Paclitaxel coated-stent for early-onset thrombosis after liver transplantation.

Hepatic artery thrombosis (HAT) is the most common vascular complication of orthotopic liver transplantation (OLT) and constitutes a potential emergency during the postoperative period. Surgical revascularization and retransplantation are the treatments of choice for this condition. The aim of this report is to present long-term follow-up on survival and graft function of three patients with paclitaxel-coated hepatic artery stents placed percutaneously after earlyonset HAT. Three patients developed early onset HAT after cadaveric-donor OLT in a tertiary care center in Mexico. These patients were treated percutaneously with balloon angioplasty and paclitaxel-coated stents. After 24 months or more of follow-up, 2 patients present total occlusion of the stent and one patient, intra-stent stenosis; interestingly, all patients have normal graft function and excellent quality of life. In conclusion, although balloon angioplasty and stent placement may be a therapeutic option for suitable patients with early-onset HAT after OLT, longterm patency is unlikely even with the use of paclitaxel- coated materials.

Nodular regenerative hyperplasia associated to aplastic anemia: a case report and literature review.

INTRODUCTION: Nodular regenerative hyperplasia (NRH) is a rare condition is associated to immune, neoplastic, vascular disorders, and certain drugs and toxins. Portal hypertension is the main complication. AIM: To report the case of a woman with NRH and aplastic anemia, association not previously described. CASE: A 31- year-old hispanic female presented with pancitopenia and cholestasis. Bone marrow biopsy: aplastic anemia. Abdominal ultrasound revealed multiple liver nodules, without hepato-splenomegaly. No abnormalities were noted in hepatic vessels. Antimitochondrial (AMAs) were positive. Coagulation tests were normal. Liver biopsy: hepatocite nodules with central atrophy and sinusoidal dilatation in the absence of significant fibrosis. No arteritis, thrombosis or bile duct damage was found. DISCUSSION: Pathogenesis of NRH remains unclear. The most accepted theory was developed by Wanless 24 years ago, and reinforced in 1997. It states that alterations in hepatic blood flow (portal obliterative venopathy) originate a specific response, initially consisting of apoptosis secondary to acute ischemia, with ensuing parenchymal atrophy and surrounding areas of liver regeneration and chronic ischemia. The common pathologic mechanism of all the diseases associated with NRH involves liver blood-flow abnormalities secondary to microthromboses, vascular congestion, or vasculitis. In the current case we were unable to document evidence of liver flow abnormalities. Noteworthy, there are previous descriptions of the as- sociation of NRH with primary biliary cirrhosis, and this patient was AMA positive, but without bile duct damage in liver biopsy. CONCLUSIONS: We cannot sustain Wanless' theory, and this is the first description of the association of NRH with aplastic anemia.

[Radical surgical treatment of a new neuroendocrine tumor of the ileocecal valve with liver metastasis and carcinoid syndrome]. / Tratamiento quirúirgico radical de un tumor neuroendocrino de la válvula ileocecal con metástasis hepáiticas y síndrome carcinoide.

BACKGROUND: Neuroendocrine tumors are rare neoplasms which have a slow growth pattern. When liver metastases are diagnosed, treatment is controversial and it is focused in symptomatic control. AIM: To present a patient with a neuroendocrine tumor that arised from the ileocecal valve and it was diagnosed with carcinoid syndrome and treated with radical liver and colonic resection. A discussion of the different forms of treatment is presented. CASE REPORT: A 41 year-old woman was sent to our hospital with liver metastases and carcinoid syndrome from a neuroendocrine tumor of the ileocecal valve for treatment. Right colectomy, right hepatic trisectionectomy and radiofrequency ablation of two left sided lesions was performed as a first procedure. A second procedure was performed two months afterwards when resection of residual left sided lesions was done. After a two year follow up a 2 cm residual liver lesion was diagnosed and percutaneous radiofre-quency ablation was done. After four years of follow up the patient has been asymptomatic without tumor recurrence CONCLUSIONS: Radical surgical treatment of neu-roendocrine tumors controls symptomatology, improving quality of life and survival. However, this treatment should only be performed in a well selected group of patients.

Intraoperative US-guided large volume ethanol injection for hepatocellular carcinoma greater than 4 cm.

