Análisis de supervivencia e identificación de factores pronósticos de metástasis hepáticas de cáncer colorrectal tras resección hepática / Survival analysis and identification of prognostic factors in colorectal liver metastasis after liver resection

Introducción: El único tratamiento curativo para las metástasis hepáticas de cáncer colorrectal es la cirugía. La identificación de factores pronósticos nos permite individualizar el tratamiento de estos pacientes, mejorando sus resultados oncológicos a largo plazo. El objetivo de nuestro estudio es identificar la supervivencia y los factores pronósticos de pacientes sometidos a tratamiento quirúrgico de metástasis hepáticas de cáncer colorrectal. Métodos: Se trata de un estudio retrospectivo de todos los casos de hepatectomías por metástasis hepáticas de cáncer colorrectal, operadas en un hospital de tercer nivel en España, entre los años 2010 y 2018. Se realizó análisis de supervivencia univariante con las curvas de supervivencia Kaplan-Meier. Mediante el modelo multivariante regresión de Cox se determinaron los factores pronósticos asociados a la supervivencia global. Resultados: La supervivencia global y supervivencia libre de enfermedad de nuestra serie, a los 5 años fue del 43% y del 33%, respectivamente. En el análisis de supervivencia, las características de las metástasis hepáticas (números, tamaño mayor, distribución bilobar y enfermedad extrahepática) y postoperatorias (transfusión sanguínea, complicaciones graves y margen afecto), así como el KRAS no mutado resultaron estadísticamente significativos. No obstante, después de aplicar la regresión de Cox, solo se identificaron 5 factores de riesgo independientes: mutación del KRAS, metástasis hepáticas >4cm, transfusión intraoperatoria, complicaciones graves y margen afecto. Conclusiones: En nuestro grupo de pacientes hemos observado que el tamaño>4cm de la metástasis hepáticas, la transfusión intraoperatoria, las complicaciones posquirúrgicas graves y el margen afecto se mantienen como factores pronósticos tradicionales vigentes. Mientras que el biomarcador KRAS cobra un valor predictivo importante como factor pronóstico de supervivencia. (AU)

Introduction: Liver resection is the only curative treatment for colorectal liver metastasis. The identification of predictive factors leads to personalize patient management to enhance their long-term outcomes. This population-based study aimed to characterize factors associated with, and survival impact of patients who received hepatectomy for colorectal liver metastasis. Methods: A retrospective cohort study of all the hepatectomies for colorectal liver metastasis performed at third-level hospital of Spain (2010–2018) was conducted. The Kaplan–Meier method was used for survival analyses. Multivariable Cox and regression models were used to determine prognostic factors associated with overall survival. Results: The 5-year overall survival and disease-free survival were 42 and 33%, respectively. Survival analysis showed that metastasis features (number, largest size, distribution, and extrahepatic disease) and postsurgical factors (transfusion, major complications, and positive margin resection), as well as non-mutated KRAS, showed a significant association with survival. Otherwise, on multivariate analysis, only 5 independent risk factors were identified: major size metastasis>4cm, RAS mutation, positive margin resection, intraoperative transfusion, and major complications. Conclusions: According to our findings, major size metastasis>4cm, intraoperative transfusion, and major postoperative complications continue to be traditional prognostic factors. Meanwhile, the KRAS biomarker has a powerful impact as a survival prognostic factor. (AU)

Survival analysis and identification of prognostic factors in colorectal liver metastasis after liver resection.

