Whipple's cephalic pancreaticoduodenectomy versus pyloric-preserving pancreaticoduodenectomy. Retrospective study.

INTRODUCTION: Controversy exists in the literature as to the best technique for pancreaticoduodenectomy (PD), whether pyloric preservation (PP-CPD) or Whipple's technique (with antrectomy [W-CPD]), the former being associated with a higher frequency of delayed gastric emptying (DGE). METHODS: Retrospective and comparative study between PP-CPD technique (n = 124 patients) and W-CPD technique (n = 126 patients), in patients who were operated for tumors of the pancreatic head and periampullary region between the period 2012 and 2023. RESULTS: Surgical time was longer, although not significant, with the W-CPD technique. Pancreatic and peripancreatic tumor invasion (p = 0.031) and number of lymph nodes resected (p < 0.0001) reached statistical significance in W-CPD, although there was no significant difference between the groups in terms of lymph node tumor invasion. Regarding postoperative morbimortality (medical complications, postoperative pancreatic fistula [POPF], hemorrhage, RVG, re-interventions, in-hospital mortality, Clavien-Dindo complications), ICU and hospital stay, no statistically significant differences were observed between the groups. During follow-up, no significant differences were observed between the groups for morbidity and mortality at 90 days and survival at 1, 3 and 5 years. Binary logistic regression analysis for DGE showed that binary relevant POPF grade B/C was a significant risk factor for DGE. CONCLUSIONS: Postoperative morbidity and mortality and long-term survival were not significantly different with PP-CPD and W-CPD, but POPF grade B/C was a risk factor for DGE grade C.

Post-transplant biliary complications using liver grafts from deceased donors older than 70 years: Retrospective case-control study.

BACKGROUND: The shortage of liver grafts and subsequent waitlist mortality led us to expand the donor pool using liver grafts from older donors. AIM: To determine the incidence, outcomes, and risk factors for biliary complications (BC) in liver transplantation (LT) using liver grafts from donors aged > 70 years. METHODS: Between January 1994 and December 31, 2019, 297 LTs were performed using donors older than 70 years. After excluding 47 LT for several reasons, we divided 250 LTs into two groups, namely post-LT BC (n = 21) and without BC (n = 229). This retrospective case-control study compared both groups. RESULTS: Choledocho-choledochostomy without T-tube was the most frequent technique (76.2% in the BC group vs 92.6% in the non-BC group). Twenty-one patients (8.4%) developed BC (13 anastomotic strictures, 7 biliary leakages, and 1 non-anastomotic biliary stricture). Nine patients underwent percutaneous balloon dilation and nine required a Roux-en-Y hepaticojejunostomy because of dilation failure. The incidence of post-LT complications (graft dysfunction, rejection, renal failure, and non-BC reoperations) was similar in both groups. There were no significant differences in the patient and graft survival between the groups. Moreover, only three deaths were attributed to BC. While female donors were protective factors for BC, donor cardiac arrest was a risk factor. CONCLUSION: The incidence of BC was relatively low on using liver grafts > 70 years. It could be managed in most cases by percutaneous dilation or Roux-en-Y hepaticojejunostomy, without significant differences in the patient or graft survival between the groups.

Duodenopancreatectomía cefálica en pacientes octogenarios con tumores de páncreas / Cephalic duodenopancreatectomy in octogenarium patients with pancreatic tumors

