Tumor carcinoide de la vía biliar extrahepática en adolescente: larga supervivencia libre de enfermedad tras resección quirúrgica / Carcinoid tumor of the extrahepatic bile duct in an adolescent: Prolonged disease-free survival after surgical resection

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Estudio multicéntrico sobre adenomas hepáticos / Multicentre study on hepatic adenomas

INTRODUCCIÓN: El adenoma hepático (AH) es un tumor benigno que puede presentar graves complicaciones por lo que, clásicamente, todos eran resecados. Actualmente se ha demostrado que los menores de 3 cm, y si no expresan Beta -catenina, solo se complican excepcionalmente, lo que ha cambiado la estrategia terapéutica. MATERIAL Y MÉTODOS: Estudio retrospectivo en 14 unidades HPB. Criterio de inclusión: pacientes con AH resecado y confirmado histológicamente. Periodo de estudio: 1995-2011. RESULTADOS: Fueron intervenidos 81 pacientes. Edad: 39,5 años (rango: 14-75). Sexo: mujeres (75%). Consumo de estrógenos en mujeres: 33%. Tamaño: 8,8 cm (rango: 1-20 cm). Solo 6 AH (7,4%) eran menores de 3 cm. La mediana de AH fue 1 (rango: 1-12). Nueve pacientes presentaban adenomatosis (> 10 AH). El 51% de los pacientes presentaban síntomas; el más frecuente (77%) era dolor abdominal. Ocho pacientes (10%) comenzaron con abdomen agudo por rotura o hemorragia. El 67% de los diagnósticos preoperatorios fueron correctos. La cirugía fue programada en el 90% de los pacientes. Las técnicas fueron: hepatectomías mayores (22%), menores (77%) y un trasplante hepático. Un 20% fueron realizadas por laparoscopia. La morbilidad fue 28%. No hubo mortalidad. Tres pacientes presentaron malignización (3,7%). El seguimiento fue 43 meses (rango: 1-192). Se detectaron 2 recidivas que fueron resecadas. DISCUSIÓN: Los pacientes con AH resecados son habitualmente mujeres con lesiones grandes, con un consumo de estrógenos inferior al esperado. Su diagnóstico preoperatorio correcto es aceptable (70%). La tasa de hepatectomías mayores es 25% y la de laparoscopia, 20%. Hemos obtenido una baja morbilidad y nula mortalidad

INTRODUCTION: Hepatic adenomas (HA) are benign tumours which can present serious complications, and as such, in the past all were resected. It has now been shown that those smaller than 3 cm not expressing Beta-catenin only result in complications in exceptional cases and therefore the therapeutic strategy has been changed. MATERIAL AND METHOD: Retrospective study in 14 HPB units. Inclusion criteria: patients with resected and histologically confirmed HA. Study period: 1995-2011. RESULTS: 81 patients underwent surgery. Age: 39.5 years (range: 14-75). Sex: female (75%). Consumption of oestrogen in women: 33%. Size: 8.8 cm (range, 1-20 cm). Only 6 HA (7.4%) were smaller than 3 cm. The HA median was 1 (range: 1-12). Nine patients had adenomatosis (> 10HA). A total of 51% of patients displayed symptoms, the most frequent (77%) being abdominal pain. Eight patients (10%) began with acute abdomen due to rupture and/or haemorrhage. A total of 67% of the preoperative diagnoses were correct. Surgery was scheduled for 90% of patients. The techniques employed were: major hepatectomy (22%), minor hepatectomy (77%) and one liver transplantation. A total of 20% were performed laparoscopically. The morbidity rate was 28%. There were no cases of mortality. Three patients had malignisation (3.7%). The follow-up period was 43 months (range 1-192). Two recurrences were detected and resected. DISCUSSION: Patients with resected HA are normally women with large lesions and oestrogen consumption was lower than expected. Its correct preoperative diagnosis is acceptable (70%). The major hepatectomy rate is 25% and the laparoscopy rate is 20%. There was a low morbidity rate and no mortality

[Multicentre study on hepatic adenomas]. / Estudio multicéntrico sobre adenomas hepáticos.

