Nonfunctioning, small, incidental pancreatic neuroendocrine tumors: Results of a nonoperative approach cohort. / Tumores neuroendocrinos no funcionantes de páncreas incidentales de pequeño tamaño: Resultados de una serie con manejo no quirúrgico.

OBJECTIVE: The availability of new imaging techniques has conditioned an increase in the incidental diagnosis of small nonfunctioning pancreatic neuroendocrine tumors (PNET-NF). The best treatment is controversial, some authors advise a conservative approach in selected cases. Our aim is to analyze the evolution of incidental, small size PNET-NF, treated with clinical follow-up without surgery. METHODS: We performed a retrospective analysis of a prospective database of patients diagnosed incidentally with PNET-NF since November 2007 to September 2015. We include those with PNET-NF ≤2cm and asymptomatic. The diagnosis was performed using imaging tests indicating endoscopic ultrasound-guided fine-needle aspiration in case of doubts in the diagnosis. The follow-up was performed at our center, registering clinical and/or radiological changes. RESULTS: We included 24 patients with a median age of 70 years, and a similar distribution in terms of sex. The diagnosis was made through computed tomography multidetector or magnetic resonance imaging and octreotide scan. The tumors were located mainly in the head and neck (46%), with a mean size of 11,5±3,55mm at diagnosis (5-19mm). In 2 cases endoscopic ultrasound fine needle aspiration was used (8%), confirming the diagnosis of low-grade PNET with Ki67<5%. The median follow-up was 39 months (7-100). In 19 patients (79%) they remained the same size, 21% (5) increased its size with a mean of 2,6±2mm (1-6). No cases had progression of disease. CONCLUSION: In selected patients, non-surgical management of PNET-NF is an option to consider, when they are asymptomatic and ≤2cm. Larger studies with more patients and more time of follow-up are needed to validate this non-operative approach.

Tumores neuroendocrinos no funcionantes de páncreas incidentales de pequeno tamano: Resultados de una serie con manejo no quirúrgico / Nonfunctioning, small, incidental pancreatic neuroendocrine tumors. Results of a nonoperative approach cohort

OBJETIVO: La disponibilidad de nuevas técnicas de imagen ha condicionado un incremento en el diagnóstico incidental de pequeños tumores neuroendocrinos pancreáticos no funcionantes (TNP-NF). El mejor tratamiento de estos tumores es controvertido: algunos autores aconsejan una actitud conservadora en casos seleccionados. Nuestro objetivo es analizar la evolución de TNP-NF incidentales de pequeño tamaño, tratados con seguimiento clínico sin cirugía. MÉTODOS: Se realizó un análisis retrospectivo de una base de datos prospectiva de pacientes diagnosticados incidentalmente de TNP-NF desde noviembre de 2007 hasta septiembre de 2015. Incluimos aquellos con TNP-NF≤2 cm y asintomáticos. El diagnóstico se realizó mediante pruebas de imagen, indicando ecoendoscopia-punción en caso de dudas diagnósticas. El seguimiento se hizo en nuestro centro, con registro de cambios clínicos y radiológicos. RESULTADOS:Incluimos a 24 pacientes con una mediana de edad de 70 años y distribución similar en cuanto al sexo. El diagnóstico se realizó mediante tomografía computarizada multidetector, resonancia nuclear magnética y gammagrafía con octreótide. Los tumores se localizaban principalmente en cabeza y cuello (46%), con un tamaño medio de 11,5 ± 3,55 mm al diagnóstico (5-19 mm). En 2 casos se asoció ecoendoscopia-punción (8%), confirmando el diagnóstico de TNP de bajo grado con Ki67 < 5%. La mediana de seguimiento fue de 39 meses (7-100). El 79% (19) mantuvieron el mismo tamaño. El 21% (5) aumentó su tamaño con una media de 2,6±2mm (1-6). En ningún caso hubo progresión de enfermedad. CONCLUSIÓN: En pacientes seleccionados, el manejo no quirúrgico de TNP-NF, asintomáticos y ≤ 2cm es una opción a tener en cuenta. Son necesarios estudios con mayor número de pacientes y un seguimiento mayor para validar esta opción conservadora

