From conventional two-stage hepatectomy to ALPPS: Fifteen years of experience in a hepatobiliary surgery unit.

BACKGROUND: Hepatectomy in patients with large tumor load may result in postoperative liver failure and associated complications due to excessive liver parenchyma removal. Conventional two-stage hepatectomy (TSH) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique are possible solutions to this problem. Colorectal liver metastases (CRLM) is the most frequent indication, and there is a need to assess outcomes for both techniques to improve surgical and long-term oncological outcomes in these patients. METHODS: A single-center retrospective study was designed to compare TSH with ALPPS in patients with initially unresectable bilateral liver tumors between January 2005 and January 2020. ALPPS was performed from January 2012 onwards as the technique of choice. Long-term overall survival (OS) and disease-free survival (DFS) were evaluated as primary outcome in CRLM patients. Postoperative morbidity, mortality and liver growth in all patients were also evaluated. RESULTS: A total of 38 staged hepatectomies were performed: 17 TSH and 21 ALPPS. Complete resection rate was 76.5% (n = 13) in the TSH group and 85.7% (n = 18) in the ALPPS group (P = 0.426). Overall major morbidity (Clavien-Dindo ≥ 3a) (stage 1 + stage 2) was 41.2% (n = 7) in TSH and 33.3% (n = 7) in ALPPS patients (P = 0.389), and perioperative 90-day mortalities were 11.8% (n = 2) vs. 19.0% (n = 4) in each group, respectively (P = 0.654). Intention-to-treat OS rates at 1 and 5 years in CRLM patients for TSH (n = 15) were 80% and 33%, and for ALPPS (n = 17) 76% and 35%, respectively. DFS rates at 1 and 5 years were 36% and 27% in the TSH group vs. 33% and 27% in the ALPPS group, respectively. CONCLUSIONS: ALPPS is an effective alternative to TSH in bilateral affecting liver tumors, allowing higher resection rate, but patients must be carefully selected. In CRLM patients similar long-term OS and DFS can be achieved with both techniques.

Extended distal pancreatectomy with thoracic wall resection after neoadjuvant FOLFIRINOX: Is there a limit of resection for pancreatic cancer after downstaging?

Indications and outcomes of extended pancreatectomies have been recently appraised by the International Study Group for Pancreatic Surgery. However, no definitive conclusions have been drawn, particularly in the setting of neoadjuvant treatments. We present here a case of 53-year-old man diagnosed with a bulky adenocarcinoma of the tail of the pancreas and infiltrating the adjacent organs and the thoracic wall. The patient was sent to neoadjuvant chemotherapy and he underwent 12 cycles of FOLFIRINOX. Since a significant radiological response was observed after chemotherapy, the patient was scheduled for extended distal pancreatectomy with en bloc resection of the thoracic wall, in order to achieve a radical resection. The surgery is herein described with all technical details. The patient was discharged after an uneventful early post-operative course and subsequently readmitted for a late grade B post-operative pancreatic fistula, which was ultimately treated successfully. Pathology showed complete response. When performed in centers with ample experience in pancreatic surgery, extended pancreatic resections represent a viable curative option with acceptable surgical outcomes. In this setting, challenging tailored resections should be considered to achieve negative margins, particularly following maximized effective downstaging strategies.

Late complications of pancreas transplant.

To summarize the long-term complications after pancreas transplantation that affect graft function, a literature search was carried out on the long-term complications of pancreatic transplantation, namely, complications from postoperative 3rd mo onwards, in terms of loss of graft function, late infection and vascular complications as pseudoaneurysms. The most relevant reviews and studies were selected to obtain the current evidence on these topics. The definition of graft failure varies among different studies, so it is difficult to evaluate, a standardized definition is of utmost importance to know the magnitude of the problem in all worldwide series. Chronic rejection is the main cause of long-term graft failure, occurring in 10% of patients. From the 3rd mo of transplantation onwards, the main risk factor for late infections is immunosuppression, and patients have opportunistic infections like: Cytomegalovirus, hepatitis B and C viruses, Epstein-Barr virus and varicella-zoster virus; opportunistic bacteria, reactivation of latent infections as tuberculosis or fungal infections. Complete preoperative studies and serological tests should be made in all recipients to avoid these infections, adding perioperative prophylactic treatments when indicated. Pseudoaneurysm are uncommon, but one of the main causes of late bleeding, which can be fatal. The treatment should be performed with radiological endovascular approaches or open surgery in case of failure. Despite all therapeutic options for the complications mentioned above, transplantectomy is a necessary option in approximately 50% of relaparotomies, especially in life-threatening complications. Late complications in pancreatic transplantation threatens long-term graft function. An exhaustive follow-up as well as a correct immunosuppression protocol are necessary for prevention.

