Have we improved postoperative and long-term outcomes of liver surgery for colorectal cancer metastasis? Analysis of 1736 hepatectomies performed over 3 decades in a single center.

INTRODUCTION: Surgery is the only potentially curative treatment for colorectal cancer liver metastases (CRLM) and its indication and results have varied in the last 30 years. METHODS: All patients operated on for CRLM in our centre from 1990 to 2021 were prospectively collected, establishing 3 subgroups based on the year of the first surgery: group A 1990-1999, group B 2000-2010, group C 2011-2021. Clinical characteristics and the results of survival, recurrence and prognostic factors were compared. RESULTS: 1736 hepatectomies were included (Group A n = 208; Group B n = 770; Group C n = 758). Patients in group C had better survival at 5 and 10 years (A 40.5%/28.2%; B 45.9%/32.2%; C 51.6%/33.1%, p = 0.013), although there were no differences between groups in overall recurrence at 5 and 10 years (A 73%/75.7%; B 67.6%/69.2%, and C 63.9%/66%, p = 0.524), nor in liver recurrence (A 46.4%/48.2%; B 45.8%/48.2%; and C 44.4%/48.4%, p = 0.899). An improvement was observed in median survival after recurrence, being 19 months, 23 months, and 31 months (groups A, B and C respectively). Prognostic factors of long-term survival changed over the 3 study periods. The only ones that remained relevant in the last decade were the presence of >4 liver metastasis, extrahepatic disease at the time of hepatectomy, and intraoperative blood transfusion. CONCLUSIONS: Survival after surgery for CRLM has improved significantly, although this cannot be explained by a reduction in overall and hepatic recurrence, but rather by an improvement in post-recurrence survival. Involvement of the resection margin has lost prognostic value in the last decade.

Paraneoplastic acquired hemophilia A associated with hilar cholangiocarcinoma arising in an intraductal papillary neoplasm of the bile duct / Paraneoplásico adquirido hemofilia A asociada con colangiocarcinoma hiliar que surge en un papilar intraductal neoplasia del conducto biliar

A 74-year-old female was admitted for painless jaundice. Laboratory tests showed hyperbilirubinemia, cholestasis, normal coagulation, and Ca19-9:163U/L. The CT-scan reported dilation of the intrahepatic and extrahepatic bile ducts secondary to a 24mm tumor in the intrapancreatic common bile duct. The magnetic cholangioresonance showed multiple endoluminal polypoid lesions, suggestive of intraductal papillary neoplasm of the bile duct (IPNB). The endoscopic bile duct brushing was non-conclusive.(AU)

Paraneoplastic acquired hemophilia A associated with hilar cholangiocarcinoma arising in an intraductal papillary neoplasm of the bile duct.

A 74-year-old female was admitted for painless jaundice. Laboratory tests showed hyperbilirubinemia, cholestasis, normal coagulation, and Ca19-9:163U/L. The CT-scan reported dilation of the intrahepatic and extrahepatic bile ducts secondary to a 24mm tumor in the intrapancreatic common bile duct. The magnetic cholangioresonance showed multiple endoluminal polypoid lesions, suggestive of intraductal papillary neoplasm of the bile duct (IPNB). The endoscopic bile duct brushing was non-conclusive.

Defining Surgical Difficulty of Liver Transplantation.

