PROGNOSTIC FACTORS IN PATIENTS WITH SURGICAL RESECTION OF PANCREATIC NEUROENDOCRINE TUMOURS.

CONTEXT: Pancreatic neuroendocrine tumours (PanNETs) are rare pancreatic neoplasms. PanNETs can be treated by multimodal approach including surgery, locoregional and systemic therapy. OBJECTIVE: The aim of the present study is to evaluate predictive factors of overall survival in patients with PanNETs surgically treated at a single center. SUBJECTS AND METHODS: The study group consisted of 120 patients with PanNETs who had undergone surgery at the Center of Digestive Diseases and Liver Transplantation of Fundeni Clinical Institute, Bucharest, Romania. Surgical resection of the primary tumor was performed in 110 patients. RESULTS: Tumor size > 2 cm (p=0.048) (90% CI) lymph node involvement (p=0.048), ENET grade (p<0.001), distant metastases (p<0.001), Ki 67 index (<2%, 2-5%, 5-10%, 10-20%, >20%) (p<0.001) were identified as significant prognostic factors for OS on univariate analysis. Using multivariate Cox proportional regression model we found that distant metastases and Ki 67 index were independent risk factors for the survival outcome. CONCLUSIONS: Surgery with curative intent should be considered in all cases if clinically appropriate and technically feasible. High grade (Ki67 index ≥10%) tumours were associated with a 2- fold increase in risk of death as compared to those with a Ki67 <10%.

Impact of a portal/superior mesenteric vein resection during pancreatico-duodenectomy for pancreatic head adenocarcinoma.

AIM: The impact of venous resection (VR) in pancreatico-dudenectomy (PD) for pancreatic adenocarcinoma (PDAC) is controversial. The aim of the study is to comparatively assess the postoperative outcomes after PD with and without VR for PDAC and to identify predictors of morbidity and survival in the subgroup of PD with VR. METHODS: The data of 51 PD with VR were compared with those of 183 PD without VR. Binary logistic regression and Cox survival analyses were performed. RESULTS: Both the operative time and estimated blood loss was significantly higher in the VR group (P<0.001). A trend towards an increased 90-day mortality (9.8% vs. 5.5%) and severe morbidity (20% vs. 13%) was observed when a VR was performed (P ≥0.264). The median overall survival time after the PD with and without VR was 13 months and 17 months, respectively (P=0.845). The absence of histological tumor invasion of the VR was found as the only independent predictor for a better survival (HR=0.359; 95% CI 0.161-0.803; P=0.013). CONCLUSION: A PD with VR can be safely incorporated in a pancreatic surgeon armamentarium. However, the trend towards increased mortality and severe morbidity rates should be expected, along with higher operative time and blood loss, compared with PD without VR. Associated VR does not appear to significantly impair the prognosis after PD for PDAC; however, histological tumor invasion of the VR has a negative impact on the survival.

Multiple visceral resection after locoregional recurrence of signet ring cell gastric cancer -- case report and literature review.

Recurrence is the most important cause of treatment failure in patients with advanced gastric cancer, even after curative surgery. Surgery plays an important role in these patients,even in cases of multivisceral involvement. In selected cases good biological resources - surgery is the only viable choice to prolong survival. This report describes the case of a 41 year-old patient presenting a locoregional recurrence with multiple visceral involvement at 15 months after radical subtotal gastrectomy with D2 lymph node dissection for antral gastric cancer.

Technical aspects of biliary reconstruction correlated with biliary complications in 46 consecutive right lobe liver transplantations from living donors.

INTRODUCTION: Biliary complications contribute to a high morbidity rate in patients with right lobe liver transplant from a living donor. We retrospectively evaluated biliary reconstructions and complications in a number of recipients with liver transplant from a living donor, in a single center. PATIENTS AND METHODS: A number of 46 patients (23 males and 23 females aged 9-63) received a right lobe liver graft between 2009 and 2013, with the following types of biliary reconstruction:duct-to-duct choledochocholedochal anastomosis (n=24)or Roux-en-Y hepaticojejunoanastomosis, with or without an external transanastomotic biliary stent. RESULTS: The rate of biliary complications (leakage 15.21%,anastomotic stenosis 4.34%, overall 17.39%) was not statistically significantly influenced by the demographics of the studied lot, by the etiology of the liver disease or by the characteristics of the biliary reconstruction; the only risk factor which showed a statistically significant influence in terms of biliary complications was MELD. CONCLUSION: The type and technique of the biliary reconstruction in LDLT should be adapted depending on the anatomy of the biliary tree of both the donor and recipient, as well as the clinical and laboratory findings of the recipient.

A case report of pancreatic transection by blunt abdominal trauma.