INTRODUCTION: Liver resection is the only curative treatment for colorectal liver metastasis. The identification of predictive factors leads to personalize patient management to enhance their long-term outcomes. This population-based study aimed to characterize factors associated with, and survival impact of patients who received hepatectomy for colorectal liver metastasis. METHODS: A retrospective cohort study of all the hepatectomies for colorectal liver metastasis performed at third-level hospital of Spain (2010-2018) was conducted. The Kaplan-Meier method was used for survival analyses. Multivariable Cox and regression models were used to determine prognostic factors associated with overall survival. RESULTS: The 5-year overall survival and disease-free survival were 42 and 33%, respectively. Survival analysis showed that metastasis features (number, largest size, distribution, and extrahepatic disease) and postsurgical factors (transfusion, major complications, and positive margin resection), as well as non-mutated KRAS, showed a significant association with survival. Otherwise, on multivariate analysis, only 5 independent risk factors were identified: major size metastasis >4 cm, RAS mutation, positive margin resection, intraoperative transfusion, and major complications. CONCLUSIONS: According to our findings, major size metastasis >4 cm, intraoperative transfusion, and major postoperative complications continue to be traditional prognostic factors. Meanwhile, the KRAS biomarker has a powerful impact as a survival prognostic factor.

Íleo biliar: reporte de casos / Biliary ileus: cases report

Resumen Introducción: El íleo biliar es una causa poco frecuente de obstrucción intestinal mecánica, siendo más frecuente en pacientes mayores de 65 años y sexo femenino. Casos Clínicos: Se exponen cuatro casos clínicos diagnosticados de íleo biliar, intervenidos en nuestro centro. Discusión: El íleo biliar es una enfermedad que se produce a consecuencia del paso de un cálculo al lumen intestinal. Esto se produce por la presencia de una fístula entre la vesícula y el intestino, localizada mayormente a nivel duodenal. Se manifiesta con una clínica muy inespecífica, lo que condiciona un retraso en su diagnóstico. La tomografía computarizada es actualmente el examen de elección. El tratamiento consiste en la enterotomía con extracción del cálculo, realizándose la reparación de la fístula en un primer o segundo tiempo. Tiene un mal pronóstico debido a comorbilidad de los pacientes y la demora diagnóstica y terapéutica.

Introduction: Gallstone ileus is a rare cause of mechanical intestinal obstruction, being more frequent in patients over 65 years and females. Clinical Cases: Four clinical cases diagnosed with gallstone ileus, operated on in our center, are reported. Discussion: Gallstone ileus frequently occurs as a result of a fistula that communicates the digestive tract with the gallbladder. Their clinic is very unspecific, which determines a delay in its diagnosis. Computed tomography is currently the gold standard. The treatment is enterolithotomy and fistula repair in a first or second stage. Prognosis is poor due to patient comorbidities and diagnostic and therapeutic delay.

Impaired immune reaction and increased lactate and C-reactive protein for early prediction of severe morbidity and pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Prediction of complications after pancreatoduodenectomy (PD) remains of interest. Blood parameters and biomarkers during first and second postoperative days (POD1, POD2) may be early indicators of complications. METHODS: This case-control study included 50 patients. Baseline, POD1 and POD2 values of leukocytes, neutrophils, lymphocytes, platelets, hemoglobin, C-reactive protein (CRP), procalcitonin and arterial lactate were compared between individuals presenting Clavien ≥ III morbidity, pancreatic fistula (PF) or clinically relevant PF (CRPF) and those without these morbidities. Common variables reaching significance were further analyzed in order to calculate a predictive score. RESULTS: Severe morbidity, PF and CRPF rates were 28.0%, 26.0% and 14.0%, respectively. Patients with severe morbidity had lower leukocytes on POD2 (P = 0.04). Patients with PF presented higher CRP on POD2 (P = 0.001), higher lactate on POD1 (P = 0.007) and POD2 (P = 0.008), and lower lymphocytes on POD1 (P = 0.007) and POD2 (P = 0.008). Patients with CRPF had lower leukocytes and neutrophils on POD1 (P = 0.048, P = 0.038), lower lymphocytes on POD1 (P = 0.001) and POD2 (P = 0.003), and higher CRP on POD2 (P = 0.001). Baseline parameters and procalcitonin obtained no statistical associations. Score was defined according to lymphocytes on POD1 < 650/µL and CRP on POD2 ≥ 250 mg/L allocating patients in 3 risk categories. PF and CRPF rates were statistically higher as risk category increased (P<0.001). Receiver operating characteristic curves and Hosmer-Lemeshow tests showed a good accuracy. CONCLUSIONS: Impaired immunological reaction during early postoperative period (lower leukocytes and, particularly, lymphocytes) in response to surgical aggression would favor complications after PD. Likewise, acidosis (higher arterial lactate) could behave as risk factor of PF. An elevated CRP on POD2 is also an early biomarker of PF. Our novel score based on postoperative lymphocyte count and CRP seems reliable for early prediction of PF.

