Efficacy of laparoscopic approach in the management of early liver transplant complications.

The use of the laparoscopic approach in managing early liver transplant complications has been shown to be safe and feasible in various settings with the advantages of shorter recovery period, decreased postoperative pain, and rapid functional recovery. The laparoscopic approach has been used to resolve postoperative complications in kidney and pancreas recipients and less often in orthotopic liver transplantation (OLT) recipients, most of them in the late period (> 1 month posttransplantation). We herein describe our experience with the laparoscopic management of early complications after liver transplantation. From May 2009 to May 2011, we successfully treated three patients with early abdominal complications after OLT using a laparoscopic approach. Three patients-two with intraabdominal bleedings and one with a small bowel obstruction were treated successfully, thereby avoiding risks of a relaparotomy. In addition to these benefits, the laparoscopic approach causes less tissue injury and consequently evokes a minor innate immune response.

Transthoracic oesophagectomy with lymphadenectomy in 100 oesophageal cancer patients: multidisciplinary approach.

OBJECTIVES Analysis of the results on the treatment of esophageal cancer by transthoracic esophagectomy by a multidisciplinary team of surgeons and oncologists. METHODS Between January 1990 and December 2009, 100 consecutive patients underwent transthoracic esophagectomy. Data were collected prospectively and clinical, pathological and histological features of the tumors were analyzed as well as the results of postoperative morbidity and mortality. RESULTS The average patient age was 55 years (range 31- 83 years). In 59 cases the tumor was located in the lower third and in 41 cases in the middle third. Forty-six patients had adenocarcinoma and 54 squamous cell carcinoma. In 54 cases radio-chemotherapy was planned preoperatively. Classifi cation according to pathological tumor stage was: stage 0 in 21 patients, stage I in 10 patients, stage IIa in 28, stage IIb in 9, stage III in 21 and stage IV in 11. The mean number of lymph nodes examined was 14 (range 0-28). Hospital mortality occurred in 4 cases and postoperative complications in 29 patients (33%). The most frequent postoperative complication was pulmonary complications in 17 cases. The average hospital stay was 15.2 days (range 10-40 days) CONCLUSIONS The results of esophageal cancer have been improved in recent years due to the formation of multidisciplinary teams in this pathology. In our study we have shown that the results obtained with the transthoracic technique for cancer of the esophagus are within the ranges reported in the literature for teams with high prevalence of the disease.

Transthoracic oesophagectomy with lymphadenectomy in 100 oesophageal cancer patients: multidisciplinary approach

OBJECTIVES Analysis of the results on the treatment of esophageal cancer by transthoracic esophagectomy by a multidisciplinary team of surgeons and oncologists. METHODS Between January 1990 and December 2009, 100 consecutive patients underwent transthoracic esophagectomy. Data were collected prospectively and clinical, pathological and histological features of the tumors were analyzed as well as the results of postoperative morbidity and mortality. RESULTS The average patient age was 55 years (range 31- 83 years). In 59 cases the tumor was located in the lower third and in 41 cases in the middle third. Forty-six patients had adenocarcinoma and 54 squamous cell carcinoma. In 54 cases radio-chemotherapy was planned preoperatively. Classifi cation according to pathological tumor stage was: stage 0 in 21 patients, stage I in 10 patients, stage IIa in 28, stage IIb in 9, stage III in 21 and stage IV in 11. The mean number of lymph nodes examined was 14 (range 0-28). Hospital mortality occurred in 4 cases and postoperative complications in 29 patients (33%). The most frequent postoperative complication was pulmonary complications in 17 cases. The average hospital stay was 15.2 days (range 10-40 days) CONCLUSIONS The results of esophageal cancer have been improved in recent years due to the formation of multidisciplinary teams in this pathology. In our study we have shown that the results obtained with the transthoracic technique for cancer of the esophagus are within the ranges reported in the literature for teams with high prevalence of the disease (AU)

Analysis of POSSUM score and postoperative morbidity in patients with rectal cancer undergoing surgery.

BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and later modifications (P-POSSUM y CR-POSSUM) have been used to predict morbidity and mortality rates among patients with rectal cancer undergoing surgery. These calculations need some adjustment, however. The aim of this study was to assess the applicability of POSSUM to a group of patients with rectal cancer undergoing surgery, analysing surgical morbidity by means of several variables. METHODS: between January 1995 and December 2004, 273 consecutive patients underwent surgery for rectal cancer. Information was gathered about the patients, tumour and therapy. To assess the prediction capacity of POSSUM, subgroups for analysis were created according to variables related to operative morbidity and mortality. RESULTS: The global morbidity rate was 23.6% (31.2% predicted by POSSUM). The mortality rate was 0.7% (6.64, 1.95 and 2.08 predicted by POSSUM, P-POSSUM and CR-POSSUM respectively). POSSUM predictions may be more accurate for patients younger than 51 years, older than 70 years, with low anaesthetic risk (ASA I/II), DUKES stage C and D, surgery duration of less than 180 minutes and for those receiving neoadjuvant therapy. CONCLUSION: POSSUM is a good instrument to make results between different institutions and publication comparable. We found prediction errors for some variables related to morbidity. Modifications of surgical variables and specifications for neoadjuvant therapy as well as physiological variables including life style may improve future prediction of surgical risk. More research is needed to identify further potential risk factors for surgical complications.

[Pancreatic transplant]. / Trasplante pancreático.

Diabetes mellitus is a health concern of the first order, given the high level of associated morbidity and mortality. The objective, in order to slow down the advance of its complications before they become irreversible, is based on correct metabolic control. The high rate of morbidity associated with the surgery of the vascularized pancreas transplant and the high index of rejection have for three decades formed an obstacle to this being considered a valid alternative in the treatment of these patients. Nowadays the pancreas transplant has come to occupy a key position, thanks to the new regimes of immunosuppression and to the perfection of surgical techniques. In this article we review the evolution of the pancreas transplant from its beginnings to its present state.

Trasplante pancreático / Pancreatic transplant

La diabetes mellitus constituye una preocupación sanitaria de primer orden, dado el alto índice de morbimortalidad asociada. El objetivo para frenar el avance de sus complicaciones, antes de que éstas sean irreversibles, se basa en un control metabólico correcto. La alta tasa de morbilidad asociada a la cirugía del trasplante vascularizado de páncreas y el alto índice de rechazo ha constituido durante tres décadas un obstáculo para que se considerara a éste como una alternativa válida en el tratamiento de estos pacientes. El trasplante de páncreas hoy día ha pasado a ocupar un lugar primordial, gracias a los nuevos regímenes de inmunosupresión y al perfeccionamiento de la técnica quirúrgica. En este capítulo revisamos la evolución del trasplante de páncreas desde sus inicios y su situación actual

Diabetes mellitus is a health concern of the first order, given the high level of associated morbidity and mortality. The objective, in order to slow down the advance of its complications before they become irreversible, is based on correct metabolic control. The high rate of morbidity associated with the surgery of the vascularized pancreas transplant and the high index of rejection have for three decades formed an obstacle to this being considered a valid alternative in the treatment of these patients. Nowadays the pancreas transplant has come to occupy a key position, thanks to the new regimes of immunosuppression and to the perfection of surgical techniques. In this article we review the evolution of the pancreas transplant from its beginnings to its present state

Risk factors related to operative morbidity in patients undergoing gastrectomy for gastric cancer.

INTRODUCTION: The purpose of this study is to analyze postoperative morbidity and mortality of patients operated on for gastric cancer in a single institution during the last twenty years, and to define risk factors for complications. MATERIAL AND METHODS: A retrospective study was carried out on 434 patients who underwent gastrectomy for gastric cancer between January 1983 and December 2002. Analysis of main medical and surgical complications and analysis of morbidity risk factors. RESULTS: Overall morbidity and mortality rates were 38.4% and 2.7% respectively. The most frequent complications were pneumonia (13%) and intra-abdominal abcesses (12%). The main cause of death was anastomotic dehiscence with abdominal sepsis. The last ten years mortality rate dropped from 4.7% to 0.8%. Risk factors for complications were gender (male, p = 0.01) and resection of spleen (p = 0.02) or pancreas (p = 0.002). A significantly lesser rate of complications was found in patients who had underwent gastrectomy during the previous five years (p = 0.001) or with tumors located in the lower third of the stomach (p = 0,01). CONCLUSION: Morbidity of gastrectomy for gastric cancer in our institution is still high but mortality has decreased significantly over the last ten years due to the specialization of the hospital and the surgical team. The main risk factor for complications was pancreatosplenectomy in the multivariate analysis.

