Experiencia de diez años en resecciones hepáticas / Ten years experience in hepatic resections

Revisamos experiencia reciente y resultados obtenidos con resecciones hepáticas mayores en pacientes referidos a nuestra institución. Revisión retrospectiva de historias clínicas de pacientes entre agosto de 1998 y agosto de 2008, con el objetivo de precisar el tipo de cirugía efectuada, indicaciones principales, complicaciones y morbimortalidad operatoria. 22 pacientes cuyas historias estuvieron disponibles para revisión. La principal indicación de cirugía fueron neoplasias malignas 86,4% de los casos, las metástasis de carcinoma colorrectal (7) la primera indicación seguida de hepatocarcinoma (4). Otras indicaciones incluyeron: colangiocarcinomas perifericos (2), metástasis de tumores neuroendocrinos (2), diversas lesiones benignas (3) otros tumores (4). La hepatectomía derecha y segmentectomías anatómicas fueron los más frecuentes con un 27,3 % cada uno, seguidos de segmentectomía lateral izquierda (II y III) en 19%. El tiempo operatorio promedio fue 270,4 min (rango: 180-560 min). El promedio de estancia hospitalaria fue 7,7 días (rango:4-30). El 8% de nuestros pacientes no requirió estancia posoperatoria inmediata en UTI. La tasa de complicaciones fue 44,5% siendo el derrame pleural reactivo y el sangrado posoperatorio más frecuentes. La tasa de reintervención fue 18,2%. La mortalidad global fue 9% (2/22), y la inherente al procedimiento quirúrgico 4,5% (1/22). Las resecciones hepáticas mayores son un procedimiento relevante en el armamento del cirujano oncólogo dedicado al tratamiento de neoplasias digestivas, la morbimortalidad operatoria en nuestra institución es similar a otros centros de mayor volumen a nivel internacional.

Review the recent experience and results of major hepatic resections of patients treated at our institution. Retrospective review of clinical records patients submitted to major hepatic resection inten years, between August 1998 to August 2008, with descriptive statistics of type of surgery, indications, complications and surgical related morbimortality. Twenty two patients with complete clinical records for review were included. The main indication for surgery were malignant neoplasms in 86,4% of the cases,being colorectal liver metastasis (7) the first one followed by hepatocarcinomas (4). Other indications included:The periferic colanghiocarcinomas (2), metastasis from neuroendocrine tumors (2), varied beningn lesions (3)and other tumors (4). Right hepatectomy and anatomical segmentectomies were the most frequent procedures 27.3% each, followed by left lateral segmentectomy (II - III) in19% of the cases. Medium operative time was 270.4 min (range: 180-560 min). Mean hospital stay was 7.7 days (range: 4-30). 8% of the patients did not required post operative ICU care. Complications rate was 44.5% being reactive pleural effusion and postoperative bleedingthe most frecuent ones. Reintervention rate was 18.2%, global mortality 9% (2/22), and surgical related mortality was 4.5% (1/22). Major hepatic resections are a relevant procedure in the armament of surgical oncologists dedicated to treatment of digestive neoplasms, the number of such procedures done at public institutions are limited. Operative morbimortality in our institution is similar to other major volume centers.

A Novel, Fully Covered Laser-Cut Nitinol Stent with Antimigration Properties for Nonresectable Distal Malignant Biliary Obstruction: A Multicenter Feasibility Study

BACKGROUND/AIMS: Stent migration occurs frequently, but the prevention of complications resulting from covered self-expandable metal stents (C-SEMSs) remains unresolved. We prospectively assessed a newly developed C-SEMS, a modified covered Zeo stent (m-CZS), in terms of its antimigration effect. METHODS: Between February 2010 and January 2011, an m-CZS was inserted into 42 patients (31 initial drainage cases and 11 reintervention cases) at a tertiary referral center and three affiliated hospitals. The laser-cut stent was flared for 1.5 cm at both ends, with a 1 cm raised bank located 1 cm in from each flared end. The main outcome of this study was the rate of stent migration, and secondary outcomes were the rate of recurrent biliary obstruction (RBO), the time to RBO, the frequencies of complications, and overall survival. RESULTS: Of the 31 patients with initial drainage, stent migration occurred in four (12.9%, 95% confidence interval, 5.1% to 29.0%), with a mean time of 131 days. RBO occurred in 18 (58%), with a median time to RBO of 107 days. Following previous C-SEMS migration, seven of 10 patients (70%) did not experience m-CZS migration until death. CONCLUSIONS: m-CZSs with antimigration properties effectively, although not completely, prevented stent migration after stent insertion.