Doble metástasis hepática de doble neoplasia de colon: adenocarcinoma y tumor neuroendocrino / Double hepatic metastasis of double colon neoplasia: Adenocarcinoma and neuroendocrine tumour

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El Prognostic Nutritional Index predice la morbilidad postoperatoria tras la cirugía curativa del cáncer colorrectal / Prognostic Nutritional Index predicts morbidity after curative surgery for colorectal cáncer

Introducción: El cáncer colorrectal (CCR) constituye un problema sanitario relevante, asociado a una morbimortalidad significativa. A lo largo de las últimas décadas se ha estudiado en profundidad el vínculo que existe entre el cáncer y el estado nutricional e inflamatorio de los pacientes oncológicos, y se han desarrollado múltiples escalas inmunonutricionales, relacionadas principalmente con el pronóstico oncológico de varios tipos de cáncer. Al generarse una interacción entre el tumor y el huésped, se desencadena una reacción inflamatoria sistémica que conduce a una serie de alteraciones neuroendocrinas. Dicha situación favorece una tendencia hacia la anorexia y el catabolismo. Nuestra hipótesis es que el estado nutricional e inflamatorio de los pacientes oncológicos se correlaciona con la morbilidad postoperatoria. Métodos: Este es un estudio observacional y prospectivo de cohortes, con pacientes tratados mediante la cirugía curativa para el CCR en nuestro centro, entre septiembre del 2015 y marzo del 2017. El estado nutricional e inflamatorio de los pacientes fue establecido mediante el uso del Prognostic Nutritional Index (PNI). Las complicaciones (globales, graves, infecciosas y fuga anastomótica) fueron cuidadosamente observadas y registradas durante los 30 primeros días del período postoperatorio. Resultados: Tras llevar a cabo el análisis multivariante, el PNI resultó ser un gran factor predictivo de complicaciones globales (RR: 0,279; IC 95%: 0,141-0,552), complicaciones graves (RR: 0,355; IC 95%: 0,130-0,965), complicaciones infecciosas (RR: 0,220; IC 95%: 0,099-0,489) y fuga anastomótica (RR: 0,151; IC 95%: 0,036-0,640). Conclusiones: Nuestro trabajo refleja que el INP es un factor predictivo independiente para el desarrollo de complicaciones tras la cirugía curativa del CCR

Introduction: Colorectal cancer (CRC) is a major health concern and it is associated with significant morbidity and mortality. Over the last decades, the relationship between cancer and nutritional and inflammatory status in oncologic patients was studied thoroughly and multiple immunonutritional scores were developed. These scores have been mainly related to the prognosis of several cancers. An interaction between the tumour and the host is generated, triggering a systemic inflammatory reaction leading to several neuroendocrine changes. This situation favours a tendency towards anorexia and catabolism. Our hypothesis is that nutritional and inflammatory status of oncologic patients is correlated to postoperative morbidity. Methods: This is a prospective observational cohort study with those patients undergoing curative surgery for CRC at our institution between September 2015 and March 2017. Nutritional and inflammatory status was established using Onodera's Prognostic Nutritional Index (PNI). Complications (overall, severe, infectious and anastomotic leakage) were carefully collected during the first 30 days of the postoperative period. Results: After carrying out the multivariate analysis, PNI turned out to be a great predictive and protective factor for overall complications (RR: 0.279; 95% CI: 0.141-0.552), severe complications (RR: 0.355; 95% CI: 0.130-0.965), infectious complications (RR: 0.220; 95% CI: 0.099-0.489) and anastomotic leakage (RR: 0.151; 95% CI: 0.036-0.640). Conclusion: Our work reports that PNI is an independent predictive factor for the development of postoperative complications following curative surgery for CRC

