51%) and pancreaticoduodenectomy (38%) were more frequently performed. Associated surgery was required in 44% of patients, including synchronous liver resections in 9patients. Two patients received a liver transplant during follow-up. According to the WHO classification they were distributed into G1: 10 (16%), G2: 45 (71%), and G3: 8 (13%). The median hospital stay was 11days. Postoperative morbidity and mortality were 49% and 1.6%, respectively. At the closure of the study, 43 (68%) patients were still alive, with a mean actuarial survival of 9.6years. The WHO classification and tumour recurrence were risk factors of mortality in the multivariate analysis. The median actuarial survival by scenarios was 131months (A), 102months (B), and 75months (C) without statistically significant differences. CONCLUSIONS: Surgical resection is the treatment for NFPNET without distant disease. Resectable liver metastases in well-differentiated tumours must be resected. The resection of the pancreatic tumour with unresectable synchronous liver metastasis must be considered in well-differentiated NFPNET. The WHO classification grade and recurrence are risk factors of long-term mortality.

Human immunodeficiency virus infection does not worsen prognosis of liver transplantation for hepatocellular carcinoma.

UNLABELLED: The impact of human immunodeficiency virus (HIV) infection on patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC) is uncertain. This study aimed to assess the outcome of a prospective Spanish nationwide cohort of HIV-infected patients undergoing LT for HCC (2002-2014). These patients were matched (age, gender, year of LT, center, and hepatitis C virus (HCV) or hepatitis B virus infection) with non-HIV-infected controls (1:3 ratio). Patients with incidental HCC were excluded. Seventy-four HIV-infected patients and 222 non-HIV-infected patients were included. All patients had cirrhosis, mostly due to HCV infection (92%). HIV-infected patients were younger (47 versus 51 years) and had undetectable HCV RNA at LT (19% versus 9%) more frequently than non-HIV-infected patients. No significant differences were detected between HIV-infected and non-HIV-infected recipients in the radiological characteristics of HCC at enlisting or in the histopathological findings for HCC in the explanted liver. Survival at 1, 3, and 5 years for HIV-infected versus non-HIV-infected patients was 88% versus 90%, 78% versus 78%, and 67% versus 73% (P = 0.779), respectively. HCV infection (hazard ratio = 7.90, 95% confidence interval 1.07-56.82) and maximum nodule diameter >3 cm in the explanted liver (hazard ratio = 1.72, 95% confidence interval 1.02-2.89) were independently associated with mortality in the whole series. HCC recurred in 12 HIV-infected patients (16%) and 32 non-HIV-infected patients (14%), with a probability of 4% versus 5% at 1 year, 18% versus 12% at 3 years, and 20% versus 19% at 5 years (P = 0.904). Microscopic vascular invasion (hazard ratio = 3.40, 95% confidence interval 1.34-8.64) was the only factor independently associated with HCC recurrence. CONCLUSIONS: HIV infection had no impact on recurrence of HCC or survival after LT. Our results support the indication of LT in HIV-infected patients with HCC.

Resultados del trasplante hepático con donantes de más de 70 años / Outcomes of liver transplant with donors over 70 years of age

La escasez de órganos para trasplante ha hecho aumentar progresivamente la aceptación de donantes con criterios marginales, como la edad. MÉTODOS: Se ha realizado un análisis comparativo de la evolución postrasplante dependiendo de la edad de los donantes (grupo I: edad inferior a 70 años [n = 474] vs. grupo II: edad superior a 70 años [n = 105]), a lo largo de un periodo de 10 años. RESULTADOS: No había diferencias significativas entre ambos grupos en días de UCI, sexo, peso y requerimientos de fármacos vasoactivos. El grupo I presentó parada cardiaca de forma más frecuente (GI: 14 vs. GII: 3%; p = 0,005). No hubo diferencias en la disfunción primaria (GI: 6 vs. GII: 7,7%; p = 0,71), estancia en UCI (GI: 2,7 ± 2 vs. GII: 3,3 ± 3,8 días; p = 0,46) y hospitalaria (GI: 13,5 ± 10 vs. GII: 15,5 ± 11; p = 0,1), ni mortalidad hospitalaria (GI: 5,3 vs. GII: 5,8%; p = 0,66). Tras una mediana de seguimiento de 42 meses, tampoco se encontraron diferencias en la incidencia de complicaciones biliares (GI: 17 vs. GII: 20%; p = 0,40) ni vasculares (GI: 11 vs. GII: 9%; p = 0,69). La supervivencia actuarial a 5 años fue similar entre ambos grupos de estudio (GI: 70 vs. GII: 76%; p = 0,54). CONCLUSIONES: En nuestra experiencia, la utilización de injertos de donantes mayores de 70 años, si se evitan factores de riesgo adicionales (tiempo de isquemia, esteatosis, hipernatremia), no empeora los resultados del trasplante hepático a corto ni a largo plazo