OBJECTIVE: The availability of new imaging techniques has conditioned an increase in the incidental diagnosis of small nonfunctioning pancreatic neuroendocrine tumors (PNET-NF). The best treatment is controversial, some authors advise a conservative approach in selected cases. Our aim is to analyze the evolution of incidental, small size PNET-NF, treated with clinical follow-up without surgery. METHODS: We performed a retrospective analysis of a prospective database of patients diagnosed incidentally with PNET-NF since November 2007 to September 2015. We include those with PNET-NF ≤ 2cm and asymptomatic. The diagnosis was performed using imaging tests indicating endoscopic ultrasound-guided fine-needle aspiration in case of doubts in the diagnosis. The follow-up was performed at our center, registering clinical and/or radiological changes. RESULTS: We included 24 patients with a median age of 70 years, and a similar distribution in terms of sex. The diagnosis was made through computed tomography multidetector or magnetic resonance imaging and octreotide scan. The tumors were located mainly in the head and neck (46%), with a mean size of 11,5 ± 3,55 mm at diagnosis (5-19 mm). In 2 cases endoscopic ultrasound fine needle aspiration was used (8%), confirming the diagnosis of low-grade PNET with Ki67 < 5%. The median follow-up was 39 months (7-100). In 19 patients (79%) they remained the same size, 21% (5) increased its size with a mean of 2,6 ± 2 mm (1-6). No cases had progression of disease. CONCLUSION: In selected patients, non-surgical management of PNET-NF is an option to consider, when they are asymptomatic and ≤ 2 cm. Larger studies with more patients and more time of follow-up are needed to validate this non-operative approach

Crecimiento endobiliar de las metástasis de carcinoma colorrectal / Intrabiliary growth of colorectal liver metastases

No disponible

Grado de homogeneidad de los grupos españoles de trasplante hepático en el tratamiento del hepatocarcinoma / Degree of uniformity in the treatment of hepatocellular carcinoma in the Spanish teams of liver transplantation

No disponible

Estrategia quirúrgica como prevención y tratamiento del síndrome de 'small for size' / No disponible

No disponible

Estudio de minimización de costes hospitalarios en el tratamiento de la coledocolitiasis / Minimising hospital costs in the treatment of bile duct calculi: A comparison study

Introducción El tratamiento de la coledocolitiasis asociada a colelitiasis es controvertido. Los costes hospitalarios podrían ser un factor decisivo para elegir entre las distintas opciones terapéuticas. Objetivos Comparar la eficacia y los costes de 2 alternativas en el tratamiento de la coledocolitiasis: 1) Un-tiempo: colecistectomía y exploración de la vía biliar por laparoscopia y 2) Dos-tiempos: colangiopancreatografía retrógrada endoscópica y colecistectomía laparoscópica secuencial. Material y métodos Estudio observacional, retrospectivo de 49 pacientes con coledocolitiasis y vesícula in situ, tratados de forma consecutiva y simultánea durante 2 años, mediante una de las 2 estrategias. Se compararon las complicaciones postoperatorias, estancia, número de procedimientos por paciente, conversión a laparotomía, eficacia en la extracción de cálculos y costes hospitalarios. Resultados No hubo diferencias en cuanto a características clínicas y morbilidad de los pacientes. La estancia postoperatoria media para el grupo Un-tiempo fue menor que para el grupo Dos-tiempos. Tres pacientes del grupo Dos-tiempos requirieron conversión a laparotomía. La mediana de costes por paciente fue menor para la estrategia en Un-tiempo, representando un ahorro global de 37.173€ durante el período estudiado. Conclusiones Entre las 2 opciones terapéuticas, no se han encontrado diferencias significativas en cuanto a la eficacia, ni la morbimortalidad postoperatorias, pero sí desde el punto de vista de la estancia y los costes hospitalarios. El manejo de los pacientes con coledocolitiasis en un solo tiempo representó un ahorro de 3 días de estancia y 1.008€ por paciente (AU)

Introduction The treatment of bile duct calculi associated with cholelithiasis is controversial. The hospital costs could be a decisive factor in choosing between the different therapeutic options. Objectives To compare the effectiveness and costs of two options in the treatment of common bile duct calculi: 1) One-stage: Laparoscopic cholecystectomy and bile duct exploration, and 2) Two-stage: sequential endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Material and methods A retrospective, observational study was performed on 49 consecutive patients with bile duct calculi and gallbladder in situ, treated consecutively and simultaneously over a two year period. The post-operate complication, hospital stay, number of procedures per patient, conversion to laparotomy, efficacy of removing the calculi, and hospital costs. Results There were no differences as regards the patient clinical features or morbidity. The mean post-surgical hospital stay for the One-stage group was less than that in the Two-stage group. Three patients of the Two-stage group required conversion to laparotomy. The median costs per patient were less for the One-stage strategy, representing an overall saving of 37,173€ during the period studied. Conclusions No significant differences were found between the two treatment options as regards efficacy or post-surgical morbidity and mortality, but there were differences in hospital stay and costs. The management of patients with gallstones in one-stage surgery represents a saving of 3 days hospital stay and 1,008€ per patient (AU)

[Minimising hospital costs in the treatment of bile duct calculi: a comparison study]. / Estudio de minimización de costes hospitalarios en el tratamiento de la coledocolitiasis.