A liver abscess secondary to a toothpick: a rare complication of accidental foreign body ingestion

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Absceso cervicotorácico secundario a punción con aguja fina guiada por ecografía endoscópica transesofágica / Cervicothoracic abscess secondary to transesophageal ultrasound-guided fine needle aspiration

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Prognostic Nutritional Index predicts morbidity after curative surgery for colorectal cancer. / El Prognostic Nutritional Index predice la morbilidad postoperatoria tras la cirugía curativa del cáncer colorrectal.

INTRODUCTION: Colorectal cancer (CRC) is a major health concern and it is associated with significant morbidity and mortality. Over the last decades, the relationship between cancer and nutritional and inflammatory status in oncologic patients was studied thoroughly and multiple immunonutritional scores were developed. These scores have been mainly related to the prognosis of several cancers. An interaction between the tumour and the host is generated, triggering a systemic inflammatory reaction leading to several neuroendocrine changes. This situation favours a tendency towards anorexia and catabolism. Our hypothesis is that nutritional and inflammatory status of oncologic patients is correlated to postoperative morbidity. METHODS: This is a prospective observational cohort study with those patients undergoing curative surgery for CRC at our institution between September 2015 and March 2017. Nutritional and inflammatory status was established using Onodera's Prognostic Nutritional Index (PNI). Complications (overall, severe, infectious and anastomotic leakage) were carefully collected during the first 30 days of the postoperative period. RESULTS: After carrying out the multivariate analysis, PNI turned out to be a great predictive and protective factor for overall complications (RR: 0.279; 95% CI: 0.141-0.552), severe complications (RR: 0.355; 95% CI: 0.130-0.965), infectious complications (RR: 0.220; 95% CI: 0.099-0.489) and anastomotic leakage (RR: 0.151; 95% CI: 0.036-0.640). CONCLUSION: Our work reports that PNI is an independent predictive factor for the development of postoperative complications following curative surgery for CRC.

A liver abscess secondary to a toothpick: a rare complication of accidental foreign body ingestion.

Perforation of the gastrointestinal tract caused by the ingested foreign bodies and subsequent hepatic abscess formation is uncommon. Early diagnosis is difficult and the treatment is mainly surgical.

Severe morbidity after pancreatectomy is accurately predicted by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center.

BACKGROUND: Major morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. METHODS: A total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. RESULTS: Of the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer-Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586-0.887; P = 0.007) and 0.712 (95% CI: 0.555-0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. CONCLUSIONS: PREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.

Quiste biliar tipo V con cistolitiasis / Type V biliary cyst with cystolithiasis

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A new dimensional-reducing variable obtained from original inflammatory scores is highly associated to morbidity after curative surgery for colorectal cancer.

