Survival analysis of the surgical treatment of hepatocellular carcinoma at a tertiary care center.

INTRODUCTION AND AIMS: Hepatocellular carcinoma (HCC) is a primary malignant tumor of liver epithelial cells and is the most frequent primary liver cancer. The broadening of transplantation and resectability criteria has made therapeutic decisions more complex. Our aim was to describe the clinical and survival characteristics of patients with HCC treated through resection or liver transplantation at our hospital and identify the presence of factors that enable outcome prediction and facilitate therapeutic decision-making. MATERIALS AND METHODS: Patients with HCC that underwent surgery with curative intent at the Hospital Universitario Marqués de Valdecilla, within the time frame of 2007 and 2017, were retrospectively identified. Survival, mortality, disease-free interval, and different outcome-related variables were analyzed. RESULTS: Ninety-six patients with a mean follow-up after surgery of 44 months were included. Overall mortality and recurrence were higher in the resection group. Mean survival was 51.4 months in the liver transplantation group and 37.5 months in the resection group, and the disease-free interval was 49.4 ±â€¯37.2 and 27.4 ±â€¯28.7 months, respectively (p = 0.002). The tumor burden score was statistically significant regarding risk for recurrence and specific mortality. CONCLUSIONS: There appears to be no patient subgroup in whom the results of surgical resection were superior or comparable to those of transplantation. Tumor burden determination could be a useful tool for patient subclassification and help guide therapeutic decision-making.

Impact of radical nephrectomy on kidney function and prognostic factors for adverse cardiovascular events. / Impacto de la nefrectomía radical en la función renal y factores pronósticos de eventos cardiovasculares adversos.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after radical nephrectomy and to evaluate risk factors for adverse cardiovascular events during a long follow-up. MATERIAL AND METHODS: Retrospective study of patients submitted to radical nephrectomy due to renal cancer from January of 1996 to January of 2016. We evaluated their renal function after nephrectomy and during follow-up. We analyzed the possible predictive factors for adverse cardiovascular events with univariate and multivariate logistic regression analyses. RESULTS: There was an acute drop in glomerular filtration rate (GFR) after nephrectomy (21.2ml/min), which stabilized during follow-up in most cases. We evaluated the possible predictive factors for adverse cardiovascular events with logistic regression analyses, which presented previous cardiovascular disease (0,270, 95% CI 0,123-0,594, P<.001), diabetes (0,364, 95% CI 0,162-0,818 P=.015) and de novo hypertension (0,239, 95% CI 0,098-0,581, P=.002) as independently associated with the occurrence of adverse cardiovascular events. CONCLUSION: There was a deleterious effect in renal function after nephrectomy which remained stable during subsequent years in most patients. Approximately half of our patients had a GFR lower than 60mL/min after nephrectomy. Previous cardiovascular disease, diabetes and de novo hypertension were shown as risk factors for adverse cardiovascular events.

Liver Transplant From Controlled Cardiac Death Donors Using Normothermic Regional Perfusion: Comparison With Liver Transplants From Brain Dead Donors.

BACKGROUND: Liver transplantation from donors after either controlled or uncontrolled cardiac death (DCD) is associated with considerable rates of primary nonfunction (PNF) and ischemic cholangiopathy (IC). Normothermic regional perfusion (NRP) could significantly reduce such rates. METHODS: Retrospective study to analyze short-term (mortality, PNF, vascular complications) and long-term (IC, survival) complications in 11 liver transplants from controlled DCDs using NRP with extracorporeal membrane oxygenation (ECMO) (group 1). They were compared with 51 patients transplanted with grafts from donors after brain death (DBD) (group 2). Mean recipient age, sex, and Model for End-stage Liver Disease (MELD) score were not significantly different. RESULTS: In group 1, mean functional warm ischemia time was 15.8 (range, 7-40) minutes and 94.1 (range, 20-150) minutes on NRP. The ischemic damage was minimal, as shown by the slight alanine aminotransferase (ALT) and aspartate aminotransferase (AST) rises in the donor serum after 1 hour on NRP and similar rises 24 hours after transplantation in both groups. No patient had IC or acute renal failure. No significant difference was found between the groups for vascular or biliary complications. One group 1 patient had PNF (9.1%), resulting in death. Overall retransplantation and in-hospital death rates were 8.1% and 4.8%, respectively, with no significant difference between groups. Estimated mean survival was 24.6 (95% confidence interval [CI], 20.2-29.1) months in group 1 and 32.3 (95% CI, 30.4-34.2) months in group 2 (not a statistically significant difference). CONCLUSION: In our experience, liver transplants from controlled DCDs using NRP with ECMO is associated with a low risk of PNF and IC, with short- and long-term results comparable to those in DBD transplants.