BACKGROUND: Percutaneous ethanol injection has been successfully used for hepatocellular carcinomas (HCC) smaller than 5 cm in size. For larger lesions large volume ethanol injection has not been well explored. AIM: Evaluate the results of intraoperative Ultrasonographic-guided large volume ethanol injection for HCC larger than 4 cm in size. PATIENTS AND METHODS: Ten patients were candidates for this treatment between June 1999 and July 2003. A retrospective review of the clinical files was performed. Absolute ethanol, average of 100 mL (range 80-120 mL) was administered intraoperatively. Follow-up evaluation included alpha-fetoprotein (AFP) and ultrasound or computed tomography. RESULTS: There were six women and four men, the median age was 62 years (range 56-80). The median lesion size was 8 cm (range 4-15 cm). Hepatitis C liver cirrhosis was the most common associated chronic liver disease (70%). A significant reduction of AFP levels after treatment was observed (Initial 966 ng/dL, post treatment levels: 42 ng/dL) US and CT scan showed tumor necrosis. Morbidity was 40%. No operative mortality was recorded. The one and four year survival rate was 60% and 20%. CONCLUSION: Intraoperative US-guided large volume ethanol injection is a safe palliative therapy for cirrhotic patients with HCC lesions greater than 5 cm in size. The impact on survival should be compared in a controlled double blind study.

[Surgical management of gallstone ileus: fourteen year experience]. / Catorce años de experiencia en el manejo quirúrgico del ileo biliar.

AIM: The aim of this study is to describe our experience in the diagnosis and treatment of gallstone ileus, as well as the morbility and mortality associated to this pathology. BACKGROUND: The first description of gallstone ileus was made by Bartholin in 1645 during a post-mortem study. It is a rare pathology, the preoperative diagnosis is difficult and controversy exists in the management that should be carried out on first instance, whether the extraction of the gallstone or the correction of the fistula which can affect outcome. METHODS: We made a case series study in which we studied a total of 25 patients in a 14 years period (1989-2003) with diagnosis of gallstone ileus, patients excluded were those with cholecystoduodenal fistula without gallstone ileus. The variables analyzed were: age, sex, preoperative and postoperative diagnosis, treatment and postoperative morbidity and mortality. RESULTS: Twenty, five patients were studied with diagnosis of gallstone ileus (20 women and 5 men) The median age was 64 (rage 41 to 99). The cholecystoenteric fistula is the most frequently was the cholecystoduodenal in 23. cases (92%) one coledocoduodenal (4%) and one cholecystogastric (4%). The most common site of obstruction was the terminal ileon in 96%. There was a morbility of 20% and the mortality in 7%. CONCLUSION: Gallstone ileus is a rare entity, with only 25 cases reported in a 14 years period in our hospitals. Initial surgical treatment should be guided to the correction of the obstruction and should be considered in a second stage the correction of the fistula, if the patient does not develop symptoms it is not necessary, decreasing morbidity and mortality.

Hepatocellular carcinoma and hepatitis C in Mexico.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) has increased in many countries as a result of an increased frequency of hepatitis C virus (HCV) infection. In Mexico, the association of HCC to HCV infection has not been evaluated. This study aims to evaluate the epidemiological factors related to HCC in Mexican patients as well as the results of treatment. METHODOLOGY: A retrospective review of clinical files of patients with HCC diagnosed between May 1992 to July 2002 was performed. RESULTS: There were 63 males and 64 females with a median age of 57 years (range 17-82). Seventy-one patients were evaluated for hepatitis status. In 43 (60%) HCV was the etiological factor. Isolated HCV infection was present in 32 (45%), HCV infection and ethanol abuse was observed in 11 (15.5%). In six (8.4%) patients hepatitis B was the etiological factor. HCV and HBV infection were found in 9 (12.6%). HCV and HBV infection associated to ethanol abuse was present in one patient. Ethanol abuse alone was observed in six (8.4%) patients. The median size of the lesion was 8cm (range 3-20cm). Alpha-fetoprotein was measured in 113 patients and was higher than 500ng/dL in 60 (53%). Sixty-five patients received supportive measures. Sixty-two were treated. Eighteen were resected. Thirteen were treated with intraoperative large volume ethanol injection (ILVEI), 12 with chemotherapy and 19 with tamoxifen-talidomide. Patients without treatment had a median survival time of 11 months and patients who received treatment had a median survival time of 25.3 months. The median survival time in patients who received surgery was 26 months, the ILVEI group survival time was 18 months, the chemotherapy survival was 8.8 months, and the tamoxifen-talidomide survival time was 7 months. CONCLUSIONS: HCC is a rare neoplasm in Mexico and HCV infection is the main etiological factor. Surgical resection is the best form of treatment of HCC in our country. However, only 14% of the patients were candidates. For non-resectable lesions, ILVEI offers the best palliative results in our center.