INTRODUCTION: The treatment of bile duct calculi associated with cholelithiasis is controversial. The hospital costs could be a decisive factor in choosing between the different therapeutic options. OBJECTIVES: To compare the effectiveness and costs of two options in the treatment of common bile duct calculi: 1) One-stage: Laparoscopic cholecystectomy and bile duct exploration, and 2) Two-stage: sequential endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. MATERIAL AND METHODS: A retrospective, observational study was performed on 49 consecutive patients with bile duct calculi and gallbladder in situ, treated consecutively and simultaneously over a two year period. The post-operate complication, hospital stay, number of procedures per patient, conversion to laparotomy, efficacy of removing the calculi, and hospital costs. RESULTS: There were no differences as regards the patient clinical features or morbidity. The mean post-surgical hospital stay for the One-stage group was less than that in the Two-stage group. Three patients of the Two-stage group required conversion to laparotomy. The median costs per patient were less for the One-stage strategy, representing an overall saving of 37,173€ during the period studied. CONCLUSIONS: No significant differences were found between the two treatment options as regards efficacy or post-surgical morbidity and mortality, but there were differences in hospital stay and costs. The management of patients with gallstones in one-stage surgery represents a saving of 3 days hospital stay and 1,008€ per patient.

Utilidad de la biopsia preoperatoria en la selección de pacientes con hepatocarcinoma para el trasplante hepático / Usefulness of pre-surgical biopsy in selecting patients with hepatocellular carcinoma for liver transplant

La selección de pacientes con hepatocarcinoma para el trasplante hepático es susceptible de mejorarse. Uno de los métodos propuestos para lograr este objetivo consiste en la incorporación al algoritmo decisorio de factores pronóstico de agresividad tumoral. Los procedimientos que permitirían valorar esta característica pueden agruparse en 3 categorías: a) biomarcadores séricos; b) respuesta a la quimioembolización, y c) datos de la histología tumoral. En este estudio de revisión se analizan los datos disponibles acerca de la utilidad de cada uno de estos tipos de marcadores, y se presta una especial atención a las evidencias relacionadas con la posible utilidad de una biopsia preoperatoria. Puede concluirse que la biopsia preoperatoria podría ser útil para indicar el trasplante hepático en pacientes con criterios expandidos, pero no en pacientes que cumplan los criterios de Milán. Este escenario podría cambiar en un futuro no muy lejano si se confirman los primeros datos del valor pronóstico de algunos parámetros de biología molecular (AU)

The selection of patients with hepatocellular carcinoma (HCC) for liver transplantation must be improved. One of the methods proposed to achieve this objective consists of including predictors of tumour aggressiveness to the decision making algorithm. The procedures that would enable this characteristic to be assessed, are: 1. Serum biomarkers, 2. Response to transarterial chemoembolisation and 3. Data on the tumour histology. In this review, the available data on the usefulness of each of these procedures are analysed. Special attention is given to the evidence associated with the possible usefulness of a preoperative biopsy. It can be concluded that a preoperative biopsy could be useful to indicate liver transplantation in patients with extended criteria, but not in patients that fulfil the Milan criteria. This scenario could soon change if the initial data on the prognostic value of some molecular markers of tumour progression are confirmed (AU)

[Usefulness of pre-surgical biopsy in selecting patients with hepatocellular carcinoma for liver transplant]. / Utilidad de la biopsia preoperatoria en la selección de pacientes con hepatocarcinoma para el trasplante hepático.

The selection of patients with hepatocellular carcinoma (HCC) for liver transplantation must be improved. One of the methods proposed to achieve this objective consists of including predictors of tumour aggressiveness to the decision making algorithm. The procedures that would enable this characteristic to be assessed, are: 1. Serum biomarkers, 2. Response to transarterial chemoembolisation and 3. Data on the tumour histology. In this review, the available data on the usefulness of each of these procedures are analysed. Special attention is given to the evidence associated with the possible usefulness of a preoperative biopsy. It can be concluded that a preoperative biopsy could be useful to indicate liver transplantation in patients with extended criteria, but not in patients that fulfil the Milan criteria. This scenario could soon change if the initial data on the prognostic value of some molecular markers of tumour progression are confirmed.

