Management of factor XI deficiency in oncological liver and colorectal surgery by therapeutic plasma exchange: A case report.

INTRODUCTION: Factor XI (FXI) deficiency is a rare congenital hemostatic disorder associated with increased bleeding tendency in trauma, surgery or when other hemostatic defects are present. Perioperative hemostatic management of a patient with a severe FXI deficiency undergoing major oncological liver and colorectal surgery with therapeutic plasma exchange (TPE) with fresh frozen plasma (FFP) is reported. CASE DESCRIPTION: A 54-year-old male with severe FXI deficiency was scheduled for resection of synchronous rectal cancer and multiple liver metastases. Baseline prothrombin time (PT) was 97 %, activated partial thromboplastin time (aPTT) 89 s(s) and FXI levels <1 IU/dL. The rotational thromboelastometry (ROTEM™) presented a prolonged INTEM clotting time (CT) = 443 s (RV 100-240 s) and a clot formation time (CFT) = 110 s (RV 30-100 s). TPE with FFP was carried out achieving FXI levels up to 46 IU/dL and an aPTT of 33 s, normalizing thromboelastometry parameters to an INTEM CT = 152 s and a CFT = 86 s before the procedure. After surgery, the patient received daily FFP to maintain FXI levels above 30 IU/dL until discharge on the eighth day. A total of 30 FFP units were transfused during hospital stay. No significant bleeding events neither transfusion related complications were observed during the perioperative period. CONCLUSION: Given the lack of correlation between FXI levels and bleeding risk, a multidisciplinary approach based on daily FXI levels monitoring, close clinical assessment and factor supplementation is mandatory. In conclusion, TPE with FFP is an efficacious alternative strategy to correct severe FXI deficiency in patients undergoing major surgery.

Short Chemotherapy-Free Interval Improves Oncological Outcome in Patients Undergoing Two-Stage Hepatectomy for Colorectal Liver Metastases.

BACKGROUND: In patients undergoing two-stage hepatectomy (TSH) for colorectal liver metastases (CRLM), chemotherapy is discontinued before portal vein occlusion and restarted after curative resection. Long chemotherapy-free intervals (CFI) may lead to tumor progression and poor oncological outcomes. OBJECTIVE: The aim of this study was to investigate the impact of the length of CFI on oncological outcome in patients undergoing TSH for CRLM. PATIENTS AND METHODS: Overall, 74 patients suffering from bilobar CRLM who underwent ALPPS (associating liver partition with portal vein ligation for staged hepatectomy; n = 43) or conventional TSH (n = 31) at two tertiary centers were investigated. The impact of CFI on long-term outcomes was analyzed by univariable and multivariable analysis. RESULTS: Preoperative chemotherapy was administered in 91 % (67/74) of patients, and chemotherapy was resumed postoperatively in 69 % (44/64) of patients who completed TSH. The use of postoperative chemotherapy was significantly associated with improved mean overall survival (36 ± 3 vs. 13 ± 3 months; p < 0.001). Overall, the median CFI from surgery to postoperative chemotherapy was 16 weeks (interquartile range 11-31) and was significantly shorter in the ALPPS group when compared with the conventional TSH group (10 vs. 21 weeks; p < 0.001). Multivariable analysis revealed a CFI ≤ 10 weeks as an independent factor associated with improved overall survival (p = 0.006) and disease-free survival (p = 0.010). CONCLUSION: A short CFI is associated with improved oncological outcome in patients undergoing TSH for CRLM. Decreased interstage intervals after ALPPS may facilitate the timely resumption of chemotherapy.

Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury.

