Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years.

BACKGROUND: The study aim is to analyze the evolution over the last 25 years of the results reported after abdominal oncological surgery in patients aged 80 years of age and older. The primary endpoint was morbidity and mortality in this group of patients; the secondary endpoint was overall survival. METHODS: A systematic search strategy was used to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials using a combination of standardized index terms. Studies published between 1997 and 2017 were selected. Only those studies that showed morbidity and mortality after digestive and hepatobiliary tract oncological surgery in individuals aged 80 years and older were included. The PROSPERO registration number is CRD42018087921. PRISMA and MOOSE guidelines were applied. RESULTS: A total of 79 studies were included, categorized by origin of malignancy: esophageal (7), stomach (26), liver (4), pancreas (19), and colorectal (23). Compared with the non-elderly group, the elderly group had similar esophageal morbidity with higher mortality (RR 2.51, 1.50 to 4.21; P = 0.0005); higher gastric morbidity (RR 1.25, 1.09 to 1.43; P = 0.001), and mortality (RR 2.51, 1.81 to 3.49; P = 0.0001); similar liver morbidity and mortality; higher pancreatic morbidity (RR 1.17, 1.03 to 1.33; P = 0.02) and mortality (RR 2.37, 1.86 to 3.03; P < 0.00001); and similar colorectal morbidity with higher mortality (RR 4.44, 1.91 to 10.32; P = 0.005). CONCLUSION: Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.

Psoas Muscle Index Does Not Predict Post-Transplant Outcomes: A Series of 57 Liver Transplant Recipients.

BACKGROUND: Sarcopenia is defined as the loss of muscle mass and function. Our aim is to evaluate the degree of sarcopenia by measuring the patients on the waiting list for liver transplantation and its influence on the different post-liver transplant outcomes in our group. METHODS: The psoas muscle index (PMI, cm2/m2) was calculated (right psoas muscle area [cm2]/the square of the body height [m2]) in 57 patients on the waiting list for liver transplantation in our center, and the post-transplant variables relevant to our study were collected. RESULTS: The 57 recipients had a mean age of 57 years (range, 35-73) and had a mean of 7.4 months (range, 0-39) on the liver transplant waiting list. The mean psoas muscle index was 2.39 (range, 1-4), and the mean body mass index was 28.01kg/m2 (range, 22-36). After multivariate analysis we found a positive correlation between the PMI and the body mass index of the recipients (r = 0.320, P = .017), intensive care unit length of stay, and donor age (r = 0.319, P = .042), and between cold ischemia time and graft survival (r = 0.366, P = .009). We found no correlation in our sample between PMI and post-liver transplant complications either in terms of graft or patient survival. CONCLUSION: PMI is not representative of total muscle mass and sarcopenia and is not effective in adequately predicting the survival of patients on the waiting list for liver transplantation.

Impact of Hepatic Artery Thrombosis on the Success of a Liver Transplant Because of Hepatocellular Carcinoma.

BACKGROUND: Hepatic artery thrombosis is one of the most serious complications after liver transplant. Our objective is to evaluate the impact of arterial thrombosis on the postoperative evolution of a series of patients who received transplants because of hepatocellular carcinoma. METHODS: A retrospective study of 100 consecutive hepatocellular carcinoma liver transplants was performed from January 2011 to November 2017. RESULTS: Of the 100 transplant recipients, we have observed hepatic artery thrombosis in 4 of them, 3 premature and 1 delayed. All of them received retransplants after diagnosis by hepatic artery ultrasonography and arteriography. The descriptive analysis showed a significant relationship between the appearance of hepatic artery thrombosis with variables of postoperative severity, such as arrhythmias, atelectasis, pleural effusion, hemodialysis requirement, acute kidney failure, and respiratory failure. Although patients with hepatic artery thrombosis had a longer mean hospital stay, this was not statistically significant. There was decreased graft survival and overall survival of patients who experienced hepatic artery thrombosis. CONCLUSION: Although the incidence of hepatic artery thrombosis has been relatively low (4%), the early detection of risk factors, such as arterial anatomic anomalies that condition a complex anastomosis, should draw our attention, thus having at our disposal strict ultrasonography and arteriography surveillance protocols as well as prophylactic anticoagulation guidelines for receptors at risk.