Risk factors related to operative morbidity in patients undergoing gastrectomy for gastric cancer

Introduction. The purpose of this study is to analyzepostoperative morbidity and mortality of patientsoperated on for gastric cancer in a single institutionduring the last twenty years, and to definerisk factors for complications.Material and methods. A retrospective study wascarried out on 434 patients who underwent gastrectomyfor gastric cancer between January 1983 andDecember 2002. Analysis of main medical and surgicalcomplications and analysis of morbidity riskfactors.Results. Overall morbidity and mortality rates were38.4% and 2.7% respectively. The most frequentcomplications were pneumonia (13%) and intra-abdominalabcesses (12%). The main cause of deathwas anastomotic dehiscence with abdominal sepsis.The last ten years mortality rate dropped from 4.7%to 0.8%. Risk factors for complications were gender(male, p = 0.01) and resection of spleen (p = 0.02) orpancreas (p = 0.002). A significantly lesser rate ofcomplications was found in patients who had underwentgastrectomy during the previous five years(p = 0.001) or with tumors located in the lower thirdof the stomach (p = 0,01).Conclusion. Morbidity of gastrectomy for gastriccancer in our institution is still high but mortalityhas decreased significantly over the last ten yearsdue to the specialization of the hospital and the surgicalteam. The main risk factor for complicationswas pancreatosplenectomy in the multivariate analysis

No disponible

Angiomiolipoma epitelioide hepático / Epithelioid angiomyolipoma of the liver

Describimos en nuestro trabajo un angiomiolipoma (AML) epitelioide hepático en una mujer de 50 años con dolor epigástrico y una masa de 47 mm bien definida en la ecografía. El AML es un tumor mesenquimal benigno poco frecuente, constituido por proporciones variables de células de músculo liso, vasos sanguíneos anormales y tejido adiposo. El diagnóstico preoperatorio es difícil. La inmunorreactividad con el anticuerpo HMB-45 ayuda a diferenciarlo de otros tumores hepáticos tanto benignos como malignos. (AU)

Conversion of liver transplant recipients on cyclosporine with renal impairment to mycophenolate mofetil.

The management of liver transplant recipients with renal function impairment remains controversial because cyclosporine withdrawal from triple immunosuppression regimens may be followed by graft rejection. A nonnephrotoxic and powerful immunosuppressant such as mycophenolate mofetil (MMF) could allow a reduction of cyclosporine dosage or its withdrawal and an improvement in renal function in these patients. Eleven patients with serum creatinine levels greater than 1.5 mg/dL, normal graft function, and a rejection-free period of at least 1 year started MMF at a dose of 2000 mg/d (reduced in case of adverse events) while cyclosporine dosage was slowly reduced. At last follow-up (63 +/- 5 weeks), 7 patients remained free of cyclosporine (6 of those patients are also free of steroids), 2 patients reduced their cyclosporine dose, and 2 patients developed mild acute rejection that responded to a switch to tacrolimus therapy. Serum creatinine and urea levels in the 7 patients free of cyclosporine decreased from 2.22 +/- 0.13 to 1.90 +/- 0.19 mg/dL (P =.05) and 0.95 +/- 0.10 to 0.60 +/- 0.10 g/L (P <.001), respectively. Creatinine clearance increased from 38.16 +/- 5.60 to 47.01 +/- 6. 76 mL/min (P =.005). Control of arterial hypertension also improved. Tolerance to MMF was good, but 6 patients required dose reductions, mainly because of asymptomatic anemia. In conclusion, in liver transplant recipients with stable graft function, MMF may allow cyclosporine dose reduction or discontinuation, thus improving renal function and the control of arterial hypertension. This change of treatment must be carefully monitored because of the frequent need for MMF dose reduction and the risk for rejection.