BACKGROUND: The role of intraoperative cholangiography (IOC) in the diagnosis, prevention and management of bile duct injury (BDI) remains controversial. The aim of the present study was to determine the value of routine IOC in the diagnosis and management of BDI sustained during laparoscopic cholecystectomy (LC) at a high-volume centre. METHODS: A retrospective analysis of a single-institution database was performed. Patients who underwent LC with routine IOC between October 1991 and May 2012 were included. RESULTS: Among 11,423 consecutive LCs IOC was performed successfully in 95.7 per cent of patients. No patient had IOC-related complications. Twenty patients (0.17 per cent) sustained a BDI during LC, and the diagnosis was made during surgery in 18 patients. Most BDIs were type D according to the Strasberg classification. The sensitivity of IOC for the detection of BDI was 79 per cent; specificity was 100 per cent. All injuries diagnosed during surgery were repaired during the same surgical procedure. Two patients developed early biliary strictures that were treated by percutaneous dilatation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results. CONCLUSION: The routine use of IOC during LC in a high-volume teaching centre was associated with a low incidence of BDI, and facilitated detection and repair during the same surgical procedure with a good outcome.

Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion -- an extension of the ALPPS approach.

BACKGROUND: Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new "ALPPS" approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE. METHODS: A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. RESULTS: The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection. CONCLUSION: Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.

Use of liver grafts from anti-hepatitis B core-positive donors: a multicenter study in Argentina.

Liver transplantation success is limited by the availability of donors. To overcome this limitation, anti-core-positive donors are increasingly being accepted, but underutilization of this resource still occurs. We performed the current study to determine the prevalence of anti-core-positive donors in our region and to describe the management of these donors and their recipients. Between January 2005 and July 2011, the national transplant database included 2,262 registered liver donors among whom 106 (4.7%) were anti-core-positive including 59 (56%) discarded and 47 (44%) implanted organs. A median of 14.5 offers (range 4-60) were rejected before harvesting and implanting the accepted grafts. The only difference between the implanted and the discarded grafts was found for the alanine aminotransferase level, which was higher among the discarded ones (50 ± 59 UI/L vs 25 ± 16, P < .05). Among 40 recipients included in the study, 5 (12.5%) did not receive any prophylaxis; 18 (45%) a nucleos(t)ide analog 11 (25.5%), heptitis B immunoglobulin and nucleos(t)ide analogs and 6 (15%) pretransplant hepatitis B vaccination. Over a mean follow-up of 871 ± 585 days, 4 de novo hepatitis B cases were identified at 545, 720, 748, and 1,080 days posttransplantation. None of these patients had received any prophylaxis. In all cases entecavir successfully controlled viral replication. We believe that better utilization of these donors and careful management of their recipients represent safe strategies to expand the liver donor pool in Argentina.

Model for end-stage liver disease-based allocation system for liver transplantation in Argentina: does it work outside the United States?

BACKGROUND: In July 2005, Argentina was the first country after the United States to adopt the MELD system. The purpose of the present study was to analyse the impact of this new system on the adult liver waiting list (WL). METHODS: Between 2005 and 2009, 1773 adult patients were listed for liver transplantation: 150 emergencies and 1623 electives. Elective patients were categorized using the MELD system. A prospective database was used to analyse mortality and probability to be transplanted (PTBT) on the WL. RESULTS: The waiting time increased inversely with the MELD score and PTBT positively correlated with MELD score. With scores >/= 18 the PTBT remained over 50%. However, the largest MELD subgroup with <10 points (n = 433) had the lower PTBT (3%). In contrast, patients with T(2) hepatocellular carcinoma benefited excessively with the highest PTBT (84.2%) and the lowest mortality rate (5.4%). The WL mortality increased after MELD adoption (10% vs. 14.8% vs. P < 0.01). Patients with <10 MELD points had >fourfold probability of dying on the WL than PTBT (14.3% vs. 3%; P < 0.0001). CONCLUSIONS: After MELD implementation, WL mortality increased and most patients who died had a low MELD score. A comprehensive revision of the MELD system must be performed to include cultural and socio-economical variables that could affect each country individually.

Complex bile duct injuries: management.

BACKGROUND: Laparoscopic cholecystectomy is the present treatment of choice for patients with gallbladder stones, despite its being associated with a higher incidence of biliary injuries compared with the open procedure. Injuries occurring during the laparoscopic approach seem to be more complex. A complex biliary injury is a disease that is difficult to diagnose and treat. We considered complex injuries: 1) injuries that involve the confluence; 2) injuries in which repair attempts have failed; 3) any bile duct injury associated with a vascular injury; 4) or any biliary injury in association with portal hypertension or secondary biliary cirrhosis. The present review is an evaluation of our experience in the treatment of these complex biliary injuries and an analysis of the international literature on the management of patients.