INTRODUCTION: Hepatic adenomas (HA) are benign tumours which can present serious complications, and as such, in the past all were resected. It has now been shown that those smaller than 3 cm not expressing ß-catenin only result in complications in exceptional cases and therefore the therapeutic strategy has been changed. MATERIAL AND METHOD: Retrospective study in 14 HPB units. INCLUSION CRITERIA: patients with resected and histologically confirmed HA. STUDY PERIOD: 1995-2011. RESULTS: 81 patients underwent surgery. Age: 39.5 years (range: 14-75). Sex: female (75%). Consumption of oestrogen in women: 33%. Size: 8.8 cm (range, 1-20 cm). Only 6 HA (7.4%) were smaller than 3 cm. The HA median was 1 (range: 1-12). Nine patients had adenomatosis (>10HA). A total of 51% of patients displayed symptoms, the most frequent (77%) being abdominal pain. Eight patients (10%) began with acute abdomen due to rupture and/or haemorrhage. A total of 67% of the preoperative diagnoses were correct. Surgery was scheduled for 90% of patients. The techniques employed were: major hepatectomy (22%), minor hepatectomy (77%) and one liver transplantation. A total of 20% were performed laparoscopically. The morbidity rate was 28%. There were no cases of mortality. Three patients had malignisation (3.7%). The follow-up period was 43 months (range 1-192). Two recurrences were detected and resected. DISCUSSION: Patients with resected HA are normally women with large lesions and oestrogen consumption was lower than expected. Its correct preoperative diagnosis is acceptable (70%). The major hepatectomy rate is 25% and the laparoscopy rate is 20%. There was a low morbidity rate and no mortality.

[Xiphoid metastasis from duodenal cancer]. / Metástasis xifoidea de cáncer de duodeno.

Duodenal cancer has a low prevalence in the general population. Metastases from this neoplasm usually affect the lymph nodes, liver or lung. Bone metastases from duodenal cancer are highly infrequent and xiphoid localization is exceptional. We present the case of a patient who, 5 years after undergoing surgery for duodenal adenocarcinoma, developed xiphoid metastasis. We discuss the utility of positron emission tomography in the diagnosis of this entity and the therapeutic options.

Metástasis xifoidea de cáncer de duodeno / Xiphoid metastasis from duodenal cancer

El cáncer duodenal es una neoplasia con baja prevalencia en la población general. Cuando produce metástasis, éstas se localizan habitualmente en ganglios, hígado y pulmones. Las metástasis óseas de cáncer duodenal son muy infrecuentes y la localización xifoidea es extraordinaria. Presentamos el caso de un paciente que 5 años después de ser intervenido de una neoplasia duodenal desarrolló una metástasis xifoidea. Debatimos la utilidad de la tomografía por emisión de positrones y las opciones terapéuticas (AU)

Duodenal cancer has a low prevalence in the general population. Metastases from this neoplasm usually affect the lymph nodes, liver or lung. Bone metastases from duodenal cancer are highly infrequent and xiphoid localization is exceptional. We present the case of a patient who, 5 years after undergoing surgery for duodenal adenocarcinoma, developed xiphoid metastasis. We discuss the utility of positron emission tomography in the diagnosis of this entity and the therapeutic options (AU)

[Mirizzi syndrome and gallbladder cancer]. / Síndrome de Mirizzi y cáncer de vesícula.

Mirizzi syndrome (MS) has a low incidence in patients with gallbladder disease. The coexistence of gallbladder cancer seems to be more frequent in patients with MS than in those with gallstones only. We present two patients with MS type II and gallbladder cancer (stages T4N1M0 and T3NxMx). The etiopathogenic mechanisms, diagnostic methods and therapeutic options are discussed.

Síndrome de Mirizzi y cáncer de vesícula / Mirizzi syndrome and gallbladder cancer

El síndrome de Mirizzi (SM) tiene una baja prevalencia en los enfermos con litiasis biliar. La del cáncer de vesícula asociado al SM parece ser muy superior a la que presentan los enfermos con colelitiasis simple. Presentamos a 2 pacientes con SM tipo II y cáncer de vesícula (estadios T4N1M0 y T3NxMx). Se discuten los mecanismos implicados en esta asociación, los métodos diagnósticos y su tratamiento (AU)

Mirizzi syndrome (MS) has a low incidence in patients with gallbladder disease. The coexistence of gallbladder cancer seems to be more frequent in patients with MS than in those with gallstones only. We present two patients with MS type II and gallbladder cancer (stages T4N1M0 and T3NxMx). The etiopathogenic mechanisms, diagnostic methods and therapeutic options are discussed (AU)

[Hepatocarcinoma in noncirrhotic liver]. / Hepatocarcinoma en hígado no cirrótico.

