Conversion to open surgery during laparoscopic common bile duct exploration: predictive factors and impact on the perioperative outcomes.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is an effective treatment for choledocholithiasis. The aim of this study was to determine the predictive factors associated with conversion during LCBDE and to assess the implications of conversion on the patients' postoperative course. METHODS: A retrospective cohort study based on patients undergoing LCBDE between 2000 and 2018 was conducted. Uni- and multivariate regression analyses were performed. RESULTS: A total of 357 patients underwent LCBDE, and the conversion rate was 14.2%. The main reasons for conversion were lithiasis extraction (21; 41%) and difficult dissection (13; 26%). Independent predictors for conversion were increasing levels of serum bilirubin prior to surgery (OR=4.745, 95% CI: 1.390-16.198; p=0.013), and emergency setting (OR=4.144, 95% CI: 1.449-11.846; p=0.008). Age was independently associated with lower odds of conversion (OR=0.979, 95% CI: 0.960-0.999; p=0.036). Conversion had a negative impact on the patients' postoperative course, including severe complication (21.6% vs. 5.2% p<0.001) and surgical reintervention (11.8% vs. 2.6% p=0.002) rates. CONCLUSION: Conversion to open surgery during LCBDE was associated with increased postoperative morbidity. Emergency surgery and increasing levels of serum bilirubin previous to surgery independently increase the probability of conversion; however age was independently associated with lower odds of conversion.

Metabolomic analysis to discriminate drug-induced liver injury (DILI) phenotypes.

Drug-induced liver injury (DILI) is an adverse toxic hepatic clinical reaction associated to the administration of a drug that can occur both at early clinical stages of drug development, as well after normal clinical usage of approved drugs. Because of its unpredictability and clinical relevance, it is of medical concern. Three DILI phenotypes (hepatocellular, cholestatic, and mixed) are currently recognized, based on serum alanine aminotransferase (ALT) and alkaline phosphatase (ALP) values. However, this classification lacks accuracy to distinguish among the many intermediate mixed types, or even to estimate the magnitude and progression of the injury. It was found desirable to have additional elements for better evaluation criteria of DILI. With this aim, we have examined the serum metabolomic changes occurring in 79 DILI patients recruited and monitored using established clinical criteria, along the course of the disease and until recovery. Results revealed that free and conjugated bile acids, and glycerophospholipids were among the most relevant metabolite classes for DILI phenotype characterization. Using an ensemble of PLS-DA models, metabolomic information was integrated into a ternary diagram to display the disease phenotype, the severity of the liver damage, and its progression. The modeling implemented and the use of such compiled information in an easily understandable and visual manner facilitates a straightforward DILI phenotyping and allow to monitor its progression and recovery prediction, usefully complementing the concise information drawn out by the ALT and ALP classification.

Manejo del gastrinoma pancreático asociado a la enfermedad de Von Hippel-Lindau. A propósito de un caso / Management of pancreatic gastrinoma associated with Von Hippel-Lindau disease: a case report

Introducción: los tumores neuroendocrinos de páncreas (TNEP) son un grupo heterogéneo y constituyen el 1,3% de todos los tumores pancreáticos. Aproximadamente el 10% aparecen en el contexto de síndromes familiares como el Von Hippel-Lindau (VHL). Caso clínico: presentamos el caso de una paciente mujer de 37 años diagnosticada de VHL e intervenida en varias ocasiones por hemangioblastomas cerebrales y carcinomas renales. Durante su seguimiento se diagnostica de 2 gastrinomas funcionantes menores de 2 cm que se enuclearon. Posteriormente desarrolló nuevo TNEP y se le realizó una duodenopancreatectomía total sin preservación pilórica. Discusión: el manejo de los TNEP en el VHL es difícil debido a la asociación de múltiples tumores en diferentes órganos y a la morbi-mortalidad asociada a la cirugía del páncreas. Su tratamiento hay que individualizarlo en cada paciente, basándonos en su capacidad de producción de hormonas y, por tanto de dar sintomatología, en su tamaño y localización y, además debe ser contextualizado con el resto de tumores que suelen presentar estos pacientes (AU)