Liver resection for non-colorectal, non-neuroendocrine metastases: analysis of a multicenter study from Argentina.

BACKGROUND AND AIM: Resection of colorectal liver metastases has become a standard of care, although the value of this procedure in non-colorectal non-neuroendocrine (NCRNNE) metastases remains controversial and is still a matter of debate. The aim of the study was to determine the utility of liver resection in the long-term outcome of patients with NCRNNE metastases. MATERIAL AND METHODS: The records of 106 patients who underwent liver resection for NCRNNE metastases in the period 1989 to 2006 at 5 HPB Centers in Argentina were analyzed. Patient demographics, tumor characteristics, type of resection, long-term outcome and prognostic factors were analyzed. Depending on primary tumor sites, a comparative analysis of survival was performed. RESULTS: Mean age was 54 (17-76). Hepatic metastases were solitary in 62.3% and unilateral in 85.6%. Primary tumor sites: Urogenital (37.7%), sarcomas (21.7%), breast (17.9%), gastrointestinal (6.6%), melanoma (5.7%), and others (10.4%). Fifty-one major hepatectomies and 55 minor resections were performed. Twenty patients underwent synchronous resections. An R0 resection could be achieved in 89.6%. Perioperative mortality was 1.8%. Overall, 1-year, 3-year, and 5-year survival rates were 67%, 34%, and 19%, respectively. Survival was significantly longer for metastases of urogenital (p=0.0001) and breast (p=0.003) origin. Curative resections (p=0.04) and metachronous disease (p=0.0001) were predictors of better survival. CONCLUSIONS: Liver resection is an effective treatment for NCRNNE liver metastases; it gives satisfactory long-term survival especially in metachronous disease, in patients with metastases from urogenital and breast tumors and when R0 procedures can be performed.

Bile duct injuries: management of late complications.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice for gallbladder stones. In the current study, this approach was associated with a higher incidence of biliary injuries. The authors evaluate their experience treating complex biliary injuries and analyze the literature. METHODS: In a 15-year period, 169 patients with bile duct injuries (BDIs) resulting from open and laparoscopic cholecystectomies were treated. The patients were retrospectively evaluated through their records. Biliary injury and associated lesions were evaluated with imaging studies. Surgical management included therapeutic endoscopy, percutaneous interventions, hepaticojejunostomy, liver resection, and liver transplantation. Postoperative outcome was recorded. Survival analysis was performed with G-Stat and NCSS programs using the Kaplan-Meier method. RESULTS: Of the 169 patients treated for BDIs, 148 were referred from other centers. The injuries included 115 lesions resulting from open cholecystectomy and 54 lesions resulting from laparoscopic cholecystectomy. A total of 110 patients (65%) fulfilled the criteria for complex injuries, 11 of whom met more than one criteria. Injuries resulting from laparoscopic and open cholecystectomies were complex in 87.5% and 72% of the patients, respectively. The procedures used were percutaneous transhepatic biliary drainage for 30 patients, hepaticojejunostomy for 96 patients, rehepaticojejunostomy for 16 patients, hepatic resection for 9 patients, and liver transplantation projected for 18 patients. Hepaticojejunostomy was effective for 85% of the patients. The mean follow-up period was 77.8 months (range, 4-168 months). The mortality rate for noncomplex BDI was 0%, as compared with the mortality rate of 7.2% (8/110) for complex BDI. Mortality after hepatic resection was nil, and morbidity was 33.3%. The actuarial survival rate for liver transplantation at 1 year was 91.7%. CONCLUSIONS: Complex BDIs after laparoscopic cholecystectomy are potentially life-threatening complications. In this study, late complications of complex BDIs appeared when there was a delay in referral or the patient received multiple procedures. On occasion, hepatic resections and liver transplantation proved to be the only definitive treatments with good long-term outcomes and quality of life.

