Valoración de la linfadenectomía en una serie consecutiva de pacientes tratados por cáncer biliar / Evaluation of lymphadenectomy in a consecutive series of patients treated for biliary cancer

Resumen Introducción: Si bien actualmente la 8a edición de la clasificación del AJCC para cáncer biliar, recomienda una linfadenectomía con 6 o más GL, su aplicación es escasa. Objetivo: Analizar la aplicabilidad y los resultados de la linfadenectomía en pacientes resecados con fines curativos por cáncer biliar. Materiales y Método: Análisis retrospectivo de pacientes operados por cáncer biliar de 2001 a 2018. Se analizaron variables perioperatorias referidas a la linfadenectomía (número de GL, GL+, morbilidad), comparando supervivencia en pacientes con < 6 y ≥ 6 GL resecados. Resultados: en 72 pacientes resecados por cáncer biliar (46 CaV, 26 CC), se realizaron 66 (91.7%) linfadenectomías N1. En 62.1% (n = 41) se obtuvieron < 6 GL y en el 37.9% (n = 25) ≥ 6 GL. El promedio de GL resecados fue de 5. En 16 (24,2%) linfadenectomías se hallaron GL+ sin diferencias entre ambos grupos. La morbimortalidad global fue de 30,3%, con una mortalidad del 4.5% sin diferencias. Con un seguimiento de 36.9 meses, la supervivencia a 5 años fue 43,7% (n = 17), 7 pacientes con ≥ 6 GL, y 10 pacientes con < 6 GL (p = NS). La supervivencia media en pacientes con GL+ fue 15 meses (6-34 meses). Conclusión: la linfadenectomía ocupa un rol primordial en la cirugía curativa del cáncer biliar, tanto para definir una estadificación y un pronóstico adecuados como para optimizar los resultados de la resección curativa en esta entidad. Su indicación debe ser sistemática con la obtención de un número adecuado de GL acorde a las recomendaciones actuales.

Introduction: Currently the 8th edition of the AJCC classification recommends the resection of 6 or more lymph nodes (LN) in gallbladder cancer and cholangiocarcinoma. However, its implementation is universally scarce. Aim: The goal is to analyze the applicability and results of lymphadenectomy in patients resected with curative purposes in biliary cancer. Materials and Method: a retrospective analysis of patients with biliary cancer (gallbladder carcinoma, intrahepatic and hilar cholangiocarcinoma) treated by curative resection from 2001 to 2018 was performed. Perioperative variables related to lymphadenectomy (LN number, LN positive, related morbidity) were analyzed, comparing survival in patients with < 6 and ≥ 6 resected LN. Results: 72 patients resected for biliary cancer (46 gallbladder cancer, 26 cholangiocarcinoma) were included with 66 (91.7%) N1 lymphadenectomies corresponding to the hepatoduodenal ligament nodes performed. In 62.1% (n = 41) < 6 LN and in 37.9% (n = 25) ≥ 6 LN were resected. Average LN count was 5. In 16 (24.2%) patients positive LN were found, 7 in the group with ≥ 6 LN (28%) vs. 9 in the group with < 6 LN (22%) (p = NS). Overall morbimortality was 30.3% (n = 20). Average follow-up was 36.9 months. Survival at 5 years was 43.7% (n = 17), 7 patients with lymphadenectomy ≥ 6 LN, and 10 patients with < 6 LN (p = NS). Survival mean in patients who had positive LN was 15 months. Conclusión: Lymphadenectomy has a primary role in the radical resection with curative intention for biliary cancer. Systematic indication of lymphadenectomy should be prioritized, with the achievement of an adequately number of LN according to the actual recommendations. Lymphadenectomy is crucial for an adequate staging and prognosis, as well as to optimize the results of curative resection in this entity.