Initial results of robot-assisted Ivor-Lewis oesophagectomy with intrathoracic hand-sewn anastomosis in the prone position.

BACKGROUND: There is scanty experience concerning robot-assisted Ivor-Lewis oesophagectomy, so every new experience is helpful. METHODS: We describe the techniques and short-term results of Ivor-Lewis oesophagectomy using a laparoscopic approach and robot-assisted thoracoscopy, and an observational study of prospective surveillance of the first 14 patients treated for oesophageal cancer. A gastric tube was created laparoscopically. Oesophagectomy was performed through a robot-assisted thoracoscopy followed by hand-sewn intrathoracic anastomosis. RESULTS: There were no conversion cases. Mortality was zero. Six patients had a major complication. There were no cases of respiratory complication or recurrent laryngeal nerve palsy. Three patients had a radiological fistula (21.4%), successfully treated by endoscopic stenting, and one (7.1%) had an anastomosis leak needing reoperation. There were two cases of chylothorax (14.3%). CONCLUSIONS: Our initial results suggest that the reported technique is safe and satisfies the oncological principles. It provides the advantages of minimally invasive surgery by overcoming some limitations of conventional thoracoscopy.

Traumatic neuroma of extrahepatic bile ducts after orthotopic liver transplantation.

Traumatic neuromas (TN) of the biliary tree causing strictures have only occasionally been described after liver transplantation. Herein, we have reported 15 cases of TN that were detected between 1 and 17 months after transplantation (median: 4 months) during surgery for obstructive jaundice (12 cases), after alterations of liver function tests (two cases), or incidentally discovered after retransplantation (n = 1) we resected the lesion and the biliary anastomosis. Pathological examination and immunostaining for S-100 protein were performed to study the nerve fascicles. After a median follow-up time of 64 months (range = 0-127), 10 patients are alive without any complication related to the previous biliary TN. We propose the following classification: type I: TN originating from and located in the main biliary tract wall, and type II: TN arising from the surrounding tissues next to the main biliary tract. We conclude that TN are not uncommon after liver transplantation and that they are sometimes symptomatic, causing a biliary stricture that requires surgical treatment. We propose a classification to help patient selection for surgery. In our opinion, resection of the TN is the operation of choice, together with resection of the involved biliary tract in type I TN.

HDA por metástasis gástrica como presentación de un carcinoma epidermoide de esófago / No disponible

No disponible

Absence of port-site metastases following staging laparoscopy for gastric carcinoma.

BACKGROUND: port-site metastases (PSM) have been reported following oncological laparoscopic surgery. However, their frequency after laparoscopic examination in gastric cancer has not been well established. MATERIAL AND METHODS: prospective follow-up of 41 patients having had a staging laparoscopy and a follow-up longer than 12 months. Mean age was 65 years (29-89). After staging, an open gastrectomy was performed in 33 cases. Mean follow-up was 21.4 (12-66) months. PSM was defined as a node in the former port-site wound with adenocarcinoma histology at biopsy. RESULTS: no patient showed clinical signs of PSM or port-site recurrence, even in advanced stages. We had no morbidity or postoperative mortality attributable to laparoscopic manoeuvres, and no need for laparotomy in cases without a gastrectomy indication. CONCLUSIONS: our results suggest that staging laparoscopy is a safe procedure in gastric carcinoma, as it is not associated with PSM after even considerable follow-up, and has a very low complication rate.