Neoplasia neuroendocrina quística múltiple: a propósito de un caso / Multiple cystic neuroendocrine neoplasm: a purpose of a case

Los tumores neuroendocrinos, independientemente del tipo de hormona que produzcan, tienen igual potencial de transformación quística. Presentamos el caso de femenino de 15 años quien presentó hace 3 años parotiditis acompañado de dolor en hemiabdomen superior y vómitos. Se realizaron estudios que diagnostican pancreatitis aguda y tomografía abdominal con evidencia de 3 lesiones ubicadas en el páncreas planteándose el diagnóstico de lesión neuroendocrina. La Gastrina en dos ocasiones reportó valores elevados de 970ng/L y 1313ng/L, es tratada con inhibidores de bomba de protones 40mg BID mejorando parcialmente los síntomas. La paciente no acudió a sus controles regulares por consulta en un lapso de 2 años. En abril de este año se realizó Ecoendoscopia superior por presentar nuevamente los mismos síntomas y se evidenció en el páncreas 5 lesiones que por las características mixtas con estructuras internas micro quístico sugieren Lesiones neuroendocrinas. Se realizó punción aspiración guiada por ecoendoscopia de 3 de las lesiones observando células epiteliales neoplásicas, sugestivos de tumores neuroendocrinos bien diferenciados. La Inmunohistoquimica reportó positiva para cromogranina, sinaptofisina y enolasa neuronal específica. Actualmente la paciente está en plan para cirugía

Neuroendocrine tumors, regardless of the type of hormone produced, have potential as cystic transformation. The case of women who presented 15 years ago 3 years accompanied mumps upper abdomen pain and vomiting. Studies were conducted to diagnose acute pancreatitis and abdominal CT with evidence of 3 lesions located one in the pancreas tail and one in considering the diagnosis of neuroendocrine injury. Gastrin twice the reported high levels of 970ng/L and 1313ng/L, is treated with proton pump inhibitors 40mg BID partially improve the symptoms. The patient did not attend regular checkups for consultation over a period of 2 years. In April this year was higher Ecoendoscopy to resubmit the same symptoms and showed 5 lesions in the pancreas of mixed characteristics internal structure micro cystic lesions suggestive of neuroendocrine. We performed EUS-guided aspiration of 3 lesions observed neoplastic epithelial cells, suggesting well-differentiated neuroendocrine tumors. The reported Immunohistochemistry positive for chromogranin, synaptophysin and neuron-specific enolase. Currently the patient is in surgical plan

Hipo (singultus): revisión de 24 casos / Hiccup: Review of 24 cases

Background: Although common and usually benign, hiccups can be an extremely uncomfortable disease. There is not much information about persistent and refractory hiccups. Aim: To report clinical features of patients admitted in a hospital due to hiccup. Patients and Methods: A retrospective study and prospective follow up of patients admitted for hiccup in Hospital Cl¡nico de Santiago de Compostela between January 1998 and May 2005. Results: Twenty four patients (age 47 to 91 years, 23 males) were studied. Nineteen (79 percent) were admitted because of persistent hiccups. In twenty one patients, at ¡east one organic etiology was identified, and thirteen patients presented two or more possible associated conditions. The most common possible causes were digestive tract disorders, followed by central nervous system diseases. Twelve patients had a history of exposure to drugs that potentially could cause hiccups, mainly corticosteroids and benzodiazepines. Chlorpromazine was the first choice treatment in 23 patients, but seven required a second line drug. Average hospital stay was 13 days (range 3-90 days). Twelve patients died during follow up. Death occurred during the first three months of follow up in 61 percent. Conclusions: Persistent hiccup is often associated with organic conditions, specially advanced tumors of the digestive tract. It is usually associated with a bad prognosis.