Colecistectomía extendida mínimamente invasiva en pacientes con cáncer de vesícula biliar / Minimal invasive extended cholecystectomy in gallbladder cancer patients

Resumen Objetivo: Describir resultados en términos de morbilidad y mortalidad de la colecistectomía extendida laparoscópica (CELap) en pacientes con cáncer de vesícula biliar (CVB) incidental. Materiales y Método Serie de casos de pacientes con CVB incidental sometidos a CELap en el Hospital Regional de Temuco entre diciembre de 2017 y marzo de 2019. Resultados: Incluimos 10 pacientes, con edad promedio de 59,2 ± 11 años, 90% de género femenino. Respecto a la invasión de pared de la vesícula biliar (TNM), 1 presentó invasión hasta mucosa (T1a) con invasión de senos de Rokitansky Aschoff y 9 hasta subserosa (T2). Dos tuvieron ganglio cístico positivo en biopsia inicial. Respecto a la CELap, el tiempo operatorio promedio fue 333 ± 40 minutos. El promedio de ganglios resecados fue 4 ± 2,78, presentando lecho hepático positivo en 1 paciente. La clasificación TNM obtenida: un paciente T1aN0M0, siete T2N0M0 y dos T2N1M0. La estancia hospitalaria promedio fue 5 ± 2,3 días. Siete pacientes recibieron, posteriormente, quimioterapia con gemcitabina + cisplatino. Hubo morbilidad en 2 pacientes, tipo I de Dindo-Clavien. No reportamos mortalidad. El seguimiento promedio fue 7,1 ±5,1 meses, no reportamos recurrencia. Discusión: Esta serie presenta menor número de ganglios resecados que otros estudios (posiblemente por ser nuestra serie inicial) y mayor morbilidad, pero sólo tipo I de Dindo-Clavien. Presentamos una estancia hospitalaria similar a series internacionales y menor presencia de metástasis según reportan análisis retrospectivos. Conclusión: La CELap es una opción terapéutica aceptable y presenta cifras de morbilidad y mortalidad comparables con series nacionales e internacionales.

Aim: Describe results in terms of morbidity and mortality of minimally invasive treatment in patients with gallbladder cancer until subserosal layer. Materials and Method: Case series of patients with gallbladder cancer undergoing CELap at Hospital Regional of Temuco between December 2017 and March 2019. Results: Ten patients were included, the average age was 59,2 ±11 years. Ninety percent female. According to the invasion in gallbladder layers (TNM Classification), 1 patient was T1a (mucosa) with invasion of Rokytansky-Aschoff sinus and 9 patients T2 (subserosa). Two patients had a positive cystic node. The average operating time of CELap was 333 ± 40 minutes. The average number of resected nodes was 4 ± 2,78 and a positive liver bed was found in 1 patient. The TNM classification was 1 patient T1aN0M0, 7 patients T2N0M0 and 2 patients T2N1M0. Mean hospitalization was 5 ± 2,3 days. Seven patients subsequently received chemotherapy with gemcitabine + cisplatin. There was 2 patients with morbidity, type I of Dindo-Clavien scale. No mortality is reported. The average follow-up was 7,1 ±5,11 months and no recurrence was reported. Discussion: This series has a lower number of resected nodes than other studies (possibly because it is our initial series) and higer morbidity, but only Dindo-Clavien type I. Furthermore, we present a hospital stay similar to international series and a lower presence of metastases as reported in retrospective analysis. Conclusion: CELap is an acceptable therapeutic option and presents morbidity and mortality comparable with the national and international series.

Técnica de linfadenectomía y resección del lecho vesicular laparoscópica por cáncer vesícula biliar incidental / Lymphadenectomy technique and laparoscopic vesicular bed resection for incidental gallbladder cancer

Resumen El cáncer de vesícula es infrecuente a nivel mundial, a diferencia de su alta incidencia en Chile. Su pronóstico es malo en general, y dependerá de su forma de presentación, siendo mejor en los casos diagnosticados después de una colecistectomía laparoscópica por patología benigna. La reintervención, que incluye la resección hepática y linfadenectomía, es el pilar de la terapia curativa en esta neoplasia. Presentamos la descripción de la técnica quirúrgica realizada en los pacientes con cáncer de vesícula de diagnóstico incidental, en el Servicio de Cirugía de Clínica Alemana de Santiago y en el Hospital de la Fuerza Aérea de Chile. El abordaje laparoscópico representa una alternativa quirúrgica válida en el tratamiento de pacientes con cáncer de vesícula biliar diagnosticados después de la colecistectomía. La estandarización de la técnica debiera contribuir a su mayor empleo y a la obtención de buenos resultados desde un punto de vista oncológico.