Liver transplantation in cirrhotic patients over 60 years of age.

Although life expectancy in Spain is above seventy years, age over sixty is considered a relative contraindication for liver transplantation (LT) in most centers. The aim of this study was to assess the outcome of LT in patients over sixty years of age comparing them to patients under that age. From January 1992 to August 1995, 61 cirrhotic patients underwent LT at our institution; of them, 43 (group I) were younger than 60 years (mean +/- SEM: 51.9 +/- 0.9 years, range: 37-59) and 18 patients (group II) were 60 years or older (64.1 +/- 0.7, range: 60-71). Main pre-transplant variables (sex, etiology of liver disease, presence of hepatocarcinoma, Child-Pugh's score and renal function) were similar in both groups. The follow-up (median and range) for group I was 28 and 3-47 months, and for group II 16.5 and 3-48 months. Actuarial survival rates at one and four years post-LT were respectively 88.3% and 85.6% for group I, and 87.8% and 87.8% for the group II (p = n.s.). There were no differences between both groups regarding the incidence of rejection, major infections, neurologic complications, renal failure, pathological bone fractures, diabetes mellitus or hypertension. Nevertheless, cardiovascular complications were significantly more frequent in group II (p = 0.002) although they were not the cause of death. In conclusion, our results show that the outcome of LT in patients over sixty years old is comparable to that observed in patients under that age. LT should not be contraindicated on the only basis of an age greater than 60 years.

Patterns of failure and long-term results in high-risk resected gastric cancer treated with postoperative radiotherapy with or without intraoperative electron boost.

BACKGROUND: To evaluate the possible role of adjuvant radiotherapy in the management of high-risk resected gastric carcinoma. METHODS: From 1982 to 1993, 62 patients surgically resected of a primary gastric cancer with adverse pathological features (serosal and/or regional lymph node involvement) were treated with postoperative radiotherapy with (Group I) or without (Group II) intraoperative electron boost to the surgical bed and coeliac axis (IORT). RESULTS: After a median follow-up of 75.6 months (range 4-120+) for IORT patients and 91.2 months (range 6-149+) for non-IORT patients, overall relapse rates for Group I and Group II patients were 44.5% and 48.6% and local-regional relapse rates were 11.1% and 20%, respectively. Actuarial survival rates projected at the maximum follow-up were 41% and 38% in Groups I and II, respectively. CONCLUSIONS: This retrospective analysis suggests a beneficial effect of adjuvant external radiotherapy in promoting local-regional control in high-risk resected gastric cancer.

[Somatostatin prophylaxis following cephalic duodenopancreatectomy]. / Profilaxis con Somatostatina tras duodenopancreatectomía cefálica.

This study was aimed at assessing the value of prophylactic somatostatin after cephalic duodenopancreatectomy. A randomized prospective study was undertaken using two groups of patients, one with prophylactic somatostatin (4.5 mg daily in continuous perfusion for 7 days postoperatively), known as group I, and group II, which did not receive somatostatin. During a five-year period, from April 1989 to April 1994, we performed 35 duodenopancreatectomies, of which 21 belonged to group I and 14 to group II. We found a lower incidence of pancreatic anastomosis fistulae in group I (9.5% vs 35.7%; p < 0.05). We did not find any correlation between prophylaxis with somatostatin and the appearance of other complications or postoperative mortality. The mean time of fistula closure in group I was 5 days while that of group II was 19.2 days. In conclusion, the administration of prophylactic somatostatin after cephalic duodenopancreatectomy reduces the incidence and duration of pancreatic fistula.

Transjugular intrahepatic portocaval shunt after thrombus disruption in partially thrombosed portal veins.

Portal vein (PV) thrombosis increases the risk of variceal bleeding in cirrhotic patients with portal hypertension. Its presence also complicates PV access during transjugular porto-caval shunt (TIPS) placement. We overcame this obstacle by using ultrasound (US) guidance for PV entry. Clot disruption by balloon catheters was then performed before placing the vascular endoprostheses for portal-venous shunting. We treated 3 cirrhotic patients in such fashion with good clinical results. Portal thrombi progressively disappeared after shunting due to both balloon disruption and the rise in portal blood flow velocity.