Posttraumatic pancreatic rupture is associated with high morbidity and mortality. Various management strategies are described, but due to the relative rarity of this pathology no standards exist. We reported a 21 years old male with post traumatic complete rupture of the pancreatic isthmus,devascularization lesion of descending duodenum, right renal artery posttraumatic thrombosis and left lobe of the liver laceration. Laparotomy for hemostasis was initially performed in a different hospital and the patient was then referred to us.Pancreaticoduodenectomy and right nephrectomy were performed. Postoperatively the patient had a pancreaticojejunal anastomosis fistula spontaneously resolved at 45 days.Pancreaticoduodenectomy can in selected cases be a solution in pancreatic trauma.

Liver transplantation in a patient with unresectable colorectal liver metastases -- a case report.

BACKGROUND: Due to the lower survival rates achieved, in the early period of liver transplantation era, in patients with colorectal liver metastases, and because of the organ shortage,in the last two decades colorectal liver metastases are considered a contraindication for liver transplantation. However, the increasing number of marginal donors, and the improvements in posttransplant immunossuppresion, chemotherapy and methods to assess the extrahepatic disseminationof colorectal cancer, opened the perspective of liver transplantation to certain patients with malignancies (such as HCC beyond Milan criteria, and selected patients with cholangiocarcinomaor liver metastases from neuroendocrine tumors).Since some of these patients experienced favorable outcomes,in the last years, there were authors that considered a rationalerevisitation of the benefits of liver transplantation in patients with unresectable colorectal liver metastases. Thus, in 2006, a Norwegian group started a study which aims to assess the results of liver transplantation in patients with unresectable colorect alliver metastases. Their results were unexpectedly favorable, revealing that 5-year overall survival rate was 60%, and the quality of life was excellent in the first year following transplantation.However, all the patients presented relapse of the disease in the first two years following transplantation. In the present paper we present the clinico-pathologic characteristics,the pre- and postoperative management and the outcome of a patient with unresectable colorectal liver metastases who underwent liver transplantation in a very advanced state of the disease (when he developed subacute liver failure due to insufficient functional liver parenchyma and toxicity of chemotherapy).We consider useful to present such observations,because collecting the data presented by different centers maybe contributive to identification of a selected group of patients who could benefit from liver transplantation. CASE REPORT: A 42-year old male patient, it was diagnosed with upper rectum cancer and multiple bilobar liver metastases in April 2009. Chemotherapy was started (in another hospital),and because the disease was stable after 7 cycles of FOLFOX and Bevacizumab, the patient was reffered to surgery (for a "two stage" liver resection). In October 2009 it was performed primary tumor resection associated with left lateral section ectomy and segment 4 metastasectomy. Because in November 2009 CT scan re-evaluation revealed progression of liver metastases, the second stage hepatectomy was precluded. Subsequent therapy consisted in radio embolization, multiple lines of chemotherapy,and targeted therapies. After more than 2 years, the liver metastases progressed and the patient developed progressive cholestatic subacute liver failure due to insufficient functional liver parenchyma and chemotherapy toxicity. In this state of the disease, he was admitted in our hospital, being dependant by liver dialysis and plasma exchange procedures. Due to the patients' age, and because the MDCT scan revealed the absence of extrahepatic disease (after almost three years of disease progression), and he could not benefited from any type of antineoplastic treatment due to progressive cholestatic subacute liver failure, liver transplantation with an organ from amarginal donor was considered and performed in January 2012.The postoperative course was uneventful, and the quality of his life improved (being fully reinserted social and professional).The immunosuppressive regimen consisted in Sirolimus and Mycophenolate mofetil, and the adjuvant chemotherapy started two months following liver transplantation. However,the patient developed extrahepatic relapse of the disease (lung metastases and retroperitoneal recurrence), but now, at morethan 20 months following transplantation, he is still alive in agood clinical condition. CONCLUSIONS: In patients with multiple unresectable liver onlycolorectal metastases, liver transplantation may improve overallsurvival and quality of life, by using marginal grafts whichcannot be allocated to the patients with standard indicationsfor liver transplantation. The advent of MDCT and PET CT scan and the use of m-TOR inhibitors may improve the resultsachieved by liver transplantation in patients with CLMs.Further studies could be useful in an attempt to disclosewhether a selected group of patients with unresectable liveronly colorectal metastases could become acceptable candidatesfor liver transplantation.

Living donor liver transplantation with dual grafts -- a case report.