Hepatocellular carcinoma (HCC) usually develops in patients with liver cirrhosis or chronic liver disease. These tumors are highly infrequent in patients without precipitating factors. We present a series of four patients with nonfibrolamellar HCC arising in healthy liver. None of the patients had viral infection, or showed alcohol abuse and/or hemochromatosis. Three patients underwent surgery. The clinical characteristics, therapeutic options, and survival and recurrence rates in this type of tumor are discussed.

Hepatocarcinoma en hígado no cirrótico / Hepatocarcinoma in noncirrhotic liver

El carcinoma hepatocelular (CHC) suele aparecer en pacientes afectos de cirrosis hepática o al menos enfermedad hepática crónica. El desarrollo de este tipo de tumores en pacientes sin factores desencadenantes es muy infrecuente. Presentamos una serie de 4 pacientes con CHC en un hígado sano, variante no fibrolamelar, sin infección viral, enolismo y/o hemocromatosis. Tres de ellos fueron intervenidos. Se debaten las características clínicas, las opciones terapéuticas y los resultados de supervivencia y recidiva obtenidos en este tipo de tumores (AU)

Hepatocellular carcinoma (HCC) usually develops in patients with liver cirrhosis or chronic liver disease. These tumors are highly infrequent in patients without precipitating factors. We present a series of four patients with nonfibrolamellar HCC arising in healthy liver. None of the patients had viral infection, or showed alcohol abuse and/or hemochromatosis. Three patients underwent surgery. The clinical characteristics, therapeutic options, and survival and recurrence rates in this type of tumor are discussed (AU)

Hemorragia digestiva e invaginación intestinal por coriocarcinoma intestinal / Gastrointestinal bleeding and intestinal invagination due to intestinal choriocarcinoma

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Tumores hepáticos sólidos benignos / Benign solid liver tumors

Los tumores sólidos hepáticos benignos son un grupo heterogéneo de lesiones (adenoma, hiperplasia nodular focal, hemangioma, etc.) con unas características epidemiológicas muy variadas. Los avances en los métodos diagnósticos han permitido mejorar el acierto diagnóstico preoperatorio. La resonancia magnética se ha convertido en la prueba clave, pero sigue habiendo un porcentaje de casos en el que el diagnóstico de certeza preoperatorio no es factible. La clínica más habitual es el dolor abdominal, aunque la ausencia de síntomas es frecuente. La indicación quirúrgica se realiza por duda diagnóstica o por la presencia de complicaciones (rotura, hemorragia, etc.), excepto en el adenoma, ya que por su riesgo de malignización debe ser siempre resecado. La morbimortalidad de la resección de estos tumores es muy baja, ya que se realiza en el hígado sano, es limitada, se realiza en personas jóvenes y sin enfermedades concomitantes (AU)

Benign solid liver tumors are a heterogeneous group of lesions (adenoma, focal nodular hyperplasia, hemangioma, etc.) with highly varied epidemiological characteristics. Advances in diagnostic methods have improved preoperative diagnosis. Magnetic resonance imaging has become the key test, but there is still a percentage of cases in which definitive preoperative diagnosis is not feasible. The most frequent symptom is abdominal pain, although patients are frequently asymptomatic. Surgery is indicated when diagnosis is uncertain or there are complications (rupture, hemorrhage, etc.). Because of the risk of malignant transformation, adenomas should always be resected. Morbidity and mortality after resection of these tumors is very low since excision is limited, performed in young people without concomitant disease, and in healthy liver (AU)

Surgical options for malignant left-sided colonic obstruction.