OBJECTIVE: To define technically Diff-LT. SUMMARY OF BACKGROUND DATA: Currently, there is no acknowledged definition of Diff-LT. METHODS: This retrospective study included all first consecutive liver-only transplantations performed in 2 centers from 2011 to 2015. Diff-LT was defined as the combination of the number of blood units transfused, cold ischemia time, and duration of operation, all at or above the median value of the entire population. The correlation of Diff-LT with short- (including the comprehensive complication index) and long-term outcomes was assessed. Outcomes were also compared to the 90-day benchmark cutoffs of LT. Predictors of Diff-LT were identified by multivariable analysis, first using only recipient data and then using all recipient, donor, graft, and surgical data. RESULTS: The study population included 467 patients. The incidence of Diff- LT was 18.8%. Diff-LT was associated with short-term outcomes, including the comprehensive complication index and mortality, but not with patient or graft long-term survival. Previous abdominal surgery, intensive care unitbound at the time of LT, split graft use, nonstandard arterial reconstruction, and porto-systemic shunt ligation were independent predictors of Diff-LT. The proportion of variables below the corresponding LT 90-day benchmark cutoffs was 8/13 (61.5%) for non-Diff-LT, and 4/13 (30.8%) for Diff-LT. CONCLUSIONS: Diff-LT, as defined, occurred frequently. Adjusting modifiable variables might decrease the risk of Diff-LT and improve the postoperative course. This definition of Diff-LT might be useful for patient information, comparison between centers and surgeons, and as a metric in future trials.

Abdominal normothermic regional perfusion in controlled donation after circulatory determination of death liver transplantation: Outcomes and risk factors for graft loss.

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p < .001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042-0.299, p < .001), graft loss (HR 0.371, 95% CI 0.267-0.516, p < .001), and patient death (HR 0.540, 95% CI 0.373-0.781, p = .001). Cold ischemia time (HR 1.004, 95% CI 1.001-1.007, p = .021) and re-transplantation indication (HR 9.552, 95% CI 3.519-25.930, p < .001) were significant independent predictors for graft loss among cDCD livers with A-NRP. While use of A-NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.

Novel Composite Endpoint for Assessing Outcomes in Liver Transplantation: Arterial and Biliary Complication-Free Survival.

Transplant and patient survival are the validated endpoints to assess the success of liver transplantation (LT). This study evaluates arterial and biliary complication-free survival (ABCFS) as a new metric. ABC, considered as an event, was an arterial or biliary complication of Dindo-Clavien grade ≥III complication dated at the interventional, endoscopic, or surgical treatment required to correct it. ABCFS was defined as the time from the date of LT to the dates of first ABC, death, relisting, or last follow-up (transplant survival is time from LT to repeat LT or death). Following primary whole LT (n = 532), 106 ABCs occurred and 99 (93%) occurred during the first year after LT. An ABC occurring during the first year after LT (overall rate 19%) was an independent factor associated with transplant survival (hazard ratio [HR], 3.17; P < 0.001) and patient survival (HR, 2.7; P = 0.002) in univariate and multivariate analyses. This result was confirmed after extension of the cohort to split-liver graft, donation after circulatory death, or re-LT (n = 658). Data from 2 external cohorts of primary whole LTs (n = 249 and 229, respectively) confirmed that the first-year ABC was an independent prognostic factor for transplant survival but not for patient survival. ABCFS was correlated with transplant and patient survival (ρ = 0.85 [95% CI, 0.78-0.90] and 0.81 [95% CI, 0.71-0.88], respectively). Preoperative factors known to influence 5-year transplant survival influenced ABCFS after 1 year of follow-up. The 1-year ABCFS was indicative of 5-year transplant survival. ABCFS is a reproducible metric to evaluate the results of LT after 1 year of follow-up and could serve as a new endpoint in clinical trials.

Textbook Outcome Following Liver Transplantation.

BACKGROUND: Textbook outcome (TBO) is a patient-oriented composite criterion achieved when all desired main health outcomes are realized. The aim was to assess the incidence and the independent factors associated with TBO following LT. METHODS: This bicentric study included all patients who underwent their first elective liver-only LT between 2011 and 2015. TBO occurred when all the following criteria were fulfilled: no mortality within 90 days, no major complications within 90 days, no reintervention within 90 days (liver graft biopsy, radiological, endoscopic or surgical interventions, or retransplantation), no prolonged intensive care unit stay, and no prolonged hospital stay. Univariable and multivariable analyses were performed to identify factors associated with TBO and to assess whether TBO is an independent factor associated with patient and graft survival. RESULTS: The study population included 530 patients. TBO occurred in 176/530 (33%) patients. Independent factors associated with TBO included the balance of risk score, the use of an intraoperative temporary portacaval shunt, and duration of the operation. TBO was identified as an independent factor associated with graft survival but not patient survival. CONCLUSIONS: TBO might be implemented in the patient-doctor decision-making regarding whether to proceed with LT and in the reporting of patient-level hospital performance related to LT.