Receptores con hipertensión portopulmonar primaria y síndrome hepatopulmonar / No disponible

No disponible

Problemas, interrogantes y controversias en el trasplante hepático por hepatocarcinoma / No disponible

No disponible

[Current treatment of hepatic trauma]. / Actualización del tratamiento de los traumatismos hepáticos.

The therapeutic and diagnostic approach of liver trauma injuries (by extension, of abdominal trauma) has evolved remarkably in the last decades. The current non-surgical treatment in the vast majority of liver injuries is supported by the accumulated experience and optimal results in the current series. It is considered that the non-surgical treatment of liver injuries has a current rate of success of 83-100%, with an associated morbidity of 5-42%. The haemodynamic stability of the patient will determine the applicability of the non-surgical treatment. Arteriography with angioembolisation constitutes a key technical tool in the context of liver trauma. Patients with haemodynamic instability will need an urgent operation and can benefit from abdominal packing techniques, damage control and post-operative arteriography. The present review attempts to contribute to the current, global and practical management in the care of liver trauma.

Actualización del tratamiento de los traumatismos hepáticos / Current treatment of hepatic trauma

El abordaje diagnóstico y terapéutico del traumatismo hepático (y, por extensión, del traumatismo abdominal) ha evolucionado notablemente en las últimas décadas. El actual manejo conservador (no quirúrgico) de la inmensa mayoría de los traumatismos hepáticos se sustenta en la experiencia acumulada y los óptimos resultados de las múltiples series publicadas hasta la fecha. Se considera que el tratamiento no quirúrgico del traumatismo hepático comporta una tasa general de éxito del 83-100%, con una morbilidad asociada del 5-42%. La estabilidad hemodinámica del paciente determinará la aplicabilidad del tratamiento conservador. Las técnicas de arteriografía y angioembolización constituyen pilares clave en el contexto de un traumatismo hepático. Los enfermos en situación de inestabilidad hemodinámica precisarán una intervención quirúrgica urgente y pueden beneficiarse de técnicas de packing abdominal, damage control y arteriografía perioperatoria. El presente trabajo de revisión pretende aportar una visión general y práctica del manejo del traumatismo hepático a la luz de los conocimientos actuales (AU)

The therapeutic and diagnostic approach of liver trauma injuries (by extension, of abdominal trauma) has evolved remarkably in the last decades. The current non-surgical treatment in the vast majority of liver injuries is supported by the accumulated experience and optimal results in the current series. It is considered that the non-surgical treatment of liver injuries has a current rate of success of 83-100%, with an associated morbidity of 5-42%. The haemodynamic stability of the patient will determine the applicability of the non-surgical treatment. Arteriography with angioembolisation constitutes a key technical tool in the context of liver trauma. Patients with haemodynamic instability will need an urgent operation and can benefit from abdominal packing techniques, damage control and post-operative arteriography. The present review attempts to contribute to the current, global and practical management in the care of liver trauma (AU)

Radicalidad en la cirugía del colangiocarcinoma hiliar (tumor de Klatskin) / Radical surgery for hilar cholangiocarcinoma (Klatskin tumor)

La supervivencia prolongada de los pacientes con colangiocarcinoma hiliar sólo puede ser lograda mediante la resección completa del tumor. No hay supervivientes a largo plazo cuando se observa infiltración microscópica de los márgenes de resección. Por otra parte, el colangiocarcinoma hiliar parece tener poca tendencia a diseminarse a distancia, mientras que con el tratamiento adyuvante postoperatorio no se ha demostrado claramente un beneficio clínico. Se debe considerar estas evidencias argumentos para realizar resecciones amplias. Con objeto de lograr resecciones R0, en los últimos años se ha incrementado el número de hepatectomías mayores, lo cual se ha asociado a una mayor resecabilidad y mejores resultados. Se recomienda la resección simultánea del lóbulo caudado, ya que es un lugar frecuente de recidiva tumoral. El estudio mediante biopsias por congelación de los márgenes de resección del conducto biliar debe ser realizado de manera sistemática. Sin embargo, no siempre es posible ampliar la resección en caso de invasión en el margen de sección proximal. La invasión macroscópica de la vena porta tiene un impacto negativo en la supervivencia. Sin embargo, no debe ser una contraindicación para la cirugía. La realización de una hepatectomía con resección venosa puede ofrecer supervivencias prolongadas en algunos pacientes con tumores avanzados. La incidencia de invasión linfática en las piezas de resección se presenta en un 30-50% de los casos y hay correlación entre la invasión del tumor primario y la afección ganglionar. Las metástasis linfáticas del colangiocarcinoma hiliar se extienden en primer lugar a los ganglios pericoledocales y después hacia la región posterior de la cabeza del páncreas, la vena porta y la arteria hepática común. La linfadenectomía habitual debe incluir todas esas áreas. Sólo la afección de los ganglios del tronco celíaco, la arteria mesentérica superior y los paraaórticos contraindica la resección del tumor. La supervivencia se relaciona estrechamente con la extensión de la invasión linfática. La aplicación de la denominada técnica no-touch, que se basa en la realización de una triseccionectomía derecha junto con la resección de la vena porta, ha sido propuesta como el procedimiento quirúrgico de elección para una cirugía más radical y para prevenir la diseminación intraoperatoria de células tumorales (AU)