Valor pronóstico de la citometría de flujo en el linfoma gástrico / Prognostic value of flow cytometry in surgically treated primary gastric lymphoma

Aim: to investigate whether flow cytometry could help to definethe optimal therapeutic strategy of primary gastric lymphomas.Material and method: retrospective study of 46 patients havingprimary gastric lymphoma –according to Dawson criteria– inAnn Arbor stage IE and IIE, who were surgically treated. From selectedparaffin-embedded tissue blocks of the tumor, DNA contentwas studied by flow cytometry (FC). Other pathological tumor featureswere analysed by hematoxiline-eosine and Giemsa stains aswell as immunohistochemical study; any possible influence onpostoperative survival was investigated through statistical analysis.Results: the DNA ploidy pattern was diploid in 40 cases(87%) and aneuploid (hyperdiploid) in 6 (13%). Postoperative survivalprobability (PSP) was 62.7% at 5 years. Statistical analysisshowed significant prognostic value for Ann Arbor classification–with higher PSP for stage IE (p = 0.009)– and FC parameters: diploidtumors had higher PSP than aneuploid tumors. Also tumorshaving S-phase (p = 0.044) or G2-M phase values (p = 0.023) underthe respective mean values had higher PSP. No influence onPSP was found for wall invasion, Helicobacter pylori infection,Isaacson’s histologic type or resection margin involvement. Nosignificant relationship was appreciated between Isaacson’s histologictype and DNA ploidy patterns.Conclusion: FC could be useful in assessing gastric lymphomaprognosis

Objetivo: investigar si la citometría de flujo (CF) en el linfomagástrico primario podría ayudar a definir la estrategia terapéutica.Material y método: estudio retrospectivo de 46 pacientescon linfoma gástrico primario –de acuerdo con los criterios deDawson– en estadio IE y IIE de Ann Arbor, tratados quirúrgicamente.Se analizó el contenido tumoral de ADN mediante CF, a partirde preparaciones tumorales conservadas en parafina. Además seestudiaron otras características tumorales mediante tinciones dehematoxilina-eosina, giemsa y análisis inmuno-histoquímico. Seinvestigó su posible influencia sobre la probabilidad de supervivenciapostoperatoria (PSP) mediante análisis estadístico.Resultados: el patrón de ploidía tumoral fue diploide en 40casos (87%) y aneuploide (hiperdiploide) en 6 (13%). El análisis estadísticodemostró valor pronóstico para la clasificación de AnnArbor –con superior PSP para el estadio IE (p = 0,009)–, así comopara los parámetros de CF: los tumores diploides se asociaron auna PSP superior (p = 0.009), al igual que los tumores con valoresde fase S (p = 0,044) o fase G2-M (p = 0,023) inferiores a lasrespectivas medias. No se observó influencia sobre la supervivenciade la invasión tumoral en la pared, presencia de Helicobacterpylori, tipo histológico de Isaacson o afectación del borde de resección.Tampoco se apreció relación significativa entre el tipohistológico de Isaacson y el contenido de ADN.Conclusión: la CF podría ser útil para determinar el pronósticodel linfoma gástrico

Ausencia de metástasis en los orificios de trócares tras laparoscopia de estadificación en el carcinoma gástrico / Absence of port-site metastases following staging laparoscopy for gastric carcinoma

Introducción: se han descrito metástasis en puertos laparoscópicostras cirugía laparoscópica oncológica. Sin embargo, lafrecuencia tras los procedimientos laparoscópicos en el carcinomagástrico es poco conocida.Material y métodos: se realizó un estudio prospectivo de 41pacientes a quienes se había realizado laparoscopia de estadificación,con un seguimiento postoperatorio mayor de un año. Laedad media era de 65 años (29-89). Tras la estadificación, se realizógastrectomía abierta en 33 pacientes. El seguimiento mediofue de 22,4 meses (12-66). La metástasis en los orificios de trócaresse definió como un nódulo en la cicatriz de la puerta laparoscópicacon biopsia de adenocarcinoma.Resultados: ningún paciente presentó metástasis clínicas enlos orificios de trócares de laparoscopia, incluso en estadios avanzados.No evidenciamos morbilidad ni mortalidad postoperatoriaatribuible a las maniobras laparoscópicas ni necesidad de laparotomíaen pacientes sin indicación de gastrectomía.Conclusiones: nuestros resultados sugieren que la laparoscopiade estadificación en el carcinoma gástrico es un procedimientoseguro ya que no se asocia a metástasis en los orificios de trócartras un seguimiento considerable, y tiene una baja frecuencia decomplicaciones