Organ shortage has forced transplant teams to progressively expand the acceptance of marginal donors. METHODS: We performed a comparative analysis of the post-transplant evolution depending on donor age (group I: less than 70 years old (n = 474) vs. group II: 70 or more years old [n = 105]) over a 10 year period (2002-2011). RESULTS: Donors over 70 years old were similar to donors less than 70 years old in terms of ICU stay, gender, weight, laboratory results, and use of vasoactive drugs. However, the younger donor group presented with cardiac arrest more often (GI: 14 vs. GII: 3%, P=.005). There were no differences in initial poor function (GI: 6% vs. GII: 7,7%; P=.71), ICU stay (GI: 2.7 ± 2 vs. GII: 3.3 ± 3.8, P=.46), hospital stay (GI: 13.5 ± 10 vs. GII: 15.5 ± 11, P=.1), or hospital mortality (GI: 5.3 vs. GII: 5.8%, P=.66) between receptors of more or less than 70 year old grafts. After a median follow up of 32 months, no differences were found in the incidence of biliary tract complications (GI: 17 vs. GII: 20%, P=.4) or vascular complications (GI: 11 vs. GII: 9%, P=.69). The actuarial 5 year survival was similar for both study groups (GI: 70 vs. GII: 76%, P=.54). CONCLUSIONS: In our experience, the use of grafts from donors older than 70 years, when other risk factors are avoided (cold ischemia, steatosis, sodium levels), does not worsen the results of liver transplantation on the short or long term

Liver Transplantation for Hereditary Transthyretin Amyloidosis: After 20 Years Still the Best Therapeutic Alternative?

BACKGROUND: Until recently, liver transplantation (Ltx) was the only available treatment for hereditary transthyretin (TTR) amyloidosis; today, however, several pharmacotherapies are tested. Herein, we present survival data from the largest available database on transplanted hereditary TTR patients to serve as a base for comparison. METHODS: Liver transplantation was evaluated in a 20-year retrospective analysis of the Familial Amyloidosis Polyneuropathy World Transplant Registry. RESULTS: From April 1990 until December 2010, data were accumulated from 77 liver transplant centers. The Registry contains 1940 patients, and 1379 are alive. Eighty-eight Ltx were performed in combination with a heart and/or kidney transplantation. Overall, 20-year survival after Ltx was 55.3%. Multivariate analysis revealed modified body mass index, early onset of disease (<50 years of age), disease duration before Ltx, and TTR Val30Met versus non-TTR Val30Met mutations as independent significant survival factors. Early-onset patients had an expected mortality rate of 38% that of the late-onset group (P < 0.001). Furthermore, Val30Met patients had an expected mortality rate of 61% that of non-TTR Val30Met patients (P < 0.001). With each year of duration of disease before Ltx, expected mortality increased by 11% (P < 0.001). With each 100-unit increase in modified body mass index at Ltx, the expected mortality decreased to 89% of the expected mortality (P < 0.001). Cardiovascular death was markedly more common than that observed in patients undergoing Ltx for end-stage liver disease. CONCLUSIONS: Long-term survival after Ltx, especially for early-onset TTR Val30Met patients, is excellent. The risk of delaying Ltx by testing alternative treatments, especially in early-onset TTR Val30Met patients, requires consideration.

Outcomes of liver transplant with donors over 70 years of age.

UNLABELLED: Organ shortage has forced transplant teams to progressively expand the acceptance of marginal donors. METHODS: We performed a comparative analysis of the post-transplant evolution depending on donor age (group I: less than 70 years old (n=474) vs. group II: 70 or more years old [n=105]) over a 10 year period (2002-2011). RESULTS: Donors over 70 years old were similar to donors less than 70 years old in terms of ICU stay, gender, weight, laboratory results, and use of vasoactive drugs. However, the younger donor group presented with cardiac arrest more often (GI: 14 vs. GII: 3%, P=.005). There were no differences in initial poor function (GI: 6% vs. GII: 7,7%; P=.71), ICU stay (GI: 2.7±2 vs. GII: 3.3±3.8, P=.46), hospital stay (GI: 13.5±10 vs. GII: 15.5±11, P=.1), or hospital mortality (GI: 5.3 vs. GII: 5.8%, P=.66) between receptors of more or less than 70 year old grafts. After a median follow up of 32 months, no differences were found in the incidence of biliary tract complications (GI: 17 vs. GII: 20%, P=.4) or vascular complications (GI: 11 vs. GII: 9%, P=.69). The actuarial 5 year survival was similar for both study groups (GI: 70 vs. GII: 76%, P=.54). CONCLUSIONS: In our experience, the use of grafts from donors older than 70 years, when other risk factors are avoided (cold ischemia, steatosis, sodium levels), does not worsen the results of liver transplantation on the short or long term.