In patients with hilar cholangiocarcinoma, long-term survival critically depends on complete tumor resection. Indeed, there are no long-term survivors with positive resection margins. Furthermore, hilar cholangiocarcinoma seems to have a low propensity for distant metastases and adjuvant therapy after surgery has not been shown to have clear clinical benefits. This evidence should be regarded as arguments for extended resections. The question remains of how to achieve an R0 resection. In the last few years greater use of major hepatectomy has increased resectability and has improved long-term results. Concomitant resection of the caudate lobe is recommended as this site is a prime area of local recurrence. Frozen sections should be routinely used to assess the remnant proximal and distal ductal stumps. However, if the proximal remnant is positive, additional ductal resection at the separating limits is not always feasible. Gross portal vein invasion has a negative impact on survival, but should not be a contraindication to resection. Hepatectomy with portal vein resection can offer long-term survival in some patients with advanced hilar cholangiocarcinoma. The incidence of nodal involvement in resected specimens has been reported to range from 30% to more than 50% and there is a correlation between primary tumor extension and nodal involvement. Lymphatic metastases from hilar cholangiocarcinoma appear to spread first to pericholedochal nodes in the hepatoduodenal ligament and then to spread widely toward the posteriorsuperior area around the pancreatic head, portal vein and common hepatic artery. Routine lymphadenectomy should include all these areas. The only factors precluding resection are involvement of celiac, superior mesenteric or para-aortic tumoral nodes. Survival is closely associated with the extent of nodal involvement. The no-touch technique including right trisegmentectomy combined with portal vein resection has been proposed as the surgical procedure of choice for a more radical approach, and as a measure to prevent dissemination of tumor cells during surgery (AU)

[Radical surgery for hilar cholangiocarcinoma (Klatskin tumor)]. / Radicalidad en la cirugía del colangiocarcinoma hiliar (tumor de Klatskin).

In patients with hilar cholangiocarcinoma, long-term survival critically depends on complete tumor resection. Indeed, there are no long-term survivors with positive resection margins. Furthermore, hilar cholangiocarcinoma seems to have a low propensity for distant metastases and adjuvant therapy after surgery has not been shown to have clear clinical benefits. This evidence should be regarded as arguments for extended resections. The question remains of how to achieve an R0 resection. In the last few years greater use of major hepatectomy has increased resectability and has improved long-term results. Concomitant resection of the caudate lobe is recommended as this site is a prime area of local recurrence. Frozen sections should be routinely used to assess the remnant proximal and distal ductal stumps. However, if the proximal remnant is positive, additional ductal resection at the separating limits is not always feasible. Gross portal vein invasion has a negative impact on survival, but should not be a contraindication to resection. Hepatectomy with portal vein resection can offer long-term survival in some patients with advanced hilar cholangiocarcinoma. The incidence of nodal involvement in resected specimens has been reported to range from 30% to more than 50% and there is a correlation between primary tumor extension and nodal involvement. Lymphatic metastases from hilar cholangiocarcinoma appear to spread first to pericholedochal nodes in the hepatoduodenal ligament and then to spread widely toward the posteriorsuperior area around the pancreatic head, portal vein and common hepatic artery. Routine lymphadenectomy should include all these areas. The only factors precluding resection are involvement of celiac, superior mesenteric or para-aortic tumoral nodes. Survival is closely associated with the extent of nodal involvement. The no-touch technique including right trisegmentectomy combined with portal vein resection has been proposed as the surgical procedure of choice for a more radical approach, and as a measure to prevent dissemination of tumor cells during surgery.