Background: Pancreatic neuroendocrine tumors (PNET) are a heterogeneous group and constitute 1.3% of all pancreatic tumors. Approximately 10% of these occur in the context of hereditary syndromes, such as VHL disease. Case report: We report a case of a female patient of 37 years diagnosed VHL and intervened on several occasions by cerebral hemangioblastoma and renal carcinomas. During its follow-up she was diagnosed 2 gastrinomas functioning under 2 cm were enucleated. Later developed new PNET and underwent a total duodenopancreatectomy without pyloric preservation. Discussion: The management of PNET in VHL is difficult due to the association of multiple tumors in different organs and the morbidity and mortality associated with the surgery of the pancreas. Management must be individualized for each patient, based on the ability to produce hormones and present symptoms, the size and location, and in the context of other tumors that usually present in these patients (AU)

Management of pancreatic gastrinoma associated with Von Hippel-Lindau disease: a case report.

BACKGROUND: Pancreatic neuroendocrine tumors (PNET) are a heterogeneous group and constitute 1.3% of all pancreatic tumors. Approximately 10% of these occur in the context of hereditary syndromes, such as VHL disease. CASE REPORT: We report a case of a female patient of 37 years diagnosed VHL and intervened on several occasions by cerebral hemangioblastoma and renal carcinomas. During its follow-up she was diagnosed 2 gastrinomas functioning under 2 cm were enucleated. Later developed new PNET and underwent a total duodenopancreatectomy without pyloric preservation. DISCUSSION: The management of PNET in VHL is difficult due to the association of multiple tumors in different organs and the morbidity and mortality associated with the surgery of the pancreas. Management must be individualized for each patient, based on the ability to produce hormones and present symptoms, the size and location, and in the context of other tumors that usually present in these patients.

Review of the treatment of liver hydatid cysts.

UNLABELLED: A review was carried out in Medline, LILACS and the Cochrane Library. Our database search strategy included the following terms: "hydatid cyst", "liver", "management", "meta-analysis" and "randomized controlled trial". No language limits were used in the literature search. The latest electronic search date was the 7(th) of January 2014. INCLUSION AND EXCLUSION CRITERIA: all relevant studies on the assessment of therapeutic methods for hydatid cysts of the liver were considered for analysis. Information from editorials, letters to publishers, low quality review articles and studies done on animals were excluded from analysis. Additionally, well-structured abstracts from relevant articles were selected and accepted for analysis. Standardized forms were designed for data extraction; two investigators entered the data on patient demographics, methodology, recurrence of HC, mean cyst size and number of cysts per group. Four hundred and fourteen articles were identified using the previously described search strategy. After applying the inclusion and exclusion criteria detailed above, 57 articles were selected for final analysis: one meta-analysis, 9 randomized clinical trials, 5 non-randomized comparative prospective studies, 7 non-comparative prospective studies, and 34 retrospective studies (12 comparative and 22 non-comparative). Our results indicate that antihelminthic treatment alone is not the ideal treatment for liver hydatid cysts. More studies in the literature support the effectiveness of radical treatment compared with conservative treatment. Conservative surgery with omentoplasty is effective in preventing postoperative complications. A laparoscopic approach is safe in some situations. Percutaneous drainage with albendazole therapy is a safe and effective alternative treatment for hydatid cysts of the liver. Radical surgery with pre- and post-operative administration of albendazole is the best treatment option for liver hydatid cysts due to low recurrence and complication rates.

Neonatal livers: a source for the isolation of good-performing hepatocytes for cell transplantation.