Sinusoidal obstruction syndrome as a manifestation of acute antibody-mediated rejection after liver transplantation.

Antibody-mediated rejection (AMR) after liver transplantation is uncommon but, when present, manifests as graft dysfunction. We report the case of a 54-year-old woman who developed portal hypertension with pleural effusion and ascites secondary to sinusoidal obstruction syndrome (SOS) due to acute AMR following an ABO-matched liver transplantation for autoimmune cirrhosis and hepatocellular carcinoma. Initial immunosuppression comprised basiliximab, decreasing prednisone, tacrolimus, and mycophenolate mofetil. After 1 month, she presented with the massive pleural effusion, slight ascites, and normal liver tests. After excluding common causes of pleural effusion, we performed a liver biopsy that showed atypical rejection with the involvement of large centrilobular veins partially occluded by marked endotheliitis and lax fibrosis suggestive of SOS. Direct immunofluorescence study of C4d showed diffuse endothelial sinusoidal staining, and de novo donor-specific anti-human leukocyte antigen antibodies were detected in his blood. Thus, we diagnosed AMR focused on centrilobular veins and initiated treatment with defibrotide, steroid pulses, and diuretics. However, this was ineffective, and the pleural effusion only resolved when plasmapheresis and intravenous immunoglobulin were started. This case shows that AMR can cause SOS with portal hypertension and present with a pleural effusion, and as such, it should be suspected after excluding other more common causes of effusion.

¿Está justificado el retrasplante hepático en la era actual? / Is Liver Retransplantation Justified in the Current Era?

Introducción: El retrasplante hepático (ReTH) es una indicación de TH controvertida. Nuestro objetivo fue determinar la tasa de ReTH y las indicaciones, morbilidad, mortalidad posoperatoria y supervivencia actuarial del paciente retrasplantado en nuestra serie. Métodos: Estudio retrospectivo de una serie prospectiva de 1.645 pacientes trasplantados entre 1984 y 2018. Se analizan los resultados según el tipo de ReTH (precoz vs. tardío), periodo de estudio e indicaciones. Resultados: Hemos realizado 150 ReTH en 140 pacientes. La tasa de ReTH fue de 9%. El 30% (45) de los ReTH fueron precoces, siendo tardíos el otro 70% (105). Las causas más frecuentes fueron: colangitis isquémica (27%), trombosis de la arteria hepática (19%), fallo primario del injerto (15%) y recidiva de la cirrosis por virus de la hepatitis C (VHC) (15%). La duración de la cirugía (395 vs. 270 min; p = 0,001), tiempo de isquemia (435 vs. 390 min; p = 0,005) y necesidad transfusional (8 vs. 5 CH; p = 0,034) fue mayor en los casos de ReTH tardío, mientras que la mortalidad posoperatoria (10 vs. 20%; p = 0,01) fue mejor en los casos de ReTH tardío. La supervivencia actuarial a uno y cinco años fue de 71% y 58%, respectivamente, con una mejoría significativa en la última década (80% y 64%). Por otra parte, la supervivencia en los casos de ReTH por colangitis isquémica es superior que otras indicaciones (78 vs. 51%; p = 0,02). Conclusiones: El retrasplante es complejo y está asociado a una elevada morbimortalidad. Sin embargo, los resultados han mejorado en los últimos años por lo que su indicación está justificada. (AU)