Catastrophic antiphospholipid syndrome complicating orthotopic liver transplantation.

Catastrophic antiphospholipid syndrome (CAPS) is an acutely devastating situation characterized by widespread thrombotic microangiopathy in the presence of elevated titers of antiphospholipid antibodies. We describe a 57-year old woman who underwent liver transplantation for primary sclerosing cholangitis and developed this malignant variant of the antiphospholipid syndrome.

Esplenectomía laparoscópica y mano asistida / Laparoscopic splenectomy and hand assited

Antecedentes: Las publicaciones sobre esplenectomías laparoscópicas (EL) son poco frecuentes, y el número de pacientes limitado por la baja prevalencia de las esplenopatías que requieren tratamiento quirúrgico. Sin embargo para algunas que requieren la remoción del bazo, es considerada la técnica de elección. Objetivo: Evaluar la experiencia realizada en el Hospital Italiano de Buenos Aires, con las técnicas endoscópicas de remoción esplénica. Diseño: Descriptivo retrospectivo. Institución: Hospital de Comunidad. Servicio de Cirugía General. Población: Entre junio de 1995 y marzo de 2001 fueron realizadas esplenectomías laparoscópicas a 25 pacientes, 68 por ciento de sexo femenino con una edad promedio de 47 años (r:19-81). La patología subyacente fue: púrpura trombocitopénica idiopática (P.T.I) en 15, síndromes linfoproliferativos en 6, esferocitosis en 2, anemia hemolítica auto inmune en 1, esplenomegalia de causa no aclarada en 1. Métodos: Se utilizó la posición en decúbito lateral derecho, usando entre 3 y 4 trocares; el pedículo esplénico se ocluyó con clips y nudos intra o extra corpóreos. No se usaron suturas mecánicas. El bazo se colocó en una bolsa abdominal, extrayéndolo fragmentado por el ombligo. En la técnica mano asistida se utilizó el sistema Hand Port (Smith & Nephew), por el hipocondro derecho para la introducción de la mano no dominante del cirujano. Resultados: Se debió convertir en 3 casos (12 por ciento) por complicaciones hemorrágicas (2) y adherencias firmes al hígado (1). En el abordaje laparoscópico, el tiempo promedio de cirugía fue de 170 minutos (r:110-270), la internación promedio de 3 días (r:1-5), y el peso promedio del bazo de 300 gramos (r:59-500). En cinco casos se resecaron bazos accesorios. En el abordaje mano asistido (2 casos), el tiempo promedio de cirugía fue de 80 minutos, la internación promedio de 2,5 días (r:2-3), y el peso promedio del bazo de 1200 gramos (r:1150-1250). Tres pacientes (12 por ciento) presentaron complicaciones (1 neumotórax, 1 hematoma subfrénico, 1 absceso subfrénico todos de localización izquierda). Ninguno debió ser reoperado. En el seguimiento alejado 2 pacientes presentaron recurrencia de su enfermedad asociada a patología sistemática de base. Uno de ellos tenía un bazo accesorio que fue resecado por vía laparoscópica...

Esplenectomía laparoscópica y mano asistida / Laparoscopic splenectomy and hand assited