Liver Transplantation for Fulminant Hepatic Failure Due to Heat Stroke: A Case Report.

Heat stroke is a condition caused by an excessive increase in body temperature in a relatively short period of time, and is clinically characterized by central nervous system dysfunction, including delirium, seizures, coma, and severe hyperthermia. In this context, the resulting fulminant hepatic failure makes liver transplant the best choice when there are no guarantees of better results with conservative treatment. We present our experience in this case, possible alternative choices, and the current role of liver transplantation in the resolution of fulminant liver failure due to heat stroke. CASE REPORT: We report the case of a 32-year-old man with a history of malabsorption syndrome and unconfirmed celiac disease controlled with a gluten-free diet, who, while working on a typical summer midday in southern Spain (approximately 40°C), abruptly presented with loss of consciousness, coma, and a temperature of 42°C, as well as seizures at the initial medical assessment that subsided after the administration of diazepam. On the third day, the patient presented with multiple organ dysfunction syndrome, requiring mechanical ventilation, hemodialysis, and inotropic support. He did not improve with the support of conservative treatment, therefore it was decided to perform an urgent liver transplant, after which he recovered completely. CONCLUSIONS: Liver transplantation should be a main choice of treatment for cases in which, despite intensive medical treatment, there is still clinical and analytical evidence of massive and/or irreversible hepatocellular damage.

Molecular Adsorbent Recirculating System Treatment Can Reduce Blood Levels of N-Acetylcysteine in Patients With Acetaminophen Overdose: Case Reports.

BACKGROUND: Acetaminophen poisoning continues to be a major cause of liver failure that can lead to liver transplantation. N-acetylcysteine (NAC) is the cornerstone of treatment. Some authors use a Molecular Adsorbent Recirculating System (MARS) system in acetaminophen poisoning. It is reported that the MARS system eliminates acetaminophen more efficiently than conventional dialysis. It is theoretically possible that treatment with MARS administered after NAC will increase the effectiveness of treatment. CASE REPORTS: The first patient, a woman of 14 years old, presented blood levels of 112 mg/dL 12 hours after ingestion of 15 g of acetaminophen. Treatment with NAC was initiated. At 17 and 23 hours after ingestion, blood levels were 23.5 µg/mL and 5.9 µg/mL, respectively. The second patient, a woman of 28 years old, presented blood levels of 115 mg/dL 4 hours after ingestion of 40 g of acetaminophen. Treatment with NAC was initiated. At 14 and 23 hours after ingestion, blood levels were 15.8 µg/mL and <2 µg/mL, respectively. In both patients, we performed MARS after completing treatment with NAC, and after the first session, blood levels were below the lower limit of detection (≤2 µg/mL). DISCUSSION: The correct timing of MARS to avoid interactions with the administered dose of NAC in acetaminophen overdose is essential so as to not impair the effectiveness of this treatment. These considerations in the management of this entity help in the resolution of liver failure, thus avoiding the need for a liver transplant.

Oncological Evaluation by Positron-emission Tomography, Circulating Tumor Cells and Alpha Fetoprotein in Patients With Hepatocellular Carcinoma on the Waiting List for Liver Transplantation.