Introducción: Según estudios previos, la duodenopancreatectomía cefálica (DPC) por cáncer de páncreas (CP) se asocia a un incremento de la supervivencia mediana tanto en pacientes octogenarios como en pacientes de menor edad. Métodos: Estudio retrospectivo y comparativo de la DPC realizada en 30 pacientes≥80 años con CP y en 159 pacientes<80 años. Resultados: Los pacientes octogenarios presentaban una tasa significativamente mayor de morbilidad cardiovascular preoperatoria y un comportamiento tumoral más agresivo (mayor anemia, ictericia y CA 19-9 preoperatorios, invasión vascular y neural y menor frecuencia de resección R0 a pesar de utilizar la misma técnica quirúrgica). No hubo diferencias significativas en cuanto a complicaciones postoperatorias. La mortalidad postoperatoria fue similar en ambos grupos (3,3% en octogenarios versus 3,1% en <80 años). Las causas de mortalidad durante el seguimiento fueron fundamentalmente por recidiva tumoral, complicaciones cardiovasculares y COVID-19 (2 octogenarios). La supervivencia actuarial a 1, 3 y 5 años fue significativamente mayor en pacientes <80 años que en octogenarios (el 85,9%, el 61,1% y el 39,2% versus el 72,7%, el 28,9% y el 9,6%, respectivamente; p=0,001). En el estudio multivariable, la presencia de una fístula pancreática y la no utilización de tutor externo del Wirsung influyeron de forma estadísticamente significativa sobre la mortalidad a 90 días post-DPC. Conclusiones: La morbimortalidad post-DPC es similar en octogenarios y <80 años, aunque la supervivencia a largo plazo es menor por la agresividad tumoral y comorbilidad asociada a la edad avanzada. (AU)

Introduction: Current literature supports the claim that performing a cephalic pancreaticoduodenectomy (CPD) as treatment for pancreatic cancer (PC) is associated with an increase in median survival, both in octogenarian (≥80 years) patients as well as younger patients. Methods: This is a retrospective and comparative trial, comparing results for CPD performed on 30 patients ≥80 years with PC and 159 patients <80 years. Results: The patients in the octogenarian group showed a significantly higher rate of preoperative cardiovascular morbidity and a more aggressive tumoral behaviour, including more significant preoperative anemia, jaundice and levels of CA 19-9, higher vascular and neural invasion, and a lower rate of R0 resection despite using the same surgical technique. There were no significant differences in terms of postoperative complications. Postoperative mortality was similar in both groups (3.3% in octogenarians vs. 3.1% in patients <80 years). Mortality during follow-up was mainly due to tumour recurrence, cardiovascular complications and COVID-19 in 2elderly patients. Actuarial survival at 1, 3 and 5 years was significantly larger for patients <80 years old, as compared to octogenarians (85.9%, 61.1% and 39.2% versus 72.7%, 28.9% and 9.6%, respectively; P=0.001). The presence of a pancreatic fistula and not using external Wirsung stenting were significantly associated with 90-day postoperative mortality after a CPD. Conclusions: Morbidity and mortality post-CPD is similar in octogenarians and patients younger than 80, although long-term survival is shorter due to more aggressive tumours and comorbidities associated with older age. (AU)

“Long-term follow-up of liver transplantation in incidental intrahepatic cholangiocarcinoma and mixed hepatocellular-cholangiocarcinoma” / “Seguimiento a largo plazo del trasplante hepático en el colangiocarcinoma y hepatocolangiocarcinoma mixto incidentales”

Introduction: The standard treatment for intrahepatic cholangiocarcinoma (iCCA) and mixed hepatocellular-cholangiocarcinoma (HCC-CC) is surgical resection, nevertheless, recent studies show adequate survival rates in selected patients with iCCA or HCC-CC undergoing liver transplantation (LT). Methods: A retrospective cohort study was design including all patients undergoing LT at our center between January, 2006 and December, 2019 with incidentally diagnosed iCCA or HCC-CC after pathological examination of the explanted liver (n = 13). Results: There were no iCCA or HCC-CC recurrences during the follow-up, and hence, there were no tumor related deaths. Global and disease-free survival were the same. The 1, 3 and 5-years patient survival were 92.3%, 76.9% and 76.9%, respectively. Survival rates in the “early-stage tumor group” at 1, 3 and 5 years were 100%, 83.3% and 83.3%, respectively, with no significant differences as compared to the “advanced-stage tumors group”. No statistically significant differences in terms of 5-year survival were found when comparing tumor histology (85.7% for iCCA and 66.7% for HCC-CC). Conclusions: These results suggest that LT could be an option in patients with chronic liver disease who develop an iCCA or HCC-CC, even in highly selected advanced tumors, but we must be cautious when analyzing these results because of the small sample size of the series and its retrospective nature. (AU)

