Unnoticed biloma due to liver puncture after Veress needle insertion.

Laparoscopic surgery has become more widespread in the last years. Creating the pneumoperitoneum is the first surgical procedure but it is still responsible for many of the adverse events described in this field. Until now, liver puncture producing a delayed biloma has not been described. We present a case where a biloma was developed after liver puncture by the Veress needle, during a laparoscopic procedure, and detected on the 3rd day. It was detected by CT scan and treated by laparoscopy. Biloma due to Veress needle is a new entity in the context of adverse events related to Veress needle insertion, which needs a high suspicious index. We recommend to do Palmer's test and to check the insertion and to look for possible lesions below with the camera in order to minimize incidence of such injuries. Should this happen, laparoscopic or percutaneous drainage are both suitable alternatives to solve this complication.

Multiple nodal locoregional recurrence of pheochromocytoma.

INTRODUCTION: Malignancy is present in 10% of pheochromocytomas (PCC) and is defined as local/vascular infiltration of surrounding tissues or the presence of chromaffin cells deposits in distant organs. The presence of isolated nodal recurrence is very rare and only 7 cases have been reported in the medical literature. PRESENTATION OF THE CASE: The case of a 32-y male with a symptomatic recurrence of a previously operated (2-years ago) PCC is presented. Radiological and functional imaging studies confirmed the presence of multiple nodules in the surgical site. A radical left nephrectomy with extensive lymphatic clearance in order to get an R0 resection was performed. The pathologist confirmed the diagnosis of massive locoregional nodal invasion. DISCUSSION: A detailed histological report and a thorough genetic study must be considered in every operated PCC in order to identify mutations and profiles of risk for malignancy. When recurrence or metastastic disease is suspected, imaging and functional exams are done in order to obtain a proper staging. Radical surgery for the metastatic disease is the only treatment that may provide prolonged survival. If an R0 resection is not possible, then a debulking surgery is a good option when the benefit/risk ratio is acceptable. CONCLUSION: Isolated lymph nodal recurrence is very rare in malignant PCC, with only 7 cases previously published. The role of surgery is essential to get long-term survival because provides clinical and functional control of the disease.

Thyroid metastasis as initial presentation of clear cell renal carcinoma.

INTRODUCTION: Metastatic tumors account for 1.4-2.5% of thyroid malignancies. About 25-30% of patients with clear cell renal carcinoma (CCRC) have distant metastasis at the time of diagnosis, being the thyroid gland a rare localization [5%]. PRESENTATION OF THE CASE: A 62-year woman who underwent a cervical ultrasonography and a PAAF biopsy reporting atypical follicular proliferation with a few intranuclear vacuoles "suggestive" of thyroid papillary cancer in the context of a multinodular goiter was reported. A total thyroidectomy was performed and the histology of a clear cell renal carcinoma (CCRC) was described in four nodules of the thyroid gland. A CT scan was performed and a renal giant right tumor was found. The patient underwent an eventful radical right nephrectomy and the diagnosis of CCRC was confirmed. DISCUSSION: Thyroid metastasis (TM) from CCRC are usually apparent in a metachronic context during the follow-up of a treated primary (even many years after) but may sometimes be present at the same time than the primary renal tumor. Our case is exceptional because the TM was the first evidence of the CCRC, which was subsequently diagnosed and treated. CONCLUSION: The possibility of finding of an incidental metastatic tumor in the thyroid gland from a previous unknown and non-diganosed primary (as CCRC in our case was) is rare and account only for less than 1% of malignancies. Nonetheless, the thyroid gland is a frequent site of metastasis and the presence of "de novo" thyroid nodules in oncologic patients must be always considered and studied.

Abdomen agudo secundario a complicación de miomatosis uterina gigante / Acute abdomen secondary to complication of a giant uterine myoma

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[Detection of neoplastic lesions in cirrhotic patients waiting for liver transplantation]. / Detección de lesiones neoplásicas en pacientes cirróticos candidatos a trasplante hepático.