Background: port-site metastases (PSM) have been reportedfollowing oncological laparoscopic surgery. However, their frequencyafter laparoscopic examination in gastric cancer has notbeen well established.Material and methods: prospective follow-up of 41 patientshaving had a staging laparoscopy and a follow-up longer than12 months. Mean age was 65 years (29-89). After staging, an opengastrectomy was performed in 33 cases. Mean follow-up was21.4 (12-66) months. PSM was defined as a node in the former portsitewound with adenocarcinoma histology at biopsy.Results: no patient showed clinical signs of PSM or port-siterecurrence, even in advanced stages. We had no morbidity orpostoperative mortality attributable to laparoscopic manoeuvres,and no need for laparotomy in cases without a gastrectomy indication.Conclusions: our results suggest that staging laparoscopy is asafe procedure in gastric carcinoma, as it is not associated withPSM after even considerable follow-up, and has a very low complicationrate

A novel mutation in the E-cadherin gene in the first family with hereditary diffuse gastric cancer reported in Spain.

AIMS: Mutations of the E-cadherin gene (CDH1) result in dominantly inherited hereditary diffuse gastric cancer (HDGC). We report a study in the first family diagnosed with HDGC in Spain, examining the presence of mutations in the CDH1 gene. METHODS: The presence of mutations was studied by direct sequencing of all CDH1 exons. Immunohistochemical analysis with specific antibodies was used to detect the expression of E-cadherin in normal and tumour tissue. RESULTS: A novel 1610delC mutation in exon 11 has been found in a Spanish family diagnosed with HDGC. This mutation generates a premature stop codon at position 1667 giving rise to a truncated protein that lacks the transmembrane and beta-catenin-binding domains. The presence of a 1610delC germline mutation was confirmed in three family members diagnosed with diffuse gastric cancer, and also in six asymptomatic members. Of note, the diffuse gastric cancer coexisted with a gastric lymphoma in the proband. Furthermore, immunohistochemical analyses of tumour tissue showed the complete absence of E-cadherin in the proband, revealing a second genetic hit at the CDH1 locus. CONCLUSIONS: We have identified a HDGC family in Spain that carries a novel germline truncating mutation in the CDH1 gene.

Do current indications for surgery of primary gastric lymphoma exist?

OBJECTIVE: To analyze the results of our series in order to assess whether surgical excision is still a valid therapeutic option in case the patient needs surgery. Secondarily, to analyze Helicobacter pylori infection rate. PATIENTS AND METHOD: A retrospective study of 69 consecutive patients having stage IE-IIE primary gastric lymphoma; of these, 65 were treated by gastrectomy between 1974 and 1999. Mean age: 62.6 years (28-85). New staining of paraffin-embedded samples from the surgical specimen were carried out (hematoxiline-eosine, Giemsa, immunohistochemistry) and reviewed. The histological classification was performed according to Isaacson's criteria. The statistical analysis was done by Chi-squared and Fisher's exact tests, as well as Kaplan-Meier and Log-Rank tests. RESULTS: Mortality was 9.2%. There were non-fatal complications in 10.8%. Helicobacter pylori was identified in 62.7%. Seven patients (11.9%) suffered a relapse. The 5-year survival probability was 87%. The statistical analysis did not show any influences of Ann Arbor stage, gastric wall invasion, Helicobacter pylori infection, histological type, or margin resection involvement on survival. CONCLUSIONS: Surgical excision provides a high rate of complete remissions and excellent long-term survival with acceptable mortality. Therefore it appears to be a valid treatment in case of emergency surgery, incidental finding, or lack of histological diagnosis.