Hepatocyte transplantation is an alternative therapy to orthotopic liver transplantation for the treatment of liver diseases. However, the supply of hepatocytes is limited given the shortage of organs available to isolate good-functioning quality cells. Neonatal livers may be a potential source alternative to adult livers to obtain good-performing hepatic cells for hepatocyte transplantation, which has not yet been explored profoundly. High-yield preparations of viable hepatocytes were isolated from 1- to 23-day-old liver donors, cryopreserved, and banked. Cell integrity and functional quality assessment were performed after thawing. Neonatal hepatocytes showed better postthawing recovery compared with adult hepatocytes, as shown by the viability values that did not differ significantly from freshly isolated cells, a higher expression of adhesion molecules (ß1-integrin, ß-catenin, and E-cadherin), better attachment efficiency, cell survival, and a lower number of apoptotic cells. The metabolic performance of thawed hepatocytes has been assessed by ureogenesis and drug-metabolizing capability (cytochrome P450 and UDP-glucuronosyltransferase enzymes). CYP2A6, CYP2C9, CYP2E1, and CYP3A4 activities were found in all cell preparations, while CYP1A2, CYP2B6, CYP2C19, and CYP2D6 activities were detected only in hepatocytes from a few neonatal donors. The expression of UGT1A1 and UGT1A9 (transcripts and protein) was detected in all hepatocyte preparations, while activity was measured only in some preparations, probably due to lack of maturity of the enzymes. However, isoforms UGT1A6 and UGT2B7 showed considerable activity in all preparations. Compared to adult liver, the hepatocyte isolation procedure in neonatal livers also provides thawed cell suspensions with a higher proportion of hepatic progenitor cells (EpCAM(+) staining), which could also participate in regeneration of liver parenchyma after transplantation. These results could imply important advantages of neonatal hepatocytes as a source of high-quality cells to improve human hepatocyte transplantation applicability.

Trasplante de hepatocitos / No disponible

No disponible

Donantes de ayer y de hoy: ¿han cambiado las características de los donantes de hígado durante los últimos 15 años? / Donors yesterday and today: have the characteristics of liver donors changed over the last 15 years?

Introducción. Los cambios sociosanitarios y demográficos de nuestra población y el crecimiento de las listas de pacientes en espera de un trasplante han condicionado ciertas variaciones en los criterios de selección de los donantes de órganos. Material y método. Estudio retrospectivo, descriptivo y comparativo de las características de los donantes cadáver de hígado utilizados en la Unidad de Trasplante Hepático del Hospital Universitario La Fe de Valencia en 2 períodos diferentes. Distribuimos los casos en 2 grupos: grupo A, los primeros 200 donantes (entre enero de 1991 y junio de 1995) y grupo B, 200 donantes más recientes (desde febrero de 2004 hasta diciembre de 2005). Resultados. El número de donaciones se ha incrementado desde los 18 donantes durante 1991 a los 106 en 2006. En el grupo A la edad media fue de 32,4 años, frente a 52,3 años del grupo B. En la serie A, la principal causa de muerte fueron los traumatismos craneoencefálicos y en el grupo B, los accidentes cerebrovasculares. El tiempo en la unidad de cuidados intensivos fue mayor en el segundo grupo, con una media de 67,2 h. En el grupo B el 17% presentaba aterosclerosis considerable de la aorta y el 29,5%, esteatosis hepática macroscópica, frente al 5 y el 12%, respectivamente, en el grupo A. Conclusiones. Actualmente, los donantes de hígado son de mayor edad, presentan más enfermedades crónicas, mueren por enfermedades cerebrovasculares, permanecen más tiempo en cuidados intensivos y sus hígados son macroscópicamente peores que los de donantes de años anteriores (AU)

Introduction. The social, medical and demographic changes of our population and the increase in the number of patients on waiting lists have led to some changes in the selection criteria of organ donors. Material and method. A retrospective, descriptive and comparative study of the liver cadaveric donors features accepted in the Liver Transplant Unit in La Fe University Hospital of Valencia (Spain) in 2 different periods. We distributed the cases into 2 groups, including in group A the first 200 first donors (from January 1991 to June 1995) and in group B the last 200 donors (from February 2004 to December 2005). Results. The number of donors increased from 18 during 1991 to 106 in 2006. In group A the mean age was 32.4 years, compared to 52.3 years in group B. In group A, the main cause of death was craneoencephalic traumatism and in group B cerebrovascular accidents. The mean time in the intensive care unit was longer in the second group with 67.2 hours. In group B, considerable atherosclerosis was reported in 17% of cadaveric donors and macroscopic liver steatosis in 29.5%, compared to 5 and 12%, respectively, in group A. Conclusions. Nowadays, cadaveric liver donors are older, suffer more chronic diseases, die due to cerbrovascular diseases, remain longer in intensive care units and the livers are macroscopically worse compared to donors accepted 15 years ago (AU)

[Donors yesterday and today: have the characteristics of liver donors changed over the last 15 years?]. / Donantes de ayer y de hoy: han cambiado las características de los donantes de hígado durante los últimos 15 años?