Antecedentes: Las publicaciones sobre esplenectomías laparoscópicas (EL) son poco frecuentes, y el número de pacientes limitado por la baja prevalencia de las esplenopatías que requieren tratamiento quirúrgico. Sin embargo para algunas que requieren la remoción del bazo, es considerada la técnica de elección. Objetivo: Evaluar la experiencia realizada en el Hospital Italiano de Buenos Aires, con las técnicas endoscópicas de remoción esplénica. Diseño: Descriptivo retrospectivo. Institución: Hospital de Comunidad. Servicio de Cirugía General. Población: Entre junio de 1995 y marzo de 2001 fueron realizadas esplenectomías laparoscópicas a 25 pacientes, 68 por ciento de sexo femenino con una edad promedio de 47 años (r:19-81). La patología subyacente fue: púrpura trombocitopénica idiopática (P.T.I) en 15, síndromes linfoproliferativos en 6, esferocitosis en 2, anemia hemolítica auto inmune en 1, esplenomegalia de causa no aclarada en 1. Métodos: Se utilizó la posición en decúbito lateral derecho, usando entre 3 y 4 trocares; el pedículo esplénico se ocluyó con clips y nudos intra o extra corpóreos. No se usaron suturas mecánicas. El bazo se colocó en una bolsa abdominal, extrayéndolo fragmentado por el ombligo. En la técnica mano asistida se utilizó el sistema Hand Port (Smith & Nephew), por el hipocondro derecho para la introducción de la mano no dominante del cirujano. Resultados: Se debió convertir en 3 casos (12 por ciento) por complicaciones hemorrágicas (2) y adherencias firmes al hígado (1). En el abordaje laparoscópico, el tiempo promedio de cirugía fue de 170 minutos (r:110-270), la internación promedio de 3 días (r:1-5), y el peso promedio del bazo de 300 gramos (r:59-500). En cinco casos se resecaron bazos accesorios. En el abordaje mano asistido (2 casos), el tiempo promedio de cirugía fue de 80 minutos, la internación promedio de 2,5 días (r:2-3), y el peso promedio del bazo de 1200 gramos (r:1150-1250). Tres pacientes (12 por ciento) presentaron complicaciones (1 neumotórax, 1 hematoma subfrénico, 1 absceso subfrénico todos de localización izquierda). Ninguno debió ser reoperado. En el seguimiento alejado 2 pacientes presentaron recurrencia de su enfermedad asociada a patología sistemática de base. Uno de ellos tenía un bazo accesorio que fue resecado por vía laparoscópica...(AU)

Liver transplantation for the sequelae of intra-operative bile duct injury.

BACKGROUND: Intra-operative bile duct injuries (IBDI) are potentially severe complications of the treatment of benign conditions, with unpredictable long-term results. Multiple procedures are frequently needed to correct these complications. In spite of the application of these procedures, patients with severe injuries can develop irreversible liver disease. Liver transplantation (LT) is currently the only treatment available for such patients, but little information has been published concerning the results of LT. METHODS: Eight patients with LT for end-stage liver disease for IBDI were studied retrospectively. They had failure of multiple previous treatments and experienced recurrent episodes of cholangitis, oesophageal variceal bleeding, severe pruritus, refractory ascites and spontaneous peritonitis. RESULTS: Mean recipient hepatectomy time was of 243 minutes (range 140-295 min), the complete procedure averages 545 minutes (260-720) and intraoperative red-blood-cells consumption was 6.5 units (1-7). One patient required reoperation due to perforation of a Roux-en-Y loop, and three developed minor complications (2 wound infections, I inguinal lymphocele). One patient died due to nosocomial pneumonia (mortality rate 12.5%). One patient required retransplantation due to delayed hepatic artery thrombosis. At follow-up 75% of patients are alive with normal graft function and an excellent quality of life. CONCLUSIONS: LT represents a safe curative treatment for end-stage liver disease after IBDI, albeit a major undertaking in the context of a surgical complication in the treatment of benign disease. The complications of the surgical procedure and the long-standing immunosuppression impart a high cost for resolutions of these sequelae but LT represents the only long-term effective treatment for these selected patients.

Nitric oxide synthase activity in the splanchnic vasculature of patients with cirrhosis: relationship with hemodynamic disturbances.