PURPOSE: We evaluated the clinical results of different techniques of resection for malignant left-sided colonic obstruction. METHODS: The subjects of this prospective nonrandomized study were 63 consecutive patients who underwent surgery between 1995 and 2000 at a single institution. Patients with nonprimary colonic tumors, lesions located proximally to splenic flexure, peritonitis, perforation, or cecal necrosis were excluded. RESULTS: Segmental colectomy with primary anastomosis (CPA) was performed in 35 patients; with intraoperative colonic irrigation (ICI) in 19, and without ICI in 16. Total or subtotal colectomy (TSC) was performed in 8, and Hartmann's procedure (HP) was performed in 20. There were no differences in age, sex, comorbidity, time of symptoms, preoperative hospital stay, or tumor staging among the groups of patients defined by the different surgical techniques. The overall incidence of postoperative complications was 43%; postoperative mortality, 5%; anastomotic dehiscence, 12%; urgent reoperations, 12%; and readmissions, 5%, without significant differences among the treatment groups. However, the postoperative and total hospital stay were significantly shorter after ICI (P = 0.016 and P = 0.012, respectively). The overall 5-year survival was 42.7%. CONCLUSIONS: We think that segmental colectomy with anastomosis after intraoperative colonic irrigation is the most effective operative treatment for neoplastic left-sided colonic obstructions, considering its safety and cost-effectiveness.

Adenocarcinoma de duodeno / Duodenal adenocarcinoma

Introducción. El adenocarcinoma de duodeno es una neoplasia infrecuente, lo que impide la existencia de grandes series que permitan extraer conclusiones sobre su diagnóstico y su tratamiento. Pacientes y método. Estudio retrospectivo (19992003) de los 5 pacientes diagnosticados de adenocarcinoma duodenal en nuestro servicio. Resultados. La edad media fue de 54 años. El 80% eran varones. Todos presentaron pérdida de peso y dolor abdominal. La localización del tumor fue: segunda (3 casos) y tercera porción (2). A todos los pacientes se les practicó una endoscopia digestiva con biopsia que informó de la presencia de adenocarcinoma. La tomografía computarizada fue la prueba diagnóstica más eficaz. El diagnóstico preoperatorio fue correcto en todos los pacientes. La técnica realizada fue duodenopancreatectomía cefálica (3 casos) y duodenectomía con resección atípica pancreática y hemicolectomía derecha (1 caso). A un paciente con metástasis hepáticas se decidió no practicar intervención quirúrgica. Dos pacientes intervenidos no presentaron ninguna complicación. Los otros presentaron vaciado gástrico lento (1 paciente) y pancreatitis del muñón, que produjo un SIRS que ocasionó el fallecimiento del paciente. La supervivencia de los pacientes intervenidos es de 60, 13 meses y 1 mes, respectivamente. Ninguno ha presentado recidiva de la enfermedad. El paciente no intervenido falleció a los 4 meses. Conclusión. El adenocarcinoma de duodeno es un tumor infrecuente asociado a diversas enfermedades. El tratamiento quirúrgico suele ser una duodenopancreatectomía cefálica. La supervivencia en los pacientes resecados es mejor que la obtenida en los tumores pancreáticos primarios (AU)

Introduction. Duodenal adenocarcinoma is an infrequent neoplasm. Consequently, there are no large series that would allow conclusions to be reached on its diagnosis and treatment. Patients and method. A retrospective study (19992003) of five patients diagnosed with duodenal adenocarcinoma in our service was performed. Results. The mean age was 54 years. Eighty percent were male. All patients showed weight loss and abdominal pain. The tumors were localized in the second portion in three patients and in the third portion in two patients. All patients underwent gastrointestinal endoscopy with biopsy, which revealed adenocarcinoma. The most effective diagnostic test was computed tomography. In all patients, the preoperative diagnosis was correct. The technique performed was cephalic duodenopancreatectomy in three patients and duodenectomy with atypical pancreatic resection and right hemicolectomy in one patient. A decision not to perform surgery was made in one patient with liver metastases. Two patients who underwent surgery showed no complications. The remaining two patients showed slow gastric emptying in one patient and pancreatitis of the stump leading to fatal systemic inflammatory response syndrome in the other. Patient survival was 60, 13 and 1 month respectively. There were no recurrences. The patient who did not undergo surgery died at 4 months. Conclusion. Duodenal adenocarcinoma is an infrequent tumor that is associated with various diseases. Surgical treatment is usually cephalic duodenopancreatectomy. Survival in resected patients is better than that obtained in primary pancreatic tumors (AU)