Gallbladder cancer is considered an infrequent disease but in Chile has a higher incidence. Prognostic is considered dismal except in those patients in whom the diagnosis is performed after the cholecystectomy specimen study. Reoperation with gallbladder bed resection and lymphadenectomy is considered the treatment in patients with incidental cases. We show the way this operation is performed in Clinica Alemana of Santiago and in the Air Force Hospital. The laparoscopic approach is an alternative to those patients in whom the diagnosis was done after the cholecystectomy. Laparoscopy allows to accomplish same objectives and to obtain identical results that the open approach. The technical standardization should contribute to spread its employment and to improve the results.

Vesícula en porcelana: un interesante hallazgo incidental. Presentación de un caso y revisión de la literatura / Porcelain gallbladder an interesting incidental finding. Case report and literature review / Vesícula em porcelana: um achado incidental interessante. Apresentação de caso e revisão de literatura

RESUMEN Se realizó la comunicación de un caso recientemente diagnosticado en el Hospital Docente Clínico Quirúrgico "Joaquín Albarrán" de La Habana. El caso que se presenta correspondió con un paciente masculino de 73 años de edad que en el estudio autópsico se reveló la presencia de vesícula en porcelana, la cual, según la literatura, su identificación es un diagnóstico incidental durante el estudio del paciente por otro padecimiento, en su mayoría neoplásico o en la autopsia. Su relación con el cáncer de vesícula presenta controversias. La vesícula en porcelana es una entidad caracterizada por la calcificación intramural de la vesícula, tiene una incidencia reportada de 0,06 a 0,8 % de las colecistectomías realizadas. Se realizó revisión de la literatura en bases de datos, MEDLINE, PubMed, ELSEVIER y SciELO, con un total de 26 publicaciones encontradas entre 1999 y 2018.

ABSTRACT The communication of a newly diagnosed case was carried out at the "Joaquín Albarrán" Surgical Clinical Teaching Hospital in Havana. The case presented corresponded with a 73-year-old male patient who in the autopsy study revealed the presence of a porcelain gallbladder, which, according to the literature, its identification is an incidental diagnosis during the study of the patient for another condition, mostly neoplastic or at autopsy. His relationship with gallbladder cancer is controversial. The porcelain gallbladder is an entity characterized by intramural gallbladder calcification, has a reported incidence of 0.06 to 0.8% of the cholecystectomies performed. We reviewed the literature in databases, MEDLINE, PubMed, ELSEVIER and SciELO, with a total of 26 publications found between 1999 and 2018.

RESUMO A comunicação de um caso recentemente diagnosticado foi realizada no Hospital de Ensino Clínico Cirúrgico "Joaquín Albarrán", em Havana. O caso apresentado correspondeu a um paciente do sexo masculino, 73 anos, que no estudo de autópsia revelou a presença de uma vesícula na porcelana, a qual, segundo a literatura, sua identificação é um diagnóstico incidental durante o estudo do paciente para outra condição, principalmente neoplásico ou na autópsia. Sua relação com o câncer de vesícula biliar é controversa. A vesícula biliar de porcelana é uma entidade caracterizada pela calcificação intramural da vesícula biliar, com incidência relatada de 0,06 a 0,8% das colecistectomias realizadas. Revisamos a literatura nas bases de dados MEDLINE, PubMed, ELSEVIER e SciELO, com um total de 26 publicações encontradas entre 1999 e 2018.

Cisto de colédoco associado à adenocarcinoma de vesícula biliar / Colognic cisto associated with biliary vesicle adenocarcinoma

Os cistos de colédoco são dilatações congênitas dos ductos biliares, que podem ser extra-hepáticos e/ou intra-hepáticos. Mais prevalentes no sexo feminino e na maioria dos casos diagnosticados até a primeira década de vida. É uma entidade pouco frequente que, quando diagnosticada na população adulta, cursa com uma grande frequência de complicações, devendo-se estar atento em especial ao seu alto risco de malignização. Os autores descrevem o caso de uma paciente de 35 anos, do sexo feminino, que iniciou um quadro de dor abdominal inespecífica, sendo identificado um cisto de colédoco associado ao adenocarcinoma de vesícula biliar.