Treatment of Malignant Biliary Obstruction with a PTFE-Covered Self-Expandable Nitinol Stent

OBJECTIVE: We wanted to determine the technical and clinical efficacy of using a PTFE-covered self-expandable nitinol stent for the palliative treatment of malignant biliary obstruction. MATERIALS AND METHODS: Thirty-seven patients with common bile duct strictures caused by malignant disease were treated by placing a total of 37 nitinol PTFE stents. These stents were covered with PTFE with the exception of the last 5 mm at each end; the stent had an unconstrained diameter of 10 mm and a total length of 50-80 mm. The patient survival rate and stent patency rate were calculated by performing Kaplan-Meier survival analysis. The bilirubin, serum amylase and lipase levels before and after stent placement were measured and then compared using a Wilcoxon signed-rank test. The average follow-up duration was 27.9 weeks (range: 2-81 weeks). RESULTS: Placement was successful in all cases. Seventy-six percent of the patients (28/37) experienced adequate palliative drainage for the remainder of their lives. There were no immediate complications. Three patients demonstrated stent sludge occlusion that required PTBD (percutaneous transhepatic biliary drainage) irrigation. Two patients experienced delayed stent migration with stone formation at 7 and 27 weeks of follow-up, respectively. Stent insertion resulted in acute elevations of the amylase and lipase levels one day after stent insertion in 11 patients in spite of performing endoscopic sphincterotomy (4/6). The bilirubin levels were significantly reduced one week after stent insertion (p < 0.01). The 30-day mortality rate was 8% (3/37), and the survival rates were 49% and 27% at 20 and 50 weeks, respectively. The primary stent patency rates were 85%, and 78% at 20 and 50 weeks, respectively. CONCLUSION: The PTFE-covered self-expandable nitinol stent is safe to use with acceptable complication rates. This study is similar to the previous studies with regard to comparing the patency rates and survival rates.

Percutaneous Placement of Self-expandable Metallic Biliary Stents in Malignant Extrahepatic Strictures: Indications of Transpapillary and Suprapapillary Methods

OBJECTIVE: To compare the efficacy of suprapapillary and transpapillary meth-ods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied. MATERIALS AND METHODS: Stents were placed in 59 patients. Strictures were cat-egorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n=16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared. RESULTS: Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p < 0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapap-illary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p =0.37) or method (p = 0.62). CONCLUSION: For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.

Percutaneous Placement of Self-expandable Metallic Biliary Stents in Malignant Extrahepatic Strictures: Indications of Transpapillary and Suprapapillary Methods

OBJECTIVE: To compare the efficacy of suprapapillary and transpapillary meth-ods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied. MATERIALS AND METHODS: Stents were placed in 59 patients. Strictures were cat-egorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n=16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared. RESULTS: Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p < 0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapap-illary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p =0.37) or method (p = 0.62). CONCLUSION: For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.

Leiomioma de duodeno como causa de hemorragia digestiva alta: relato de caso / Duodenum leiomyoma due to upper digestive bleeding

O leiomioma do duodeno se constitui numa causa muito rara de hemorragia digestiva alta. Relata-se aqui o caso de um paciente de 61 anos, que apresentou sangramento digestivo alto, devido a um liomioma situado na primeira porçäo do duodeno. Através da endoscopia houve a suspeita de um tumor mesenquimal benigno e por sua localizaçäo submucosa näo se procedeu a biópsia. Após compensado, o paciente foi operado eletivamente, sendo realizada a exrese do tumor, constatando tratar-se de um leiomioma duodenal

Evaluacion gamagrafica de metastasis hepaticas por carcinoma de vias digestivas / Radionuclide imaging evaluation of liver metastasis secondary to digestive tract carcinoma

Se revisaron las historias clinicas de 100 pacientes del Instituto Nacional de Cancerologia con carcinoma de vias digestivas, con el fin de evaluar la certeza diagnostica de la gamagrafia hepatica en la busqueda de metastasis. Se compararon los hallazgos gamagraficos con los resultados del examen directo del higado durante el acto operatorio. El estudio dio como resultado una especificidad de 76%, sensibilidad kde 97% y certeza diagnostica de 91%. Las 5 principales fuentes de error consistieron en el tamano de las metastasis y defectos tecnicos. Los hallazgos comparten valores similares con los encontrados en el analisis de la literatura pertinente. La gamagrafia hepatica continua siendo un examen de primera eleccion en la busqueda de lesiones focales en higado, si consideramos que estudios de mayor sofisticacion no muestran mejores indices de certeza en el diagnostico.