PURPOSE: Several scores have been developed to define the inflammatory status of oncological patients. We suspect they share iterative information. Our hypothesis is that we may summarise their information into one or two new variables which will be independent. This will help us to predict, more accurately, which patients are at an increased risk of suffering postoperative complications after curative surgery for CRC. METHODS: Observational prospective study with those patients undergoing curative surgery for CRC between September 2015 and February 2017. We analysed the influence of inflammatory scores (PNI, GPS, NLR, PLR) on postoperative morbidity (overall and severe complications, anastomotic leakage and reoperation). RESULTS: Finally, 168 patients were analysed. We checked these four original scores are interrelated among them. Using a complex and innovative statistical method, we created two new independent variables (resultant A and resultant B) which resume the information coming from them. One of these two new variables (resultant A) was statistically associated to overall complications (OR, 2.239; 95% CI, 1.541-3.253; p = 0.0001), severe complications (OR, 1.773; 95% CI, 1.129-2.785; p = 0.013), anastomotic leakage (OR, 3.208; 95% CI, 1.416-7.268; p = 0.005) and reoperation (OR, 2.349; 95% CI, 1.281-4.305; p = 0.006). CONCLUSIONS: We evinced the four original scores we used share redundant information. We created two new independent new variables which resume their information. In our sample of patients, one of these variables turned out to be a great predictive factor for the four complications we analysed.

Type V biliary cyst with cystolithiasis.

We present the case of a 40-year-old female who presented to the General Surgery clinic due to a single episode of abdominal pain which required a visit to the Emergency Department. The patient had undergone surgery during childhood due to the suspicion of a hepatic hydatid cyst. However, an intraoperative cholangiography identified a small, non-complicated biliary cyst. Therefore, a hepatic resection was not performed. The patient did not undergo follow-up of the lesion.

Preoperative platelet-lymphocyte ratio is an independent factor of poor prognosis after curative surgery for colon cancer.

Interaction between tumour and host triggers a systemic inflammatory response. This situation has been associated to cancer progression. Several peripheral blood inflammatory scores have been recently developed, as PLR. Data about the relationship between these scores and cancer prognosis are contradictory. Therefore, the aim of our work is to evaluate the capability of PLR to predict long-term outcomes (OS and RFS) in patients who underwent curative surgery for colon cancer. A retrospective study was designed with patients who underwent curative surgery for colon cancer between September 2008 and January 2012 at Rio Hortega University Hospital, Valladolid (Spain). We analysed the influence of PLR and other clinical variables on OS and RFS. Finally, 201 patients were analysed. Optimal cut-off value for PLR, established with ROC curves, was 153. 1-, 3- and 5-year OS were: 99.0, 90.4 and 82.3% for low PLR, and 93.8, 74.9 and 61.9% for high PLR, p < 0.001. 1-, 3- and 5-year RFS were: 92.4, 84.7 and 77.6% for low PLR, and 83.3, 64.5 and 52.6% for high PLR, p < 0.001. In MVA, high PLR was an independent negative prognostic factor for OS (HR = 2.11; 95% CI 1.22-3.66; p = 0.008) and RFS (HR = 1.99; 95% CI 1.19-3.34; p = 0.009). PLR represents an independent negative prognostic factor for OS and RFS in our sample of patients who underwent curative surgery for colon cancer. However, further studies with a larger sample size from different populations are necessary to confirm this conclusion.

Neoplasia papilar intraductal de los conductos biliares con malignización: una entidad diferenciada del colangiocarcinoma con mejor pronóstico. A propósito de tres nuevos casos / Intraductal papillary neoplasia of the bile duct with malignancy: a differentiated entity of cholangiocarcinoma with a better prognosis. A review of three new cases