INTRODUCTION: Hepatocellular carcinoma is a frequent complication of cirrhosis. Liver transplantation is a valid therapeutic option for this disease providing that certain morphologic selection criteria (Milan criteria) are fulfilled. OBJECTIVE: To evaluate the accuracy of pretransplantation imaging examinations in the detection and characterization of neoplastic lesions in cirrhotic candidates for liver transplantation. PATIENTS AND METHOD: We performed a retrospective study of 250 cirrhotic patients who underwent liver transplantation. The preoperative radiological diagnosis was compared with the definitive pathological diagnosis, allowing the diagnostic sensitivity of the different techniques, as well as the degree of agreement between pre- and postoperative tumoral staging, to be identified. RESULTS: Analysis of 250 specimens from total hepatectomy identified 58 patients with hepatic tumors, with a total of 136 nodules. Fifty-three patients had hepatocarcinoma, nine of which were found incidentally. There were six radiological false positive diagnoses. Sixty-two percent of patients with hepatocarcinoma had multiple lesions. The most sensitive technique for the diagnosis of tumors smaller than 1 cm was magnetic resonance imaging. Agreement between pre- and postoperative staging was found in only 63.6% of cases; consequently, 43% of the patients who exceeded the Milan criteria (20% stage T3 and 23% stage T4a) underwent transplantation. CONCLUSIONS: Currently used imaging techniques lead to a substantial proportion of incorrect stagings in terms of the size and number of lesions in cirrhotic patients.

Detección de lesiones neoplásicas en pacientes cirróticos candidatos a trasplante hepático / Detection of neoplastic lesions in cirrhotic patients waiting for liver transplantation

Introducción. El hepatocarcinoma es una complicación frecuente de la cirrosis. El trasplante hepático es una opción terapéutica válida para esta enfermedad siempre que se cumplan unos criterios morfológicos de selección (criterios de Milán). Objetivo. Valorar la eficacia de las pruebas de imagen en la detección y caracterización preoperatoria de lesiones neoplásicas en pacientes cirróticos candidatos a trasplante hepático. Pacientes y método. Estudio retrospectivo de 250 pacientes cirróticos trasplantados, en el que se compara el diagnóstico radiológico preoperatorio con el anatomopatológico definitivo, lo que permite conocer la sensibilidad diagnóstica de las diferentes pruebas, así como identificar el grado de concordancia entre la estadificación tumoral preoperatoria y la postoperatoria. Resultados. El estudio de las 250 piezas de hepatectomía total permitió identificar a 58 pacientes con tumor hepático, con un total de 136 nódulos tumorales. En 53 casos se trataba de hepatocarcinomas, 9 de los cuales fueron incidentales. Hubo 6 casos falsos positivos radiológicos. Los pacientes con hepatocarcinoma presentaban lesiones múltiples en el 62% de los casos. La resonancia magnética fue la técnica más sensible para el diagnóstico de lesiones menores de 1 cm. Sólo hubo concordancia entre la estadificación preoperatoria y la postoperatoria en el 63,6% de los casos, y ello condicionó que hubiera un 43% de pacientes que fueron trasplantados superando los criterios de Milán (el 20% en estadio T3 y el 23% en estadio T4a). Conclusiones. Las técnicas de imagen presentan un importante porcentaje de incorrecta estadificación en cuanto al diagnóstico del tamaño y el número de lesiones tumorales (AU)

Introduction. Hepatocellular carcinoma is a frequent complication of cirrhosis. Liver transplantation is a valid therapeutic option for this disease providing that certain morphologic selection criteria (Milan criteria) are fulfilled. Objective. To evaluate the accuracy of pretransplantation imaging examinations in the detection and characterization of neoplastic lesions in cirrhotic candidates for liver transplantation. Patients and method. We performed a retrospective study of 250 cirrhotic patients who underwent liver transplantation. The preoperative radiological diagnosis was compared with the definitive pathological diagnosis, allowing the diagnostic sensitivity of the different techniques, as well as the degree of agreement between pre- and postoperative tumoral staging, to be identified. Results. Analysis of 250 specimens from total hepatectomy identified 58 patients with hepatic tumors, with a total of 136 nodules. Fifty-three patients had hepatocarcinoma, nine of which were found incidentally. There were six radiological false positive diagnoses. Sixty-two percent of patients with hepatocarcinoma had multiple lesions. The most sensitive technique for the diagnosis of tumors smaller than 1 cm was magnetic resonance imaging. Agreement between pre- and postoperative staging was found in only 63.6% of cases; consequently, 43% of the patients who exceeded the Milan criteria (20% stage T3 and 23% stage T4a) underwent transplantation. Conclusions. Currently used imaging techniques lead to a substantial proportion of incorrect stagings in terms of the size and number of lesions in cirrhotic patients (AU)

[Pancreatic transplantation. Results of the Málaga group]. / Trasplante de páncreas: resultados del grupo Málaga.