BACKGROUND/AIMS: It has been demonstrated that an overproduction of nitric oxide plays an important role in the pathogenesis of the hyperdynamic circulation exhibited by cirrhotic patients. Nevertheless, evidence is supported by studies performed in experimental models or by indirect measurements in humans. The purpose of this study has been to evaluate nitric oxide production in splanchnic vasculature of patients with cirrhosis and to investigate its possible relationship with systemic and splanchnic hemodynamics. METHODS: Nitric oxide synthase (NOS) activity was measured in hepatic artery and portal vein tissues of nine cirrhotic patients. Samples were obtained during liver transplantation. Control samples were obtained simultaneously from the corresponding tissues of the liver donors. Hemodynamic parameters were determined with Doppler ultrasonography. RESULTS: NOS activity was significantly higher in hepatic artery of cirrhotic patients than in controls (8.17 +/- 1.30 vs 4.57 +/- 0.61 pmoles/g of tissue/min, P < 0.05). Patients with ascites showed a higher hepatic artery NOS activity than patients without ascites. Highly significant correlation was observed between cardiac output and hepatic artery NOS activity as well as between portal blood flow and hepatic artery NOS activity. CONCLUSIONS: The present study demonstrates an enhanced production of nitric oxide in the splanchnic vasculature of patients with cirrhosis.

[Multimodal treatment of hepatocellular carcinoma]. / Tratamiento multimodal del hepatocarcinoma.

BACKGROUND: Several options now available create the need for a multidisciplinary approach to the treatment of patients with hepatocellular carcinoma (HCC). OBJECTIVE: To describe the experience with a group of patients with HCC diagnosed and treated with the current modalities for control of this entity. POPULATION AND METHOD: A total of 169 consecutive patients with HCC treated between January 1990 and February 1998; 41 liver resections, 14 liver transplants, 87 chemoembolizations and 8 alcoholizations were performed. The median follow-up time was 23.6 months (range: 0.2-94). In the other 29 patients, only support treatment was administered. RESULTS: Resected patients had a lower median hospitalization rate, blood transfusions, and hospitalization mortality. Recurrence was 42.1% in the resected group but 0% in transplanted patients. The overall survival at 36 months was better for transplanted than for resected patients (100% vs. 62.3%; p < 0.02). The median survival time was 13 months (IC: 95%: 11-15 months) in chemoembolizated patients. CONCLUSIONS: 1. The outcome of patients with HCC is influenced by several factors, therefore calling for multimodal approach. 2. Surgical procedures should be indicated with low morbimortality rates. 3. The overall survival and disease free survival time is better in transplanted patients than in the resected group. 4. The survival time of patients with unresectable HCC without extra-liver disease could be improved with chemoembolization.

Tratamiento multimodal del hepatocarcinoma / Multimodal treatment of hepatocellular carcinoma

Antecedentes: La variedad y complementación de las diferentes posibilidades terapéuticas disponibles en la actualidad hacen necesario un enfoque multidisciplinario de los pacientes portadores de carcinoma hepatocelular (CHC). Objetivo: Describir la experiencia en el tratamiento de un grupo de pacientes con CHC. Población y Método: Se estudiaron 169 pacientes portadores de CHC en el período de enero de 1990 a febrero de 1998. En 149 enfermos se practicaron 41 resecciones hepáticas, 14 trasplantes de hígado, 87 quimioembolizaciones y 8 alcoholizaciones. En los restantes 29, sólo se realizó tratamiento de sostén clínico. Se analizaron las diferentes modalidades terapéuticas en función de los resultados, recurrencia y sobrevida. Resultados: Los pacientes resecados tuvieron menor internación, consumo sanguíneo, mortalidad intrahospitalaria (0 por ciento) que los trasplantados. Se detectó recidiva en 42,1 por ciento de los resecados mientras que en los trasplantados fue de 0 por ciento. La única variable significativa para la recidiva fue el tamaño tumoral. La supervivencia global a 36 meses de los pacientes trasplantados fue mayor que la de los resecados (100 por ciento vs. 62,3 por ciento; p<0,02). En los enfermos embolizados la supervivencia global promedio fue de 13 meses (IC 95 por ciento; 11-15 meses). Conclusiones: 1) Las múltiples variables que influencian la evolución de un paciente con CHC obligan a su tratamiento multimodal. 2) Los procedimientos quirúrgicos pueden ser aplicados con bajos índices de morbimortalidad. 3) La sobrevida global y libre de enfermedad es superior en los pacientes trasplantados que en los resecados. 4) En los pacientes portadores de CHC irresecables sin enfermedad extrahepática, la quimioembolización Es un procedimiento que mejora el tiempo de supervivencia.

