ABSTRACT
OBJECTIVE: To propose to our community a common language about extreme liver surgery. BACKGROUND: The lack of a clear definition of extreme liver surgery prevents convincing comparisons of results among centers. METHODS: We used a two-round Delphi methodology to quantify consensus among liver surgery experts. For inclusion in the final recommendations, we established a consensus when the positive responses (agree and totally agree) exceeded 70%. The study steering group summarized and reported the recommendations. In general, a five-point Likert scale with a neutral central value was used, and in a few cases multiple choices. Results are displayed as numbers and percentages. RESULTS: A two-round Delphi study was completed by 38 expert surgeons in complex hepatobiliary surgery. The surgeon´s median age was 58 years old (52-63) and the median years of experience was 25 years (20-31). For the proposed definitions of total vascular occlusion, hepatic flow occlusion and inferior vein occlusion, the degree of agreement was 97%, 81% and 84%, respectively. In situ approach (64%) was the preferred, followed by ante situ (22%) and ex situ (14%). Autologous or cadaveric graft for hepatic artery or hepatic vein repair were the most recommended (89%). The use of veno-venous bypass or portocaval shunt revealed the divergence depending on the case. Overall, 75% of the experts agreed with the proposed definition for extreme liver surgery. CONCLUSION: Obtaining a consensus on the definition of extreme liver surgery is essential to guarantee the correct management of patients with highly complex hepatobiliary oncological disease. The management of candidates for extreme liver surgery involves comprehensive care ranging from adequate patient selection to the appropriate surgical strategy.
Subject(s)
Carcinoma, Hepatocellular/surgery , Decision Support Techniques , Health Status Indicators , Liver Neoplasms/surgery , Liver Transplantation , Waiting Lists , Biomarkers, Tumor/analysis , Carcinoma, Hepatocellular/diagnosis , Carcinoma, Hepatocellular/mortality , Carcinoma, Hepatocellular/secondary , Diagnostic Imaging , Evidence-Based Medicine , Humans , Liver Neoplasms/diagnosis , Liver Neoplasms/mortality , Liver Transplantation/adverse effects , Liver Transplantation/mortality , Neoplasm Recurrence, Local , Neoplasm Staging , Patient Selection , Practice Guidelines as Topic , Predictive Value of Tests , Risk Assessment , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
Introducción La presentación, el tratamiento y el pronóstico del hepatocarcinoma dependen de la presencia o la ausencia de cirrosis. Existen pocos estudios de hepatocarcinoma en pacientes sin cirrosis. Objetivo Analizar una serie consecutiva de pacientes operados por hepatocarcinoma en hígado no cirrótico e identificar los factores de pronóstico de la recidiva y la supervivencia. Material y método Se operó a 51 pacientes entre 1990 y 2006. Se organizó una base de datos retrospectiva hasta el año 2001 y prospectiva desde esa fecha. Se evaluaron los resultados de la cirugía. Se realizaron análisis univariado y multivariado para identificar los factores asociados con la supervivencia y el tiempo libre de enfermedad. Resultados Treinta y tres pacientes eran de sexo masculino (mediana de edad de 49,8 años). Al 72,5% se le realizó una hepatectomía mayor. La mortalidad intrahospitalaria fue del 0% y la morbilidad del 43%. El tiempo de supervivencia fue del 90, el 75 y el 67% a uno, a 2 y a 3 años. El tiempo libre de enfermedad fue del 65, el 41 y el 37% a uno, a 2 y a 3 años. En el análisis univariado, la invasión vascular y la infiltración ganglionar fueron estadísticamente significativas para la supervivencia, pero ninguno de éstas fue significativa en el estudio multivariado. Conclusiones La resección hepática mayor es un tratamiento seguro para el tratamiento del hepatocarcinoma en el hígado no cirrótico. Tanto la presencia de invasión vascular como la infiltración ganglionar están estadísticamente relacionadas con la supervivencia, pero no se identificaron como factores pronósticos independientes de ésta (AU)