Pancreatectomía corporocaudal: una misma técnica con variadas indicaciones / Distal pancreatectomy: one technique with several indications

Introducción. La pancreatectomía corporocaudal (PCC) es una técnica que se realiza para diferentes enfermedades pancreáticas. Su frecuencia ha disminuido desde que no se realiza sistemáticamente en la cirugía gástrica oncológica y se ha restringido su uso a pacientes con pancreatitis crónica. Presentamos una serie de enfermos a los que se practicó PCC y debatimos aspectos técnicos y de indicación quirúrgica. Pacientes y método. Estudio retrospectivo realizado entre 1998 y 2003 de los pacientes a los que se ha practicado una PCC clásica con esplenectomía asociada (CIE: 52.52) en nuestro servicio. En dicho período se practicaron 14 PCC. Resultados. La edad media fue de 52,6 años. El 36% era varón (5/14). El diagnóstico fue de tumor quístico mucinoso pancreático en 5 pacientes, tumor neuroendocrino en 3, pancreatitis focal sobre pancreatitis crónica en 2, cáncer de páncreas en 2, traumatismo pancreático por herida con arma blanca en 1 y metástasis pancreática de cáncer renal en 1. La prueba diagnóstica más utilizada fue la tomografía computarizada (TC) abdominal (13/14). La cirugía fue electiva en el 86%. La técnica de cierre del muñón distal se realizó con sutura manual (29%), grapado mecánico (64%) y sutura más grapado (7%). No hemos observado ninguna relación estadística entre el cierre del muñón y el desarrollo de una fístula pancreática. La morbilidad fue del 35% y la mortalidad, nula. La estancia media fue de 18 días. Conclusiones. La PCC es una técnica que se puede realizar sin mortalidad pero con una morbilidad no desdeñable, asociada habitualmente al desarrollo de fístula pancreática. Las indicaciones de PCC han cambiado y en la actualidad se realiza por varias enfermedades pancreáticas cada vez más frecuentes (AU)

Introduction. Distal pancreatectomy (DP) is performed for various pancreatic processes. This procedure has become less frequent since it ceased to be systematically used in oncologic gastric surgery and it is now performed mainly in patients with chronic pancreatitis. We present a series of patients who underwent DP and discuss technical features and surgical indications. Patients and methods. We performed a retrospective study of patients who underwent classical DP with associated splenectomy (CIE: 52.52) in our service from 1998-2003. Fourteen DP were performed during the study period. Results. The mean age was 52.6 years. Thirty-six percent of the patients were male (5/14). Diagnosis was mucinous cystic tumor of the pancreas (5), neuroendocrine tumor (3), focal chronic pancreatitis (2), pancreatic cancer (2), pancreatic injury due to a sharp instrument wound (1), and pancreatic metastases from renal cancer (1). The most frequently used diagnostic procedure was abdominal computerized axial tomography (13/14). Surgery was elective in 86%. The technique used to close the distal stump was manual suture (29%), mechanical stapling (64%) and suture plus stapling (7%). No statistically significant relationship was observed between closure of the stump and the development of pancreatic fistula. Morbidity was 35% and mortality was 0%. The mean length of hospital stay was 18 days. Conclusions. DP can be performed without mortality but morbidity is not inconsiderable and is usually associated with the development of pancreatic fistulas. The indications for DP have changed and currently this procedure is performed for several pancreatic processes that are becoming increasingly frequent (AU)

[Surgical treatment of liver metastases from breast cancer]. / Tratamiento quirúrgico de las metástasis hepáticas de cáncer de mama.