BACKGROUND: Living donor liver transplantation (LDLT) exposes to risks both the donor, due to a potential small residual liver volume, and the recipient, who faces the risk of small-for-size graft syndrome. In order to overcome these drawbacks, liver grafts from two different donors can be used. This paper presents a case of dual graft LDLT using a right hemiliver and a left lateral section from related donors. CASE PRESENTATION: A 14-year old female diagnosed with chronic hepatic failure due to Wilson's disease with Model-for-End- Stage-Liver-Disease score of 25, underwent a dual graft LDLT, receiving a right hemiliver with a reconstructed middle hepatic vein from her sister, and a left lateral section from her mother. None of the grafts complied with a satisfactory graft-to-recipient weight ratio (GRWR), if they would have been independently transplanted. The combined GRWR was 1.10. The donors and the recipient have been followed-up for over 1 year. RESULTS: The donors had no postoperative complications. The donors and the recipient were discharged 8 and 19 days after surgery, respectively. After 12-month follow-up, both donors and the recipient were alive, with normal graft function. CONCLUSION: Dual graft LDLT can be a feasible solution to overcome the risk of small-for-size graft syndrome. ABBREVIATIONS: BSA = body surface area, GRWR = graft-to-recipient weight ratio, GV SLV = recipient standard liver volume, HA = hepatic artery, HD = hepatic duct, HV = hepatic vein, LDLT = Living donor liver transplantation, LL = left lobe, LLS = left lateral section, MELD = Model for End-Stage Liver Disease, POD = postoperative day, PV = portal vein, RL = right lobe, SFS = small-for-size graft, SLV = standard liver volume, WD = Wilson's disease.

[The role of the middle hepatic vein in the living donor liver transplantation with right hemiliver]. / Rolul venei hepatice medii în transplantul hepatic de la donator viu cu hemificat drept.

BACKGROUND: Living donor liver transplantation has appeared and developed as a consequence to the shortage of organs. In case of right hemiliver procurement, the role of the middle hepatic vein is crucial for the prevention of right anterior section congestion and the promotion of liver regeneration. MATERIAL AND METHOD: We performed a retrospective study on a group of 36 adult patients who underwent living donor liver transplantation with right hemiliver in Fundeni Clinical Institute, having as a major indication liver cirrhosis. Concerning the middle hepatic vein, this was procured in 10 cases, not procured nor reconstructed in another 10 cases, and reconstructed on the bench in 16 cases. RESULTS: The immediate postoperative survival was roughly 91%, with 7 cases of "small for size syndrome", 2 cases being retransplanted. CONCLUSIONS: In case of living donor liver transplantation with the right hemiliver, the reconstruction of the middle hepatic vein helps the liver regeneration and prevent the "small for size" syndrome.

[Biliary complications following liver transplantation]. / Complicatiile biliare post transplant hepatic.

The biliary complications (BC) were always considered the "Achilles heel" of liver transplantation, being one of the leading causes of postoperative morbidity. The technique of the biliary reconstruction depends on the surgical procedure and it has a major impact on the patients and the graft evolution. The most frequent types of BC were stenoses, leaks, bilomas, cholangitis, etc. As an incidence, there is a peak of BC in the first 6 months after the transplant, a third of them appearing in the first month. Among the major BC risk factors, the most important are: hepatic artery pathology, the use of partial liver graft, bilioplasty and the number of biliary ducts and anastomoses. The BC management can be conservative, interventional or surgical depending on the type of BC. Along with the improvement of the interventional radiological and endoscopic methods, a large number of BCs are successfully treated non-surgically. There are still a few circumstances in which surgery is mandatory such as important persistent biliary leaks, even more when a partial liver graft was used or in association with hepatic artery pathology when re-transplantation is required. Multiple or serial biliary stenoses can lead to surgical revision. Although BC plays an important role in the patients postoperative morbidity, by early diagnosis and through numerous therapeutic methods promptly applied, there is no major impact on mortality.

[Liver transplantation--indications, surgical technique, results--the analysis of a clinical series of 200 cases]. / Transplantul hepatic--indicati, tehnica, rezultate-analiza unei serii clinice de 200 de cazuri.

INTRODUCTION: Initially considered experimental, liver transplantation (LT) has become the treatment of choice for the patients with end-stage liver diseases. MATERIAL AND METHODS: Between April 2000 and October 2009, 200 LTs (10 reLTs) were performed in 190 patients, this study being retrospective. There were transplanted 110 men and 80 women, 159 adults and 31 children with the age between 1 and 64 years old (mean age--39.9). The main indication in the adult group was represented by viral cirrhosis, while the pediatric series the etiology was mainly glycogenosis and biliary atresia. There were performed 143 whole graft LTs, 46 living donor LTs, 6 split LTs, 4 reduced LTs and one domino LT RESULTS: The postoperative survival was 90% (170 patients). The patient and graft one-year and five-year survivals were 76.9%, 73.6% and 71%, 68.2%, respectively. The early complications occurred in 127 patients (67%). The late complications were recorded in 71 patients (37.3%). The intraoperative and early postoperative mortality rate was 9.5% (18 patients). CONCLUSIONS: The Romanian liver transplantation program from Fundeni includes all types of current surgical techniques and the results are comparable with those from other international centers.