Introduction: Liver retransplantation (LRT) is a controversial indication. Our aim was to evaluate the rate of LRT at our institution, and to analyze its indications and short- and long-term results. Methods: We conducted a retrospective study of a prospectively collected database, including 1645 LT from 1984 to 2018. Results have been analyzed depending on type of LRT (early vs late), study period and indications. Results: We performed 150 LRT in 140 patients. The LRT rate was 9%. Of these, 45 LRT were early (30%), and the other 70% were late LRT. The main indications were: ischemic cholangitis (27%), arterial thrombosis (19%), primary non-function (15%), and HCV recurrence (15%). Mean surgery duration (395 vs. 270 min; P = .001), cold ischemia time (435 vs. 390 min; P = .005) and transfused units required (8 vs. 5 RBC; P = .034) were higher in cases of late LRT. Postoperative mortality (10 vs. 20%; P = .01) was better in cases of late LRT. One- and 5-year actuarial survival rates were 71% and 58%, respectively, which were significantly better during the last decade (80% and 64%). Five-year actuarial survival for ischemic cholangitis is better than other indications, such as recurrence of HCV (78 vs. 51%; P = .02). Conclusions: Liver retransplantation is complex and associated with high morbidity and mortality. However, indications and long-term results have improved during recent years. Therefore, LRT is justified. (AU)

Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement.

BACKGROUND: There are no clearly defined indications for pancreas-preserving duodenectomy. The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreas-preserving duodenectomy. METHODS: Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included. We divided the series according to indication: scenario 1, primary duodenal tumors; scenario 2, tumors of another origin with duodenal involvement; and scenario 3, emergency duodenectomy. RESULTS: We included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35). CONCLUSIONS: Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

Is Liver Retransplantation Justified in the Current Era? / ¿Está justificado el retrasplante hepático en la era actual?

INTRODUCTION: Liver retransplantation (LRT) is a controversial indication. Our aim was to evaluate the rate of LRT at our institution, and to analyze its indications and short- and long-term results. METHODS: We conducted a retrospective study of a prospectively collected database, including 1645 LT from 1984 to 2018. Results have been analyzed depending on type of LRT (early vs late), study period and indications. RESULTS: We performed 150 LRT in 140 patients. The LRT rate was 9%. Of these, 45 LRT were early (30%), and the other 70% were late LRT. The main indications were: ischemic cholangitis (27%), arterial thrombosis (19%), primary non-function (15%), and HCV recurrence (15%). Mean surgery duration (395 vs. 270 min; P = .001), cold ischemia time (435 vs. 390 min; P = .005) and transfused units required (8 vs. 5 RBC; P = .034) were higher in cases of late LRT. Postoperative mortality (10 vs. 20%; P = .01) was better in cases of late LRT. One- and 5-year actuarial survival rates were 71% and 58%, respectively, which were significantly better during the last decade (80% and 64%). Five-year actuarial survival for ischemic cholangitis is better than other indications, such as recurrence of HCV (78 vs. 51%; P = .02). CONCLUSIONS: Liver retransplantation is complex and associated with high morbidity and mortality. However, indications and long-term results have improved during recent years. Therefore, LRT is justified.

Adenocarcinoma duodenal: resultados del tratamiento quirúrgico de una serie unicéntrica de 27 pacientes / Duodenal adenocarcinoma: Surgical results of 27 patients treated at a single center