INTRODUCTION: The social, medical and demographic changes of our population and the increase in the number of patients on waiting lists have led to some changes in the selection criteria of organ donors. MATERIAL AND METHOD: A retrospective, descriptive and comparative study of the liver cadaveric donors features accepted in the Liver Transplant Unit in La Fe University Hospital of Valencia (Spain) in 2 different periods. We distributed the cases into 2 groups, including in group A the first 200 first donors (from January 1991 to June 1995) and in group B the last 200 donors (from February 2004 to December 2005). RESULTS: The number of donors increased from 18 during 1991 to 106 in 2006. In group A the mean age was 32.4 years, compared to 52.3 years in group B. In group A, the main cause of death was craneoencephalic traumatism and in group B cerebrovascular accidents. The mean time in the intensive care unit was longer in the second group with 67.2 hours. In group B, considerable atherosclerosis was reported in 17% of cadaveric donors and macroscopic liver steatosis in 29.5%, compared to 5 and 12%, respectively, in group A. CONCLUSIONS: Nowadays, cadaveric liver donors are older, suffer more chronic diseases, die due to cerbrovascular diseases, remain longer in intensive care units and the livers are macroscopically worse compared to donors accepted 15 years ago.

[Hepatic undifferentiated (embryonal) sarcoma in an adult: a case report and literature review]. / Sarcoma indiferenciado (embrionario) de hígado del adulto: informe de un caso y revisión de la literatura médica.

Undifferentiated (embryonal) sarcoma of the liver (USL) is a rare malignant hepatic tumor in adults. We report the case of a 40-year-old man with USL who was successfully treated with surgical resection and chemotherapy using ifosfamide and adriamycin. To our knowledge, only 70 cases of USL in adults have been reported worldwide in the 40 years since this clinicopathological entity was defined. Although the prognosis of the disease remains generally poor, long term survival has been achieved in patients with a combination of surgery and chemotherapy.

Sarcoma indiferenciado (embrionario) de hígado del adulto: informe de un caso y revisión de la literatura médica / Hepatic undifferentiated (embryonal) sarcoma in an adult: a case report and literature review

El sarcoma indiferenciado (embrionario) de hígado (SIH) es un tumor hepático maligno que en raras ocasiones afecta al adulto. Presentamos el caso de un varón de 40 años de edad con SIH, tratado con cirugía y quimioterapia basada en iofosfamida y adriamicina con buenos resultados. Según nuestros datos, sólo hay 70 casos publicados en la literatura médica de pacientes adultos con SIH desde que se definió esta entidad clinicopatológica. En general, los pacientes tratados con cirugía asociada a quimioterapia obtuvieron mejores resultados que los sometidos únicamente a cirugía, si bien el pronóstico de este tipo de tumores sigue siendo poco esperanzador

Undifferentiated (embryonal) sarcoma of the liver (USL) is a rare malignant hepatic tumor in adults. We report the case of a 40-year-old man with USL who was successfully treated with surgical resection and chemotherapy using ifosfamide and adriamycin. To our knowledge, only 70 cases of USL in adults have been reported worldwide in the 40 years since this clinicopathological entity was defined. Although the prognosis of the disease remains generally poor, long term survival has been achieved in patients with a combination of surgery and chemotherapy

Reflexiones sobre 250 intervenciones de metástasis hepáticas de carcinoma colorrectal / Reflections on 250 interventions for colorectal carcinoma metastases to the liver