INTRODUCTION: Pancreatic transplantation is currently the only therapeutic alternative able to restore normal blood glucose levels in diabetic patients. Moreover, this procedure can halt or even reverse diabetes-related complications. The aim of this study was to present our experience and the results of the first 4 years of a pancreatic transplantation program in our center. MATERIAL AND METHOD: From February 2000 to June 2004, 43 pancreatic transplantations were performed in 42 recipients in the Carlos Haya Regional Hospital in Malaga (Spain). In all patients, the technique of enteric drainage of exocrine pancreatic secretions and systemic venous shunting of endocrine secretions (to the inferior vena cava) was used. RESULTS: There were 37 (88.1%) simultaneous pancreas-kidney transplantations, 4 (9.5%) in patients with prior kidney transplantation and 1 retransplantation (2.4%). In all patients, glycosylated hemoglobin and C-peptide levels returned to normal. Patient and pancreatic graft survival were 91% and 84%, respectively, with a median follow-up of 19 months. The reintervation rate was 31%, with an overall rate of graft loss of 16%. CONCLUSIONS: The results obtained in our series are similar to those reported for large series.

Trasplante de páncreas: resultados del grupo Málaga / Trasplante de páncreas: resultados del grupo Málaga

Introducción. El trasplante de páncreas supone, hoy día, la única alternativa terapéutica capaz de restablecer una absoluta normalidad en las cifras de glucemia en el paciente diabético; además, va a frenar e incluso revertir las complicaciones derivadas de la diabetes. El objetivo de nuestro estudio es presentar la experiencia y los resultados de los 4 primeros años del programa de trasplante pancreático en nuestro centro. Material y método. Desde febrero de 2000 hasta junio de 2004 se han realizado en el Hospital Regional Carlos Haya de Málaga 43 trasplantes de páncreas en 42 receptores. En todos los pacientes se ha utilizado la técnica de drenaje entérico de la secreción exocrina y la derivación venosa sistémica (a cava inferior) para la endocrina. Resultados. Treinta y siete (88,1%) casos fueron trasplantes simultáneos páncreas-riñón (SPR), 4 (9,5%) en pacientes con riñón previamente trasplantado (PDR) y en 1 (2,4%) caso se trató de un retrasplante. En todos los casos se consiguió la normalización de la hemoglobina glucosilada y del péptido C. La supervivencia del paciente y del injerto pancreático han sido del 91 y del 84%, respectivamente, con una mediana de seguimiento de 19 meses. La tasa de reintervenciones ha sido del 31%, con un 16% del global de pérdida del injerto. Conclusiones. Nuestros resultados obtenidos son equiparables a lo publicado por las grandes series (AU)

Introduction. Pancreatic transplantation is currently the only therapeutic alternative able to restore normal blood glucose levels in diabetic patients. Moreover, this procedure can halt or even reverse diabetes-related complications. The aim of this study was to present our experience and the results of the first 4 years of a pancreatic transplantation program in our center. Material and method. From February 2000 to June 2004, 43 pancreatic transplantations were performed in 42 recipients in the Carlos Haya Regional Hospital in Malaga (Spain). In all patients, the technique of enteric drainage of exocrine pancreatic secretions and systemic venous shunting of endocrine secretions (to the inferior vena cava) was used. Results. There were 37 (88.1%) simultaneous pancreas-kidney transplantations, 4 (9.5%) in patients with prior kidney transplantation and 1 retransplantation (2.4%). In all patients, glycosylated hemoglobin and C-peptide levels returned to normal. Patient and pancreatic graft survival were 91% and 84%, respectively, with a median follow-up of 19 months. The reintervation rate was 31%, with an overall rate of graft loss of 16%. Conclusions. The results obtained in our series are similar to those reported for large series (AU)