Intraoperative radiotherapy in locally advanced recurrent colorectal cancer.

PURPOSE: In an effort to promote local control and improve quality of life in patients with recurrent colorectal cancer, a multimodality approach has been used. METHODS AND MATERIALS: Twenty-seven patients were treated with moderate doses of pre/postoperative radiotherapy with/without simultaneous systemic chemotherapy, surgical re-resection and IORT electron boost over areas at high risk for local recurrence. RESULTS: The 2-year actuarial disease-free and local relapse-free survival for the entire group were 14% and 26%, respectively. The most important factor predicting a favorable outcome was the radicality of surgical procedure. The determinate local control rate and the actuarial 2-year local relapse-free, and disease-free survival for patients undergoing complete resections were 50%, 56%, and 34%, respectively, whereas for patients undergoing partial resections these figures were 16%, 13%, and 6%. The radicality of surgical procedure was influenced by both tumoral size and previous treatment with irradiation. Complete resection rate was higher in patients with tumors less than 5 cm vs. more than 5 cm (40% vs. 22%), and in patients without previous radiotherapy versus those with previous radiotherapy (40% vs. 28%). Distant metastasis rate was high (41%). The most significant toxicities attributable to the whole treatment protocol were enteritis (37%), hydronephrosis (30%), and pelvic neuropathy (52%). CONCLUSION: Currently, our policy is to recommend IORT in patients with "favorable factors" such as: absence of previous pelvic radiotherapy, single previous surgical procedure, and complete resections.

Intraoperative and external radiotherapy in resected gastric cancer: updated report of a phase II trial.

From September 1984 to August 1991, 48 evaluable patients with resected gastric cancer and apparent disease confined to locoregional area were treated with intraoperative electron beam boost to the celiac axis and peripancreatic nodal areas (15 Gy) and external irradiation (40 to 46 Gy in 4 to 5 weeks) including the gastric bed and upper abdominal nodal draining regions. At the time of evaluation for IORT, the disease was primary in 38 cases, recurrent but resectable in four (anastomosis), and unresectable in four (nodal). Post operative complications were reversible. Acute tolerance to the complete treatment program was acceptable. Late complications included life-threatening events: Six episodes of gastro intestinal bleeding (three of them had an arteriographic documentation of arterioenteric fistula) and nine with severe enteritis (five required reoperation). Other long-term treatment related complications were six cases of vertebral collapse. The median follow-up time for the entire group is 22 months. Locoregional recurrence/persistence of disease has been identified in five patients (three with residual and/or recurrent postsurgical tumor). Systemic tumor progression has been detected in 15 patients (11 in intra-abdominal sites). Overall actuarial survival for patients with positive or negative serosal involvement was 33% versus 56%. It is concluded that the treatment program described is able to induce a high locoregional tumor control rate (100%) when used strictly in an adjuvant setting and might control long term, a small portion of patients not amenable for curative surgery (2 out of 8 patients with confirmed residual post-surgical disease). Gastrointestinal bleeding and enteritis are findings that indicate treatment intensity at the upper limits of tissue tolerance. Assessment of long term tolerance of pancreatic parenchyma and large blood vessels (tissues included in the IRORT field) are pending for longer follow-up and the appropriate selective studies.

[The role of leukotrienes and other eicosanoids in the response to an allograft. New perspectives on the control of rejection]. / Papel de los leucotrienos y otros eicosanoides en la respuesta al aloinjerto. Nuevas perspectivas en el control del rechazo.

The role of eicosanoids in the development of immune response may be important to the viability of the implanted organ, given their complicated interaction with lymphokines and monokines which regulate the response. Due to this reason, more experiments in vivo are necessary to provide a better understanding of the behaviour of these compounds. This would help to clearly determine the role of these substances in the immune response--more exactly, in the allogenic transplant rejection--creating new ways for its control.