Introducción. Los mejores resultados en el tratamiento de las metástasis hepáticas de carcinoma colorrectal se obtienen con la resección quirúrgica, que debe realizarse con unos estándares de calidad. Objetivos. Presentar la experiencia de 11 años en el tratamiento quirúrgico de las metástasis hepáticas de carcinoma colorrectal en una unidad de referencia y comprobar si se cumplen los estándares actuales de calidad. Pacientes y método. Desde enero de 1995 hasta diciembre de 2005 se realizaron 250 intervenciones en 221 pacientes diagnosticados de metástasis hepáticas de origen colorrectal, con 201 resecciones hepáticas. Resultados. El 19% de los pacientes tenían una edad ≥ 70 años, con factores comórbidos asociados en el 54% de los casos. De las 201 resecciones, el 8,5% fue una segunda resección. En el 39% se realizó una hepatectomía mayor. La resección fue R0 en el 85% de los casos. No se transfundió en el 80% de los casos. La mediana de estancia postoperatoria fue de 6 días, la mortalidad postoperatoria fue del 0% y la morbilidad, del 19%. Se relacionaron con la morbilidad el número de segmentos resecados y la transfusión peroperatoria. Las supervivencias actuariales generales a 1, 3 y 5 años fueron del 96, el 69 y el 52% y las supervivencias actuariales libres de enfermedad para los mismos períodos fueron del 58, el 32 y el 24%, respectivamente. Conclusiones. La resección de las metástasis hepáticas de carcinoma colorrectal es una buena opción terapéutica cuando se cumplen los estándares de calidad actuales (AU)

Introduction. The best results in the treatment of colorectal cancer metastases to the liver are currently achieved with surgical resection performed under high quality standards. Objectives. To analyze the results and quality standards of the surgical treatment of colorectal cancer liver metastases in a referral liver unit over an 11-year period. Patients and method. From January 1995 to December 2005, 250 surgical interventions were performed in 221 patients diagnosed with colorectal cancer liver metastases, resulting in 201 hepatic resections. Results. Nineteen percent of patients were ≥ 70 years old and comorbidity was present in 54%. Of the 201 hepatic resections, 8.5% were second resections. Major hepatectomy was performed in 39% of the patients. R0 resection was achieved in 85% of the patients. Blood transfusions were not required in 80% of the patients. The median length of postoperative stay was 6 days. Postoperative mortality was nil and morbidity was 19%. Morbidity was associated with the number of resected segments and the need for blood transfusion. The estimated 1-, 3- and 5-year cumulative survival rates were 96%, 69% and 52%, respectively, while estimated disease-free survival rates were 58%, 32% and 24%, respectively. Conclusions. Resection of colorectal cancer liver metastases is an effective therapeutic alternative if high current quality standards are achieved (AU)

Tratamiento quirúrgico de la dilatación quística congénita de la vía biliar / Surgical treatment of congenital cystic dilatation of the biliary tract

Introducción. La dilatación quística congénita de la vía biliar (DQCVB) es una afección poco frecuente en nuestro medio. Pese a ser una enfermedad congénita, aproximadamente un tercio de los casos no se diagnostican en la infancia. Se clasifican en varios tipos, siendo el tipo I, o dilatación fusiforme de la vía biliar extrahepática, el más frecuente, presentándose en el 50-90 por ciento de casos, según las series. Pacientes y método. Se presentan los resultados de una serie de pacientes adultos ingresados en nuestro hospital durante los últimos 25 años con el diagnóstico de DQCVB; dicha serie consta de 11 pacientes, 8 mujeres y 3 varones, con una edad media de 41,8 años. Se revisan los antecedentes personales, la clínica, las exploraciones complementarias realizadas, la anatomía de la vía biliar y la encrucijada biliopancreática, la clasificación, las técnicas quirúrgicas llevadas a cabo, el análisis histopatológico de las piezas de resección, la evolución postoperatoria y el seguimiento a medio y largo plazo. Resultados. La variante más frecuente fue el tipo I (8 casos); el tamaño medio de la dilatación quística fue de 6,2 cm; la existencia de un canal común largo se pudo objetivar en tres de los 11 casos (27 por ciento); la técnica quirúrgica más empleada fue la exéresis completa del quiste, seguida de reconstrucción mediante hepaticoyeyunostomía en Y de Roux (7 casos); en un caso, la anatomía patológica informó de un adenocarcinoma adenopapilar infiltrante en la pared del quiste, y en otro de una metaplasia intestinal focal; un paciente falleció en el postoperatorio a consecuencia de un cuadro de sepsis. Conclusiones. Reafirmar la implicación de la existencia de un canal común largo en la fisiopatogenia de la DQCVB, la necesidad de disponer preoperatoriamente de un conocimiento de la anatomía de la vía biliar y la unión biliopancreática, y la indicación de elección de resección de la vía biliar afectada, con reconstrucción de la misma mediante hepaticoyeyunostomía en Y de Roux (AU)