Choledochal cysts are congenital dilatation of the bile ducts, which can be extrahepatic or intrahepatic. They are more prevalent in women, and in most cases diagnosed until the first decade of life. They are a less common entity that, when diagnosed in the adult population, attends with a high frequency of complications, what makes important to be specially attentive to its high risk of malignant transformation. The authors describe the case of a 35 year-old female patient, who started an unspecific abdominal pain, being identified a choledochal cyst associated to a gallbladder adenocarcinoma.

Gallbladder cancer and nutritional risk factors in Chile / Cáncer de vesícula biliar en Chile y factores nutricionales de riesgo.

Gallbladder cancer is the most malign neoplasm of the biliary tract. Chile presents the third highest prevalence of gallbladder cancer in the Americas, being Chilean women from the city of Valdivia the ones with the highest prevalence. The main risk factors associated with gallbladder cancer are: sex, cholelithiasis, obesity, ethnicity, chronic inflammation, history of infection diseases such as Helicobacter pyloriand Salmonellaand family history of gallbladder cancer. In Chile gallbladder cancer mortality is close to prevalence level. This is related to the silent symptomatology of this cancer, as well as the lack of specific symptoms. The high prevalence of obesity and infectious diseases present in Chile are two of the main risk factors of gallbladder cancer and Chile has prevalence of obesity close to 30%. The aim of this literary review is to inform and summarize the main risk factors of gallbladder cancer that are prevalent in Chile, in order to be able to focus preventive and management interventions of this risk factor for the reduction in prevalence and mortality of gallbladder cancer in Chile.

El cáncer de vesícula biliar es la neoplasia maligna más común en el tracto biliar. Chile presenta la tercera prevalencia más alta de cáncer de vesícula en el continente americano, siendo las mujeres chilenas de la ciudad de Valdivia las que presentan la prevalencia más alta. Los principales factores que se han asociado al cáncer de vesícula son: ser mujer, colelitiasis, obesidad, etnia, inflamación crónica, historia de enfermedades infecciones, como H. pyloriy Salmonellae historia familiar de cáncer. En Chile la mortalidad por cáncer de vesícula es cercana al nivel de prevalencia. Esto se debe en parte a que el cáncer de vesícula es una enfermedad silenciosa y sin síntomas específicos en primeras instancias. Presentar obesidad y ser portador de agentes infecciosos, como Helicobacter pylori, son dos de los factores de riesgo más importantes para desarrollar cáncer de vesícula en Chile, ya que existe y una prevalencia de obesidad cercana al 30%. El objetivo de esta revisión literaria es informar y resumir los factores de riesgo de cáncer de vesícula prevalentes en Chile, para así enfocarse en la prevención y cuidado de estos, con el propósito de reducir la prevalencia de esta letal enfermedad.

Ultrasound findings associated to gallbladder carcinoma.

OBJECTIVE: This article reviews the most relevant ultrasound findings associated with gallbladder cancer. MATERIAL AND METHOD: A descriptive and retrospective study was made of clinical features and imaging studies in patients subjected to surgery for gallbladder neoplasm in the Reina Sofía General University Hospital (Murcia) during the time period 2000-2011. RESULTS: A total of 15 cases of gallbladder cancer were found during the study period, 9 of whom were women. The mean age was 77 years (range 61-96). Pain was the principal complaint. The patients had cholelithiasis in 13 cases, smoking in 2 cases, and obesity in 3 cases. The ultrasound showed gallbladder wall thickening (>4mm) in 8 cases, intraluminal mass in 4, scleroatrophic gallbladder in 2, and mass replacing the gallbladder in one. Only in 4 cases was the suspicion of gallbladder carcinoma established preoperatively. According to the pTNM staging, 4 patients were carcinoma in situ (Tis), one case T1a, 6 cases T2, 3 cases T3 and one case T4. In 7 cases, the only evidence was the preoperative ultrasound, and in 8 the study was completed with an abdominal CT. CONCLUSION: Early diagnosis of gallbladder cancer is rare. The ultrasound diagnostic approach is difficult; only a localized thickening coexisting with gallstones seems to be significant, and requires a biopsy. The image of a mass and a stone occupying the gallbladder is associated with later stages of the disease.