Introducción: El adenocarcinoma de duodeno es una neoplasia poco frecuente, sobre la que existen pocas experiencias publicadas de los resultados tras su resección. El objetivo es analizar los resultados obtenidos en nuestro centro tras la resección curativa del adenocarcinoma duodenal (AD). Métodos: Estudio retrospectivo de los pacientes intervenidos con resección curativa por AD entre 1990 y 2017 en nuestro hospital. Resultados: Se intervino a 27 pacientes. En 23 casos (85%) se realizó duodenopancreatectomía cefálica (DPC) y en 4 casos (15%) con localización en la 3.ª-4.ª porción duodenal se realizó duodenectomía (DD) segmentaria. La morbilidad postoperatoria global fue del 67% (18 pacientes). La mortalidad postoperatoria global fue 7% (2 pacientes), sin embargo, la mortalidad postoperatoria relacionada con la cirugía fue de 4% (un paciente). El estudio anatomopatológico evidenció resección con márgenes libres en todos los casos intervenidos. La mediana de adenopatías resecadas fue 18 (0 a 38), siendo 1 (0 a 8) las adenopatías afectadas. Tras una mediana de seguimiento de 23 (9-69,7) meses, la supervivencia actuarial fue de 62,2 (25,2 a 99,1) meses y la supervivencia actuarial libre de enfermedad fue de 49 (0 a 133) meses. Conclusiones: La resección quirúrgica del AD comporta una elevada morbilidad postoperatoria, sin embargo, consigue una supervivencia prolongada. Dependiendo de la localización y en ausencia de infiltración pancreática, la DD segmentaria con márgenes libres es una alternativa a la DPC

Introduction: Duodenal adenocarcinoma is a rare malignancy. Given the rarity of the disease, there is limited data related to resection results. The objective is to analyze results at our hospital after the curative resection of duodenal adenocarcinoma (DA). Methods: The variables were retrospectively collected from patients operated on between 1990 and 2017 at our hospital. Results: A total of 27 patients were treated. Twenty-three patients (85%) underwent pancreaticoduodenectomy, and 4 patients (15%) with tumors located in the third and fourth portions of the duodenum underwent segmental duodenal resection. The overall postoperative morbidity was 67% (18 patients). Postoperative mortality was 7% (2 patients); however, postoperative mortality related to surgery was 4% (1 patient). All patients had negative resection margins. A median of 18 lymph nodes (range, 0-38) were retrieved and evaluated, with a median of 1 involved node (range, 0-8). Median follow up was 23 (9-69.7) months. Actuarial overall survival was 62.2 (25.2-99.1) months. Actuarial disease-free survival was 49 (0-133) months. Conclusions: The surgical treatment of duodenal adenocarcinoma is associated with a high morbidity, although it achieves considerable survival. Depending on the tumor location and if there is no pancreatic infiltration, segmental duodenal resection with negative margins is an alternative to cephalic pancreaticoduodenectomy

Duodenal adenocarcinoma: Surgical results of 27 patients treated at a single center. / Adenocarcinoma duodenal: resultados del tratamiento quirúrgico de una serie unicéntrica de 27 pacientes.

INTRODUCTION: Duodenal adenocarcinoma is a rare malignancy. Given the rarity of the disease, there is limited data related to resection results. The objective is to analyze results at our hospital after the curative resection of duodenal adenocarcinoma (DA). METHODS: The variables were retrospectively collected from patients operated on between 1990 and 2017 at our hospital. RESULTS: A total of 27 patients were treated. Twenty-three patients (85%) underwent pancreaticoduodenectomy, and 4 patients (15%) with tumors located in the third and fourth portions of the duodenum underwent segmental duodenal resection. The overall postoperative morbidity was 67% (18 patients). Postoperative mortality was 7% (2 patients); however, postoperative mortality related to surgery was 4% (1 patient). All patients had negative resection margins. A median of 18 lymph nodes (range, 0-38) were retrieved and evaluated, with a median of 1 involved node (range, 0-8). Median follow up was 23 (9-69.7) months. Actuarial overall survival was 62.2 (25.2-99.1) months. Actuarial disease-free survival was 49 (0-133) months. CONCLUSIONS: The surgical treatment of duodenal adenocarcinoma is associated with a high morbidity, although it achieves considerable survival. Depending on the tumor location and if there is no pancreatic infiltration, segmental duodenal resection with negative margins is an alternative to cephalic pancreaticoduodenectomy.