Tratamiento multimodal del hepatocarcinoma. / [Multimodal treatment of hepatocellular carcinoma]

BACKGROUND: Several options now available create the need for a multidisciplinary approach to the treatment of patients with hepatocellular carcinoma (HCC). OBJECTIVE: To describe the experience with a group of patients with HCC diagnosed and treated with the current modalities for control of this entity. POPULATION AND METHOD: A total of 169 consecutive patients with HCC treated between January 1990 and February 1998; 41 liver resections, 14 liver transplants, 87 chemoembolizations and 8 alcoholizations were performed. The median follow-up time was 23.6 months (range: 0.2-94). In the other 29 patients, only support treatment was administered. RESULTS: Resected patients had a lower median hospitalization rate, blood transfusions, and hospitalization mortality. Recurrence was 42.1

in the resected group but 0

in transplanted patients. The overall survival at 36 months was better for transplanted than for resected patients (100

vs. 62.3

; p < 0.02). The median survival time was 13 months (IC: 95

: 11-15 months) in chemoembolizated patients. CONCLUSIONS: 1. The outcome of patients with HCC is influenced by several factors, therefore calling for multimodal approach. 2. Surgical procedures should be indicated with low morbimortality rates. 3. The overall survival and disease free survival time is better in transplanted patients than in the resected group. 4. The survival time of patients with unresectable HCC without extra-liver disease could be improved with chemoembolization.

Tratamiento multimodal del hepatocarcinoma / Multimodal treatment of hepatocellular carcinoma

Antecedentes: La variedad y complementación de las diferentes posibilidades terapéuticas disponibles en la actualidad hacen necesario un enfoque multidisciplinario de los pacientes portadores de carcinoma hepatocelular (CHC). Objetivo: Describir la experiencia en el tratamiento de un grupo de pacientes con CHC. Población y Método: Se estudiaron 169 pacientes portadores de CHC en el período de enero de 1990 a febrero de 1998. En 149 enfermos se practicaron 41 resecciones hepáticas, 14 trasplantes de hígado, 87 quimioembolizaciones y 8 alcoholizaciones. En los restantes 29, sólo se realizó tratamiento de sostén clínico. Se analizaron las diferentes modalidades terapéuticas en función de los resultados, recurrencia y sobrevida. Resultados: Los pacientes resecados tuvieron menor internación, consumo sanguíneo, mortalidad intrahospitalaria (0 por ciento) que los trasplantados. Se detectó recidiva en 42,1 por ciento de los resecados mientras que en los trasplantados fue de 0 por ciento. La única variable significativa para la recidiva fue el tamaño tumoral. La supervivencia global a 36 meses de los pacientes trasplantados fue mayor que la de los resecados (100 por ciento vs. 62,3 por ciento; p<0,02). En los enfermos embolizados la supervivencia global promedio fue de 13 meses (IC 95 por ciento; 11-15 meses). Conclusiones: 1) Las múltiples variables que influencian la evolución de un paciente con CHC obligan a su tratamiento multimodal. 2) Los procedimientos quirúrgicos pueden ser aplicados con bajos índices de morbimortalidad. 3) La sobrevida global y libre de enfermedad es superior en los pacientes trasplantados que en los resecados. 4) En los pacientes portadores de CHC irresecables sin enfermedad extrahepática, la quimioembolización Es un procedimiento que mejora el tiempo de supervivencia. (Au)

Partial left lateral segment transplant from a living donor.

A shortage of liver donors for low-weight transplant recipients has prompted the development of procedures for liver-reduction, split-liver, and living related donor transplantations. For pediatric recipients weighing less than 10 kg, the left lateral segment is often still too large. We describe the procedure of monosegmental transplantation using segment II after segment III was resected in situ from a living related donor. Successful monosegmental transplantation is technically feasible and is a valid alternative to be considered for cases of size discrepancy between the recipient's volume and the donor's left lateral segment.