¿Existen indicaciones actuales para la cirugía en el linfoma gástrico? / Do current indications for surgery of primary gastric lymphoma exist?

Objetivo: analizar los resultados de nuestra serie a fin de establecer si la extirpación quirúrgica continúa siendo una opción terapéutica válida para las situaciones en las que pudiera precisarse cirugía. Como objetivo secundario, analizar la prevalencia de infección por Helicobacter pylori. Pacientes y método: estudio retrospectivo de 69 pacientes consecutivos diagnosticados de linfoma gástrico primario, en estadio IE y IIE de Ann Arbor, 65 de los cuales fueron tratados mediante gastrectomía entre 1974 y 1999. Edad media: 62,6 años (28-85). En 60 casos se revisó la histología de la pieza de resección con nuevas tinciones (hematoxilina-eosina, Giemsa), y estudio inmunohistoquímico de los bloques de parafina. La clasificación histológica se realizó de acuerdo con la clasificación de Isaacson. El análisis estadístico se realizó mediante las pruebas de Chi cuadrado y prueba exacta de Fisher y Kaplan-Meier y Log-Rank para el análisis de supervivencia. Resultados: la mortalidad fue de 9,2%. Se produjeron complicaciones no mortales en 10,8%. Se identificó Helicobacter pylori en 62,7%. Se produjo recaída en 7 pacientes (11,9%). La probabilidad de supervivencia fue de 87% a 5 años. El análisis estadístico no demostró influencia del estadio de Ann Arbor, invasión en la pared gástrica, infección por Helicobacter pylori, tipo histológico, ni afectación de bordes sobre la supervivencia. Conclusiones: la extirpación quirúrgica posibilita un alto grado de remisión completa y una excelente supervivencia a largo plazo, con mortalidad aceptable, por lo que es un tratamiento válido en caso de ausencia de diagnóstico histológico, hallazgo incidental o urgencia

Objective: to analyze the results of our series in order to assess whether surgical excision is still a valid therapeutic option in case the patient needs surgery. Secondarily, to analyze Helicobacter pylori infection rate. Patients and method: a retrospective study of 69 consecutive patients having stage IE-IIE primary gastric lymphoma; of these, 65 were treated by gastrectomy between 1974 and 1999. Mean age: 62.6 years (28-85). New staining of paraffin-embedded samples from the surgical specimen were carried out (hematoxiline-eosine, Giemsa, immunohistochemistry) and reviewed. The histological classification was performed according to Isaacson’s criteria. The statistical analysis was done by Chi-squared and Fisher’s exact tests, as well as Kaplan-Meier and Log-Rank tests. Results: mortality was 9.2%. There were non-fatal complications in 10.8%. Helicobacter pylori was identified in 62.7%. Seven patients (11.9%) suffered a relapse. The 5-year survival probability was 87%. The statistical analysis did not show any influences of Ann Arbor stage, gastric wall invasion, Helicobacter pylori infection, histological type, or margin resection involvement on survival. Conclusions: surgical excision provides a high rate of complete remissions and excellent long-term survival with acceptable mortality. Therefore it appears to be a valid treatment in case of emergency surgery, incidental finding, or lack of histological diagnosis

Prognostic value of flow cytometry in surgically treated primary gastric lymphoma.