Hepatocellular carcinoma in the youth. A comparative analysis with hepatocellular carcinoma in adulthood.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) is a very rare disease among young individuals. Epidemiological, clinical and histopathological features of this malignancy in the youth have not been thoroughly studied. METHODOLOGY: A review of the clinical files of patients with HCC younger than 40 years of age, who were treated between May 1990 and July 2002, was performed. RESULTS: Seventeen patients were included for analysis; nine were female and eight male. The mean age at diagnosis was 24 years (range 12-39 years). Abdominal pain was the main symptom, followed by vomiting and nausea. Enlargement of the liver was observed in 11 patients (65%). In seven patients (41%), an etiological factor was not found. Five of these cases were of the fibrolamellar variant (29%). Only four patients were resected (23%) two of which belonged to the fibrolamellar type. Three patients (18%) are still alive after 64.9 months of follow-up. CONCLUSIONS: HCC is a very uncommon disease in the youth and affects similarly both genders. It is discovered at an advanced stage. Hepatitis B and C are uncommon etiological factors. The frequency of fibrolamellar carcinoma is higher in this age group. Though resection is more feasible, the overall survival rates remain low.

Identification of patients with high-risk lymph node-negative colorectal cancer and potential benefit from adjuvant chemotherapy.

BACKGROUND: Adjuvant chemotherapy is not indicated in lymph node-negative colorectal adenocarcinoma (CRC), even though some cases will present recurrent disease. It is important to identify a subgroup of patients with the highest risk of relapse because of the potential benefit of adjuvant chemotherapy. The objective of this study is to define the prognostic factors and describe a method for the selection of this subgroup. METHODS: A retrospective cohort of 124 patients with lymph node-negative CRC with complete surgical resection was studied. Cox's proportional hazards model was used to define the prognostic factors associated with CRC-related survival and to develop a method for prediction of recurrence probability. RESULTS: The cohort included 62 women and 62 men with mean age 55.8 years. The mean follow-up period was 11.7 years. T classification of the primary tumor, differentiation grade, carcinoembryonic antigen level, gender and the presence of neural invasion were significant prognostic factors according to the multivariate analysis (final model P=0.00001). Using risk ratios for these prognostic factors, we defined a high-risk group of 78 patients and a low-risk group of 46 patients with 24 and 5 recurrences, respectively (recurrence rates of 30.8% and 10.9% respectively, P=0.011). CONCLUSIONS: Using these factors, a prognostic scale was developed to predict high risk of recurrence in cases of completely resected CRC and to identify them as a subgroup of patients with potential benefit of adjuvant chemotherapy.

[Survival prognostic factors in a cohort of patients with esophageal carcinoma]. / Factores pronósticos en una cohorte de pacientes con carcinoma esofágico.

INTRODUCTION: The epidemiology of esophageal carcinoma (EC) has changed in the last decades. Adenocarcinoma and squamous cell carcinoma are analyzed as a single condition because prognosis is similar. The aim of this study was to define prognostic factors in EC, considering each histopathologic type independently. MATERIALS AND METHODS: We studied a retrospective cohort of patients treated from 1981 to 2001 at the National Cancer Institute (Instituto Nacional de Cancerología, INCan) in Mexico City. Patients with EC (including siewert I type neoplasms), with endoscopic biopsy, of adenocarcinoma or squamous cell carcinoma older than 18 years of age, and with complete clinical evaluation were included in the study. RESULTS: A total of 236 cases were included: 60 (25.4%) were adenocarcinoma and 176 (74.6%), squamous cell carcinoma. Median survival times were 5.2 months (95% CI, 0.7 to 9.6) and 2.9 months (95% CI, 2.2 to 3.6 months), respectively (p = 0.0042). In bivariate analysis, age, histopathologic type, T classification, M classification, differentiation grade, history of hiatal hernia, presence of Barrett esophagus, anemia, surgical resection, and use of other antineoplastic treatments were related to survival (p = 0.00001). CONCLUSIONS: At our hospital, EC is a lethal neoplasia with a dismal prognosis. Adenocarcinoma has a better prognosis than squamous cell carcinoma. However, in multivariate analysis, T classification and possibility of surgical resection were the most important prognostic factors determining survival.

[Current status and long-term results of laparoscopic anti-reflux surgery]. / Estado actual y resultados a largo plazo de la cirugía antirreflujo por laparoscopia.