Tuberculosis ganglionar peripancreática primaria como diagnóstico diferencial de neoplasia pancreática / Primary peripancreatic lymph node tuberculosis as a differential diagnosis of pancreatic neoplasia

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Hiperplasia estromal seudoangiomatosa. Una lesión de la mama infrecuente y de presentación variable / Pseudoangiomatous stromal hyperplasia. A rare breast lesion with variable presentation

La hiperplasia estromal seudoangiomatosa es una lesión mamaria poco frecuente y de carácter benigno. Se caracteriza por un sobrecrecimiento de tejido conectivo fibroso que produce numerosos espacios que semejan estructuras vasculares. Generalmente afecta a mujeres en edad reproductiva, aunque se ha descrito en pacientes de edades comprendidas entre los 12 y los 75 años. Puede presentarse bien como un hallazgo incidental en el estudio histológico tras una cirugía por patología benigna o maligna, bien como una tumoración mamaria indolora, simulando un fibroadenoma, o bien como una gigantomastia o deformidad que se hace más evidente al tener en cuenta la mama contralateral. La biopsia percutánea guiada por ecografía permite detectar la naturaleza de la lesión con certeza y descartar patología maligna, como el angiosarcoma de bajo grado. El tratamiento es quirúrgico y abarca tanto la exéresis quirúrgica de la lesión como la mastectomía con reconstrucción protésica. Se describe una serie de 3 casos con diferente presentación clínica y tratamiento. El primer caso fue un hallazgo radiológico e histopatológico relacionado con una deformidad y asimetría mamarias, mientras que los 2 últimos casos se manifestaron como una tumoración mamaria palpable, única e indolora (AU)

Pseudoangiomatous stromal hyperplasia is a rare benign mammary lesion. It is characterised by an overgrowth of fibrous connective tissue that produces numerous spaces resembling vascular structures. This lesion usually affects women of reproductive age but has been described in patients aged between 12 and 75 years. It may appear as an incidental finding in histological analysis after surgery for benign or malignant disease, either as a painless breast tumour, simulating a fibroadenoma, or as a gigantomastia or deformity that becomes more evident on comparison with the contralateral breast. Percutaneous ultrasound-guided biopsy allows definitive identification of the type of lesion and exclusion of malignant disease, such as low-grade angiosarcoma. Treatment is surgical and includes both surgical removal of the lesion and mastectomy with prosthetic reconstruction. We describe a series of three cases with different clinical presentations and treatment. The first case was a radiological and histopathological finding related to a breast deformity and asymmetry, while the remaining two cases presented as a palpable, single and painless breast tumour (AU)

Primary peripancreatic lymph node tuberculosis as a differential diagnosis of pancreatic neoplasia.

Primary peripancreatic lymph node tuberculosis is an exceptional entity in immunocompetent patients, but its incidence is increasing in developed countries in recent years due to increasing immigration. It usually presents as a pancreatic mass and is misdiagnosed as pancreatic neoplasia in most cases, with the diagnosis of tuberculosis occurring after surgery. We report the case of a 38 year old Pakistani man with abdominal pain of several months duration, who was initially diagnosed with a pancreatic neoplasm after detecting a mass in the pancreatic isthmus by computed tomography (CT) and abdominal magnetic resonance imaging (MRI). However, after performing an endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB), the patient was diagnosed with peripancreatic lymph node tuberculosis. After receiving anti-tuberculous treatment, the patient presented clinical improvement, despite a small reduction in the lesion size. In conclusion, peripancreatic lymph node tuberculosis is part of the differential diagnosis of pancreatic neoplasia. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) represents a valuable and useful diagnostic tool for detecting this pathology, avoiding surgeries with a high morbidity and mortality.

ALPPS monosegmento: una nueva variante de las técnicas de regeneración hepática rápida. Revisión crítica de los resultados iniciales de nuestra serie / Monosegment ALPPS: A new variant of the techniques for rapid hepatic regeneration. Critical review of the initial results of our series

La hepatectomía secuencial, descrita en la literatura anglosajona con el acrónimo ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) es una técnica novedosa que ofrece un crecimiento rápido y efectivo del volumen remanente hepático, y que permite la resección quirúrgica de lesiones hepáticas consideradas inicialmente irresecables. Los resultados a corto y largo plazo y la conveniencia de realizar esta técnica son cuestiones que permanecen en discusión a la espera de los resultados finales de los registros multicéntricos. El objetivo del presente trabajo es la revisión crítica de los resultados de la serie de casos realizados en nuestro centro (n = 8). Por otra parte, es posible con esta técnica dejar un único segmento hepático como remanente y realizamos una descripción de esta variante técnica novedosa (ALPPS monosegmento), llevada a cabo en uno de los casos

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a novel surgical technique that provides fast and effective growth of liver remnant volume, allowing surgical resection of hepatic lesions initially considered unresectable. Short and long-term results and the convenience of carrying out this technique are issues that still remain under debate while waiting for the final outcomes of the multicenter registries with larger number of cases. The aim of this paper is to describe, from a critical point of view, the outcomes of the cases performed at our center (n = 8). On the other hand, it is possible to leave only one hepatic segment as a liver remnant and we illustrate this new surgical procedure (ALPPS monosegment) performed in one patient

Monosegment ALPPS: A new variant of the techniques for rapid hepatic regeneration. Critical review of the initial results of our series.

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a novel surgical technique that provides fast and effective growth of liver remnant volume, allowing surgical resection of hepatic lesions initially considered unresectable. Short and long-term results and the convenience of carrying out this technique are issues that still remain under debate while waiting for the final outcomes of the multicenter registries with larger number of cases. The aim of this paper is to describe, from a critical point of view, the outcomes of the cases performed at our center (n=8). On the other hand, it is possible to leave only one hepatic segment as a liver remnant and we illustrate this new surgical procedure (ALPPS monosegment) performed in one patient.