Introducción: El tratamiento de elección del colangiocarcinoma intrahepático (iCCA) y el hepato-colangiocarcinoma mixto (HCC-CC) es la resección quirúrgica, sin embargo, estudios recientes han demostrado buenos resultados en pacientes seleccionados sometidos a un trasplante hepático (TH). Métodos: Estudio retrospectivo de una cohorte formada por todos los pacientes que recibieron un TH en nuestro centro entre Enero 2006 y Diciembre 2019 con hallazgo incidental de un iCCA o un HCC-CC durante el estudio histopatológico después del trasplante (n = 13). Resultados: Después de una mediana de seguimiento de 65 meses no hubo ninguna recurrencia tumoral, por lo que la supervivencia global y libre de enfermedad fueron iguales. La supervivencia a 1, 3 y 5 años de la muestra fue del 92.3%, 76.9% y 76.9%, respectivamente. La supervivencia de los pacientes con un ‘early stage’ a 1, 3 y 5 años fue del 100%, 83.3% y 83.3%, respectivamente; sin encontrar diferencias estadísticamente significativas al compararla con la de los pacientes con un ‘advanced stage’. Aunque la supervivencia de los pacientes con iCCA fue mayor que la de los pacientes con HCC-CC (85.7% vs. 66.7% a 5 años, respectivamente), las diferencias no fueron estadísticamente significativas. Conclusiones: El TH podría ser una opción de tratamiento en pacientes con enfermedad hepática terminal que desarrollan un iCCA o un HCC-CC, incluso en estadios avanzados seleccionados, pero estos resultados deben ser analizado con precaución dada la naturaleza retrospectiva del estudio y el escaso tamaño muestral. (AU)

Gastric pneumatosis, an uncommon complication of a lung transplant, prognosis, diagnostic and treatment management.

We present a case of a 40-year-old woman with double-lung transplant with extracorporeal circulation (EC) due to pulmonary hypertension (pulmonary veno-occlusive disease form (PVOD)) secondary to mixed connective tissue disease (MCTD). On day 6 postoperatively, abdominal pain and distension was noticed, since abdominal CT scan was performed, showing emphysematous gastritis with gastric wall ischemia and peritonitis. Therefore, emergent surgery was proposed. By open surgery approach, a total gastrectomy with Roux-en-Y and esophagojejunal anastomosis was performed. On day 6 after gastrectomy, intraluminal bleeding of the esophagojejunal anastomosis was detected in control CT, which was not need any aggressive treatment. Postoperative evolution was favourable, being discharged from the intensive care unit on the day 34 and from the hospital two months later.

Cephalic pancreatoduodenectomy in octogenarian patients with pancreatic tumors.

INTRODUCTION: Current literature supports the claim that performing a cephalic pancreaticoduodenectomy (CPD) as treatment for pancreatic cancer (PC) is associated with an increase in median survival, both in octogenarian (≥80 years) patients as well as younger patients. METHODS: This is a retrospective and comparative trial, comparing results for CPD performed on 30 patients ≥80 years with PC and 159 patients <80 years. RESULTS: The patients in the octogenarian group showed a significantly higher rate of preoperative cardiovascular morbidity and a more aggressive tumoral behaviour, including more significant preoperative anemia, jaundice and levels of CA 19-9, higher vascular and neural invasion, and a lower rate of R0 resection despite using the same surgical technique. There were no significant differences in terms of postoperative complications. Postoperative mortality was similar in both groups (3.3% in octogenarians vs 3.1% in patients <80 years). Mortality during follow-up was mainly due to tumour recurrence, cardiovascular complications and COVID-19 in 2 elderly patients. Actuarial survival at 1, 3 and 5 years was significantly larger for patients <80 years old, as compared to octogenarians (85.9%, 61.1% and 39.2% versus 72.7%, 28.9% and 9.6%, respectively; P = 0.001). The presence of a pancreatic fistula and not using external Wirsung stenting were significantly associated with 90-day postoperative mortality after a CPD. CONCLUSIONS: Morbidity and mortality post-CPD is similar in octogenarians and patients younger than 80, although long-term survival is shorter due to more aggressive tumours and comorbidities associated with older age.