Introducción: las neoplasias papilares intraductales de la vía biliar se han reconocido como una entidad diferenciada de otros tumores biliares desde 2001. Se caracteriza por un crecimiento intraductal, puede o no producir moco y tiene potencial de malignización, aunque con mejor pronóstico que otros tipos de colangiocarcinoma. Casos clínicos: desde enero de 2010 a agosto de 2015, incluimos tres pacientes con diagnóstico confirmado de neoplasia papilar intraductal de la vía biliar con malignización tratados en nuestro centro. Dos casos eran hombres y el tercero, una mujer con una edad media de 67,3 años. Los tres pacientes presentaban malignización en el momento del diagnóstico. Un paciente era asintomático y el hallazgo fue en la pieza de hepatectomía tras un trasplante hepático por virus de la hepatitis C (VHC). Los otros dos pacientes se presentaron con colestasis y colangitis aguda y el diagnóstico se estableció en base a las pruebas de imagen (tomografía axial computarizada [TAC] y resonancia magnética [RMN]) y colangiopancreatografía retrógrada endoscópica (CPRE) con cepillado y biopsia. El tratamiento en ambos fue quirúrgico con hepatectomía izquierda y resección del conducto biliar izquierdo y del segmento I. o recibieron tratamiento adyuvante. Ninguno de los tres pacientes presenta recidiva de la enfermedad. Discusión: las neoplasias papilares intraductales de la vía biliar malignizadas representan una entidad diferenciada de los colangiocarcinomas con un mejor pronóstico. Su diagnóstico se basa en las pruebas de imagen y en la histología por CPRE. El tratamiento es quirúrgico consiguiendo altas tasas de curación con baja recidiva (AU)

Introduction: Intraductal papillary neoplasms of the bile duct have been recognized as a differentiated entity to other biliary tumors since 2001. They are characterized by intraductal growth, with or without mucus production, and have malignant potential, although they have a better prognosis than other types of cholangiocarcinoma. Case reports: From January 2010 to August 2015, we included three patients with a confirmed diagnosis of bile duct intraductal papillary neoplasia with malignancy that were treated at our center. Two cases were male and one female with a mean age of 67.3 years. All three patients presented malignancy at the time of diagnosis. One patient was asymptomatic and the diagnosis was reported in the hepatectomy specimen after a liver transplant due to autoimmune hepatitis. The other two patients presented with cholestasis and acute cholangitis and the diagnosis was made based on imaging tests (computed tomography [CT] and magnetic resonance imaging [MRI]) and endoscopic retrograde cholangiopancreatography (ERCP) with brushing and a biopsy. The treatment in both cases was surgical with a left hepatectomy, and resection of the left bile duct and segment I. They did not receive adjuvant treatment. None of the cases had recurrence of the disease. Discussion: Malignant intraductal papillary neoplasias of the biliary tract represent a different entity of cholangiocarcinoma with a better prognosis. Its diagnosis is based on imaging tests and histology by ERCP. The treatment is surgical, achieving a high rate of success with a low relapse rate (AU)

Recidiva en la anastomosis 13 años después de cirugía curativa para cáncer de recto / Anastomotic recurrence 13 years after curative resection for rectal cancer

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Intraductal papillary neoplasia of the bile duct with malignancy: a differentiated entity of cholangiocarcinoma with a better prognosis. A review of three new cases.

INTRODUCTION: Intraductal papillary neoplasms of the bile duct have been recognized as a differentiated entity to other biliary tumors since 2001. They are characterized by intraductal growth, with or without mucus production, and have malignant potential, although they have a better prognosis than other types of cholangiocarcinoma. CASE REPORTS: From January 2010 to August 2015, we included three patients with a confirmed diagnosis of bile duct intraductal papillary neoplasia with malignancy that were treated at our center. Two cases were male and one female with a mean age of 67.3 years. All three patients presented malignancy at the time of diagnosis. One patient was asymptomatic and the diagnosis was reported in the hepatectomy specimen after a liver transplant due to autoimmune hepatitis. The other two patients presented with cholestasis and acute cholangitis and the diagnosis was made based on imaging tests (computed tomography [CT] and magnetic resonance imaging [MRI]) and endoscopic retrograde cholangiopancreatography (ERCP) with brushing and a biopsy. The treatment in both cases was surgical with a left hepatectomy, and resection of the left bile duct and segment I. They did not receive adjuvant treatment. None of the cases had recurrence of the disease. DISCUSSION: Malignant intraductal papillary neoplasias of the biliary tract represent a different entity of cholangiocarcinoma with a better prognosis. Its diagnosis is based on imaging tests and histology by ERCP. The treatment is surgical, achieving a high rate of success with a low relapse rate.