AIM: To investigate whether flow cytometry could help to define the optimal therapeutic strategy of primary gastric lymphomas. MATERIAL AND METHOD: Retrospective study of 46 patients having primary gastric lymphoma--according to Dawson criteria--in Ann Arbor stage IE and IIE, who were surgically treated. From selected paraffin-embedded tissue blocks of the tumor, DNA content was studied by flow cytometry (FC). Other pathological tumor features were analysed by hematoxiline-eosine and Giemsa stains as well as immunohistochemical study; any possible influence on postoperative survival was investigated through statistical analysis. RESULTS: The DNA ploidy pattern was diploid in 40 cases (87%) and aneuploid (hyperdiploid) in 6 (13%). Postoperative survival probability (PSP) was 62.7% at 5 years. Statistical analysis showed significant prognostic value for Ann Arbor classification--with higher PSP for stage IE (p = 0.009)--and FC parameters: diploid tumors had higher PSP than aneuploid tumors. Also tumors having S-phase (p = 0.044) or G2-M phase values (p = 0.023) under the respective mean values had higher PSP. No influence on PSP was found for wall invasion, Helicobacter pylori infection, Isaacson's histologic type or resection margin involvement. No significant relationship was appreciated between Isaacson's histologic type and DNA ploidy patterns. CONCLUSION: FC could be useful in assessing gastric lymphoma prognosis.

Fatal portal thrombosis after laparoscopic Nissen fundoplication.

Portal and mesenteric vein thrombosis is a very uncommon complication of laparoscopic surgery, especially after anti-reflux procedures. We report the case of a twenty-year-old man with a history of alcohol and cocaine consumption. A Nissen fundoplication was performed. The patient received a single 20-mg dose of enoxaparin (Clexane, Aventis Pharma, Spain) two hours before surgery for antithrombotic prophylaxis. On the seventh postoperative day the patient had a portal and mesenteric venous thrombosis, which was confirmed at laparotomy, with both extensive small-intestine necrosis and partial colon necrosis. Despite anticoagulant therapy, the patient died 24 hours later. Surgical findings were confirmed at necropsy. Portal and mesenteric venous thrombosis is an uncommon but severe and even fatal complication after laparoscopic anti-reflux surgery. When other pro-thrombotic, predisposing conditions such as laparoscopic surgery and cocaine consumption are present, the usual prophylactic doses of low molecular weight heparin might not be sufficient to protect against this life-threatening complication.

Trombosis mesentérica y portal tras funduplicatura de Nissen laparoscópica / Fatal portal thrombosis after laparoscopic Nissen fundoplication

La trombosis venosa mesentérica y portal es una complicacióninfrecuente de la cirugía laparoscópica. Presentamos el caso de unvarón de 20 años, consumidor de cocaína inhalada, al que se realizauna funduplicatura de Nissen laparoscópica, administrándose20 mg de enoxaparina (Clexane®, Aventis Pharma, Spain) preoperatoriamente.El séptimo día postoperatorio, el paciente presentauna trombosis venosa mesentérica y portal, que se confirmaen la laparotomía, con necrosis de todo el intestino delgado y segmentariadel colon, falleciendo el paciente a las 24 horas, a pesarde la terapia anticoagulante y confirmándose el diagnóstico en lanecropsia.La trombosis mesentérica y portal es una complicación infrecuentre,pero grave y potencialmente mortal, de la cirugía laparoscópicadel reflujo gastroesofágico. Cuando se asocian variosfactores predisponentes con un potencial trombótico demostradoaislado, como la cirugía laparoscópica y el consumo de cocaína,no parece que las dosis habituales de profilaxis tromboembólicasean suficientes para evitar esta grave complicación

Portal and mesenteric vein thrombosis is a very uncommoncomplication of laparoscopic surgery, especially after anti-refluxprocedures. We report the case of a twenty-year-old man with ahistory of alcohol and cocaine consumption. A Nissen fundoplicationwas performed. The patient received a single 20-mg dose ofenoxaparin (Clexane®, Aventis Pharma, Spain) two hours beforesurgery for antithrombotic prophylaxis. On the seventh postoperativeday the patient had a portal and mesenteric venous thrombosis,which was confirmed at laparotomy, with both extensivesmall-intestine necrosis and partial colon necrosis. Despite anticoagulanttherapy, the patient died 24 hours later. Surgical findingswere confirmed at necropsy.Portal and mesenteric venous thrombosis is an uncommon butsevere and even fatal complication after laparoscopic anti-refluxsurgery. When other pro-thrombotic, predisposing conditionssuch as laparoscopic surgery and cocaine consumption are present,the usual prophylactic doses of low molecular weight heparinmight not be sufficient to protect against this life-threateningcomplication