"Long-term follow-up of liver transplantation in incidental intrahepatic cholangiocarcinoma and mixed hepatocellular-cholangiocarcinoma".

INTRODUCTION: The standard treatment for intrahepatic cholangiocarcinoma (iCCA) and mixed hepatocellular-cholangiocarcinoma (HCC-CC) is surgical resection, nevertheless, recent studies show adequate survival rates in selected patients with iCCA or HCC-CC undergoing liver transplantation (LT). METHODS: A retrospective cohort study was design including all patients undergoing LT at our center between January, 2006 and December, 2019 with incidentally diagnosed iCCA or HCC-CC after pathological examination of the explanted liver (n = 13). RESULTS: There were no iCCA or HCC-CC recurrences during the follow-up, and hence, there were no tumor related deaths. Global and disease-free survival were the same. The 1, 3 and 5-years patient survival were 92.3%, 76.9% and 76.9%, respectively. Survival rates in the "early-stage tumor group" at 1, 3 and 5 years were 100%, 83.3% and 83.3%, respectively, with no significant differences as compared to the "advanced-stage tumors group". No statistically significant differences in terms of 5-year survival were found when comparing tumor histology (85.7% for iCCA and 66.7% for HCC-CC). CONCLUSIONS: These results suggest that LT could be an option in patients with chronic liver disease who develop an iCCA or HCC-CC, even in highly selected advanced tumors, but we must be cautious when analyzing these results because of the small sample size of the series and its retrospective nature.

Bile duct schwannoma, an uncommon cause of a bile duct tumor, diagnosis and therapeutic management.

Biliary Schwannoma is an uncommon tumor in the digestive system and extremely rare in the bile duct. We report 48 year-old male with an incidentally found in the CT, a tumor in the hepatic hilum (3.2 cm), abutting the first portion of the duodenum, without common bile duct obstruction or lymphadenopathy. The patient was asymptomatic and had normal tumor markers. The endoscopic ultrasound (EUS) demonstrated contact between the tumor, common bile duct and right hepatic artery and the biopsy suggested of mesenchymal tumor. Tumor board recommended excision of the tumor, due to the risk of malignancy and biliary obstruction. The tumor was resected through laparoscopic approach, with a Roux-en-Y hepatico-jejunostomy. The histological report showed a biliary Schwannoma (positivity for S100 and focal GFAP), which infiltrated the external wall of the bile duct, without affecting the cystic duct, surgical margins were free of neoplasia.

Expanding donor age in liver transplantation using liver grafts from nonagenarian donors.

INTRODUCTION: Satisfactory outcomes in a series of liver transplantations (LT) with octogenarian liver grafts have been reported, as well as several cases of LT using nonagenarian liver grafts with short follow-up. METHODS: From October 2013 to December 2019, we performed 426 LT. Six LTs used nonagenarian livers (case group) and 49 used octogenarian livers (control group). A comparative analysis was performed between groups. Median donor age was significantly higher in the nonagenarian group than in the octogenarian group (90.6 years versus 83.4 years; (P < .001). There was a significant difference in LT indications (P = .026) between the groups, but not in perioperative recipient variables, morbidity, or mortality. The 1-, 3-, and 5-year patient survival rates were 67.7% in the recipients of nonagenarian livers and 85.7%, 78.0%, and 74.4%, respectively, in the recipients of octogenarian livers (P = .631). The 1-, 3-, and 5-year graft survival rates were 66.7% in the recipients of nonagenarian livers and 81.3%, 73.8%, and 70.3%, respectively, in the recipients of octogenarian livers (P = .745). CONCLUSIONS: The results of LT with nonagenarian liver grafts are not significantly different from those obtained with octogenarian donors, taking into consideration the small sample size and careful selection of donors and adequate donor-recipient matching.