Background Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients. Objective To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival. Material and methods Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival. Results Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis. Conclusions Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable (AU)
Subject(s)
Humans , Male , Female , Child , Adolescent , Adult , Middle Aged , Aged , Carcinoma, Hepatocellular/surgery , Liver Neoplasms/surgery , Carcinoma, Hepatocellular/mortality , Liver Neoplasms/mortality , Neoplasm Recurrence, Local/epidemiology , Prognosis , Survival RateABSTRACT
Objetivo: Analizar los resultados de las resecciones simultáneas colónicas y hepáticas por cáncer colorrectal. Diseño: Entre junio 1982 y julio de 2003, en 750 pacientes se realizaron resecciones hepáticas de las cuales 138 fueron simultáneas con resecciones colónicas por cáncer colorrectal. Se analizó morbilidad, mortalidad, sobrevida general y tiempo libre de enfermedad. El seguimiento medio fue de 29 meses (rango entre 6 y 162 meses). Fueron analizados factores pronósticos y su influencia en los resultados obtenidos. Resultados: El tiempo medio de estadía hospitalaria fue de 8 días (rango entre 4 y 24 días). La morbilidad fue de 21 por ciento incluyendo 18 derrames pleurales, 14 abscesos de herida, 8 insuficiencias hepáticas, 3 infecciones sistémicas, 3 abscesos abdominales, 1 dehiscencia anastomótica y 1 dehiscencia de gastroentero anastomosis. La mortalidad postoperatoria fue del 2.1 por ciento. La recurrencia fue del 64 por ciento. La sobrevida general y el periodo libre de enfermedad fue a 1, 3 y 5 años de 88, 45 y 38 por ciento; y 67 por ciento, 17 por ciento y 9 por ciento respectivamente. El factor pronóstico con mayor influencia sobre los resultados fue el TNM del tumor de colon, número de metástasis hepáticas (=< 2cm vs > 2cm), y el diámetro (menor o mayores de 5 cm). Conclusiones: Las resecciones simultáneas del cáncer colorrectal y metástasis hepáticas pueden realizarse con baja morbilidad y mortalidad, evitando un segundo acto operatorio.
Subject(s)
Humans , Male , Adolescent , Adult , Female , Middle Aged , Aged, 80 and over , Colorectal Neoplasms/surgery , Colorectal Neoplasms/mortality , Liver Neoplasms/surgery , Liver Neoplasms/mortality , Liver Neoplasms/secondary , Colonoscopy/methods , Disease-Free Survival , Neoplasm Metastasis , Postoperative Complications , Preoperative Care , PrognosisABSTRACT
This article describes results obtained when human liver cells obtained from reduced grafts are cultured in a chemically defined medium. Remnants of livers after reduction for pediatric transplantation were processed by a multiple cannulation system through the existing vasculature, which allowed the homogeneous perfusion of collagenase. The graft weight ranged between 55 and 1000 g (median value: 145.6 g). The yield ranged between 0.13 x 10(6) and 38 x 10(6) cells/g of tissue (median value 14.73 x 10(6) cells/g), and the viability was 61.17 +/- 27.43%. The total number of cells ranged between 57.6 x 10(6) and 12 150 x 10(6) cells (median value: 740 x 10(6) cells). Cells were cultured for 30 days. Albumin synthesis was observed during the first 2 weeks, with a peak value at day 6 (27.85 +/- 1.77 micro g/mL). Urea production was detected during the first week (peak value at day 6: 17.12 +/- 2.11 mg/dL). Light microscopy showed the presence of cells in a monolayer. Biliary pigments were observed at day 20. By immunohistochemistry, positive cells for albumin, for hepatocyte marker, cytokeratin 19, CD 34, CD 68, and for alpha actin for smooth muscle, were observed. Our results showed that hepatocytes obtained from reduced liver grafts are easily cultured and are able to maintain viability and functionality in vitro. This alternative source of human cells maintained under controlled culture conditions may play an important role in the development of a bioartificial liver.