BACKGROUND: Laparoscopic surgery has a great application for the treatment of different pathologies of the gastrointestinal tract. In the management of gastroesophageal reflux disease it is not a exception, since its introduction in 1991 this technique has evolved constantly. OBJECTIVE: Analyze and evaluate indications, surgical technique and long term results of laparoscopic surgery as a treatment for gastro-esophageal reflux disease. PATIENTS AND METHODS: In this review paper we analyze literature to evaluate the current status of laparoscopic surgery and its application to the treatment of gastro-esophageal reflux disease. Besides we briefly report long term results from authors experience. RESULTS: Indications for laparoscopic treatment of patients with gastroesophageal reflux disease include patients with moderate to severe erosive esophagitis, patients with non-typical symptoms in which a 24 hours pH measurement shows these symptoms are correlated with gastroesophageal reflux and those who do not tolerate medical treatment, also Barrett's disease is considered a relative indication. Laparoscopic surgery has increased the number of patients treated surgically because it is well tolerated. Long term results in terms of controlling gastroesophageal reflux must be superior to 90% with a low complication rate. CONCLUSIONS: Laparoscopic surgery for the treatment of gastroesophageal reflux disease has shown better recovery, hospital stay, return to daily activities and global morbidity, which our group has been able to reproduce. Selection criteria must be strict with an adequate long term follow up.

[Laparoscopic liver surgery]. / Cirugía hepática por laparoscopia.

INTRODUCTION: Laparoscopic surgery has been widely used for digestive tract diseases, specially for gallbladder pathology. Laparoscopic liver surgery pretends to accomplish the same objectives of open surgery but with the advantages of minimally invasive surgery. AIMS: To evaluate the indications and recent results of laparoscopic liver surgery, as well as the technique. MATERIAL AND METHODS: A review of the world literature was performed on the roll of laparoscopic surgery for hepatic diseases. The results of the authors are also reported. RESULTS: Nowadays hepatic laparoscopic surgery is reserved for anterior non-parasitic liver cysts and type I polycystic liver disease. The treatment of choice is wide deroofing. For hydatic liver disease pericystectomy or wide deroofing plus omentoplasty are also described. For benign solid liver disease, hepatic resection can be performed with the same outcome that the one observed with open surgery when the lesions are symptomatic, small, anterior or peripherally located. Laparoscopic liver surgery is recommended for the treatment of malignant hepatic lesions only in very specific cases. Nonetheless there are no prospective randomized studies that show benefits of laparoscopic over open surgery. Several local ablative therapies like radiofrequency, ethanol injection, cryotherapy or laser can be also performed through the laparoscope. The results reported so far have been encouraging. Intra-arterial chemotherapy is an option for the treatment of liver malignancies via laparoscopy, considering that the arterial catheter can be placed under this approach. CONCLUSIONS: For years, the liver has been considered a challenging organ for its approach, even with open surgery. Laparoscopic liver surgery should be performed by an experienced surgeon with the adequate technology. To our knowledge there are no reported results that decisively point toward the benefits of laparoscopic surgery over open surgery for the management of liver disease. Nonetheless more experience in laparoscopic liver surgery is needed.

A retrospective analysis of patients with gallbladder cancer treated with radical resection versus cholecystectomy plus external radiotherapy.

BACKGROUND/AIMS: To compare patients with gallbladder cancer treated with radical resection and regional lymphadenectomy (RR-RL) versus simple cholecystectomy and adjuvant external radiotherapy (SC-ERT) and determine outcome. METHODOLOGY: Presentation, operative data, complications and survival were examined in 137 patients. In particular, the 45 patients treated with RR-RL or SC-ERT. RESULTS: Twenty-five had SC-ERT and 20 had a RR-RL. There were no epidemiological differences between groups. Resection of segments IV-b and V and en bloc dissection of regional lymph nodes was the most frequently used procedure (75%). The morbidity and mortality of the radical procedure were 25% and 10%. The morbidity of SC-ERT was 16%. All patients with Nevin I are alive. For lesions Nevin II and Nevin III RR-RL offered a 100% 5-year survival rate and SC-ERT had a 62% and 39% 5-year survival rate respectively. For lesions Nevin IV and V there was no difference in long-term survival. CONCLUSIONS: RR-RL is better than SC-ERT in patients with Nevin II and III lesions because it improves survival rate. SC-ERT can be recommended as an alternative treatment. For more advanced lesions further trials are needed.

[Arterial hypertension as clinical manifestation of non-parasitic hepatic cyst. A case report]. / Hipertensión arterial como manifestación clínica de quiste no parasitario de hígado. Reporte de un caso.