INTRODUCTION: A small number of patients with breast cancer develop liver metastases (LM) as the sole site of regional dissemination. In these patients, surgical resection seems to be the best therapeutic option. We present our experience of LM from breast cancer and discuss the indications for resection. MATERIAL AND METHODS: Between July 2003 and March 2005, we performed five hepatectomies for LM from breast cancer. The mean age was 51 years (range: 38-66). Patients received diverse combinations of chemotherapy, hormone therapy and radiotherapy after mastectomy. The disease-free interval between mastectomy and diagnosis of LM was 61 months (range: 36-80). The number of LM was 1.83 (range: 1-6) with a median of one LM. The mean size was 4.1 cm (range: 1.5-6). RESULTS: Surgery consisted of segmentectomy (three patients), bisegmentectomy (one patient), right hepatectomy associated with isolated metasectomies of the left lobe and hilar lymphadenectomy (one patient). Operative mortality was 0%. Morbidity was 20% (one patient). The mean length of hospital stay was 8 days. The mean length of follow-up was 11.4 months (range: 3-21). The mean survival was 11.4 months (range: 3-21). Disease-free survival was 9.6 months (range: 3-21). Two patients have had recurrence (one local and one regional). CONCLUSIONS: Given its characteristics, LM from breast cancer is an infrequent indication for liver resection and should be performed whenever technically feasible, whenever R0 resection can be achieved, and when there is low operative risk. Postoperative survival is better with resection than with any other therapeutic modality, even though the period of disease-free survival is short.

[Distal pancreatectomy: one technique with several indications]. / Pancreatectomía corporocaudal: una misma técnica con variadas indicaciones.

INTRODUCTION: Distal pancreatectomy (DP) is performed for various pancreatic processes. This procedure has become less frequent since it ceased to be systematically used in oncologic gastric surgery and it is now performed mainly in patients with chronic pancreatitis. We present a series of patients who underwent DP and discuss technical features and surgical indications. PATIENTS AND METHODS: We performed a retrospective study of patients who underwent classical DP with associated splenectomy (CIE: 52.52) in our service from 1998-2003. Fourteen DP were performed during the study period. RESULTS: The mean age was 52.6 years. Thirty-six percent of the patients were male (5/14). Diagnosis was mucinous cystic tumor of the pancreas (5), neuroendocrine tumor (3), focal chronic pancreatitis (2), pancreatic cancer (2), pancreatic injury due to a sharp instrument wound (1), and pancreatic metastases from renal cancer (1). The most frequently used diagnostic procedure was abdominal computerized axial tomography (13/14). Surgery was elective in 86%. The technique used to close the distal stump was manual suture (29%), mechanical stapling (64%) and suture plus stapling (7%). No statistically significant relationship was observed between closure of the stump and the development of pancreatic fistula. Morbidity was 35% and mortality was 0%. The mean length of hospital stay was 18 days. CONCLUSIONS: DP can be performed without mortality but morbidity is not inconsiderable and is usually associated with the development of pancreatic fistulas. The indications for DP have changed and currently this procedure is performed for several pancreatic processes that are becoming increasingly frequent.

[Duodenal adenocarcinoma]. / Adenocarcinoma de duodeno.

INTRODUCTION: Duodenal adenocarcinoma is an infrequent neoplasm. Consequently, there are no large series that would allow conclusions to be reached on its diagnosis and treatment. PATIENTS AND METHOD: A retrospective study (1999-2003) of five patients diagnosed with duodenal adenocarcinoma in our service was performed. RESULTS: The mean age was 54 years. Eighty percent were male. All patients showed weight loss and abdominal pain. The tumors were localized in the second portion in three patients and in the third portion in two patients. All patients underwent gastrointestinal endoscopy with biopsy, which revealed adenocarcinoma. The most effective diagnostic test was computed tomography. In all patients, the preoperative diagnosis was correct. The technique performed was cephalic duodenopancreatectomy in three patients and duodenectomy with atypical pancreatic resection and right hemicolectomy in one patient. A decision not to perform surgery was made in one patient with liver metastases. Two patients who underwent surgery showed no complications. The remaining two patients showed slow gastric emptying in one patient and pancreatitis of the stump leading to fatal systemic inflammatory response syndrome in the other. Patient survival was 60, 13 and 1 month respectively. There were no recurrences. The patient who did not undergo surgery died at 4 months. CONCLUSION: Duodenal adenocarcinoma is an infrequent tumor that is associated with various diseases. Surgical treatment is usually cephalic duodenopancreatectomy. Survival in resected patients is better than that obtained in primary pancreatic tumors.