We present the case of a 32-year-old female patient referred to the Instituto Nacional de Cancerología (INCan) with a history of several months of systemic hypertension and epigastric pain associated to early postprandial satiety, fatigue, and dyspnea. At physical examination, a smooth, non-tender, palpable mass was found in right upper quadrant 7 cm below costal margin. Computed tomography (CT) scan showed right-sided non-parasitic liver cyst. The patient was taken to the operating room, where she presented hypertensive crisis of 180/125 mm Hg, which did not respond to midazolam therapy. The procedure was suspended and deferred. After blood pressure control with angiotensin II-antagonist and calcium-antagonist, the patient was submitted to laparotomy, where a wide deroofing of the lesion was performed. The postoperative evolution was uneventful and the patient has remained normotense without anti-hypertensive medication after 6 months of follow-up.

[Neuroendocrine gastric carcinoma. A case report and review of current management]. / Carcinoma neuroendocrino gástrico. Presentación de un caso clínico y revisión actual del manejo.

Neuroendocrine or carcinoid tumors of the gastrointestinal tract considered previously extremely rare, are diagnosed at present with increased frequency due to the better capacity to identify neuroendocrine system cells in normal and pathologic conditions. Occasionally, these tumors secrete a great variety of vasoactive substances, producing the carcinoid syndrome. Gastric carcinoids are classified, according to their degree of differentiation into well differentiated and poorly differentiated tumors, also called neuroendocrine carcinomas. Neuroendocrine gastric carcinomas or poorly differentiated gastric carcinoids are seen in 5-15% of all gastric carcinoids, mainly in older male patients. Generally they are large, very aggressive tumors with extensive local infiltration. Due to poor differentiation, they are not frequently associated with an endocrine syndrome. They can be located in any part of the stomach but are mainly seen in antrum. These tumors have an aggressive behavior and must be treated in a radical manner; recurrences are not uncommon. We report the case of a patient with a neuroendocrine gastric carcinoma treated with an en bloc subtotal gastrectomy and colectomy.

[Cavernous hemangioma of the liver and hepatic hemangiomatosis. Indications and results of the surgical resection]. / Hemangioma cavernoso de hígado y hemangiomatosis hepática. Indicaciones y resultados de la resección quirúrgica.

INTRODUCTION: Cavernous hemangioma is the most frequent focal liver lesion. It affects mainly women and may cause symptoms such as abdominal pain, mass, and early satiety, or complications such as heart failure or coagulopathy. There are several options for treatment in symptomatic patients. However, it seems that surgical resection is the only curative treatment. AIM: Evaluate indications and results of liver resection in patients with cavernous hemangiomas and hepatic hemangiomatosis. PATIENTS AND METHODS: We conducted a retrospective analysis of clinical files of patients treated at the Instituto Nacional de Cancerología (INCan) and the Centro Médico ISSEMYM during a 8-year period. Epidemiological data as well as diagnostic work-up and treatment were analyzed. RESULTS: From August 1995 to May 2003, 24 patients with liver hemangiomas were resected at both institutions. Twenty three were female (95.8%) and one, male (4.1%). Indications for surgery were presence of symptoms in 20 patients (83.3%), undefined diagnosis in three (12.5%), and rapid growth in one (4.1%). Most frequent symptoms were abdominal pain in 20 (83.3%) patients, followed by abdominal mass in five (20.8%), and early gastric satiety in four (16.6%). Abdominal computed tomography (CT) scan was the most frequent imaging study used in 22 patients (91.6%), followed by ultrasound in 20 (83.3%). Size of lesion ranged from 4-30 cm (X: 8.7 cm), 16 patients were submitted to formal liver resection (66.6%), and eight to enucleation (33.3%). Four patients presented operative complications (16.6%) that included postoperative bleeding in two (8.3%), fever in one (4.1%) and abdominal haematoma in one (4.1%). There was no operative mortality. Twenty two patients were asymptomatic at time of evaluation (91%). CONCLUSIONS: This lesion affects mainly women, and presence of symptoms is the most common indication for treatment. Choice of surgical procedure to be carried out depends on location and morphology of the lesion. Liver resection or enucleation are safe forms of treatment that properly controlled symptomatology.

[Undifferentiated embryonal sarcoma of the liver. Case report of an adult woman]. / Sarcoma indiferenciado (embrionario) de hígado. Informe de un caso en una mujer adulta.

Undifferentiated (embryonal) sarcoma of the liver (USL) is a rare hepatic tumor and is generally considered an aggressive neoplasm with unfavorable prognosis. USL has a predilection for children and young adults in the first two decades of life, although a few cases have been reported in adults. The present report describes occurrence of such tumor in a 24-year-old woman who came for treatment in our hospital. She underwent exploratory laparotomy, and tumorectomy was performed. Histological examination resulted in diagnosis of USL. The patient died one month after her operation. Clinical and histopathologic features of this tumor are discussed.