INTRODUCTION: The objectives of this study are the determination of the number of circulating tumor cells (CTCs), by means of the IsoFlux enrichment system (Fluxion Biosciences Inc, San Francisco, California, United States) in patients with hepatocellular carcinoma (HCC) in compliance with the Milan criteria and on the waiting list for hepatic transplantation, as well as the study of its relation with the of α-fetoprotein levels (AFP) and positron-emission tomography-computed tomography (PET-CT) findings. PATIENTS AND METHODS: An oncologycal evaluation with PET-CT, CTCs, and AFP was conducted in 24 consecutive patients with HCC eligible for orthotopic liver transplantation according to the Milan criteria. The diagnosis of HCC was made according to clinical, biological, and radiological findings. RESULTS: We detected CTCs in peripheral blood in 21 of 24 patients (87.5%) before liver transplantation, with a mean number CTCs of 156 ± 370 (range, 2 to 1768) with statistically significant association between number of CTCs detected in peripheral blood and the time within the waiting list (P < .05), but not betwen AFP levels and standard uptake value and time to orthotopic liver transplantation (P > .05). CONCLUSIONS: PET-TC, CTCs, and AFP levels could be an essential key for the correct management of the patients with HCC on the waiting list for liver transplantation.

Should ALPPS be Used for Liver Resection in Intermediate-Stage HCC?

BACKGROUND: Extended liver resections in patients with hepatocellular carcinoma (HCC) are problematic due to hepatitis, fibrosis, and cirrhosis. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been promoted as a novel method to induce hypertrophy for patients with extensive colorectal liver metastases, but outcomes in HCC have not been well investigated. METHODS: All patients registered in the international ALPPS Registry ( www.alpps.org ) from 2010 to 2015 were studied. Hypertrophy of the future liver remnant, perioperative morbidity and mortality, age, overall survival, and other parameters were compared between patients with HCC and patients with colorectal liver metastases (CRLM). RESULTS: The study compared 35 patients with HCC and 225 patients with CRLM. The majority of patients undergoing ALPPS for HCC fall into the intermediate-stage category of the Barcelona clinic algorithm. In this study, hypertrophy was rapid and extensive for the HCC patients, albeit lower than for the CRLM patients (47 vs. 76 %; p < 0.002). Hypertrophy showed a linear negative correlation with the degrees of fibrosis. The 90-day mortality for ALPPS used to treat HCC was almost fivefold higher than for CRLM (31 vs. 7 %; p < 0.001). Multivariate analysis showed that patients older than 61 years had a significantly reduced overall survival (p < 0.004). CONCLUSION: The ALPPS approach induces a considerable hypertrophic response in HCC patients and allows resection of intermediate-stage HCC, albeit at the cost of a 31 % perioperative mortality rate. The use of ALPPS for HCC remains prohibitive for most patients and should be performed only for a highly selected patient population younger than 60 years with low-grade fibrosis.

Clinical Significance of Contamination of the Preservation Solution in Liver Transplantation.

INTRODUCTION: The aim of the present study was to describe the incidence and microbiological profiles of positive cultures obtained from preservation solution (PS) and correlate these findings with infectious complications detected in the liver transplant (LT) recipient. PATIENTS: We conducted a single-center, retrospective study between December 2010 and August 2014 among 178 LT. In all grafts, a PS culture was carried out. All the infections in the receipt until hospital discharge were collected. In patients with >1, infection was considered the most severe according to Clavien-Dindo classification. RESULTS: PS culture was positive for bacterial or fungal agents in 79 of 178 LT recipients (44%). The most commonly cultured organisms were coagulase-negative staphylococci (64%), Enterobacteriaceae (17%), and Staphylococcus aureus (4.7%). In the 79 patients with positive PS, 49 blood cultures were requested in the period after LT. Twenty-five postoperative infections (31.7%) were diagnosed. Only 4 of 79 patients (5%) with PS contamination had a postoperative infections related with isolated microorganism. CONCLUSIONS: Contamination of PS appears in a high percentage of liver grafts before LT, although there is a poor correlation with postoperative infections in LT recipient. In these patients, a standardized process including fungal and bacterial cultures could be useful.

Improving the waiting list by using 75-year-old donors for recipients with hepatocellular carcinoma.

The best treatment for hepatocellular carcinoma (HCC) associated with liver cirrhosis is liver transplantation and the best results are obtained when the tumors fulfill the Milan criteria. However, although the number of transplants is increasing, the organ deficit is growing, which lengthens time on the waiting list, increasing the risk of tumor progression of and exclusion from the list. The use of elderly donors is a valid option for patients on the transplant waiting list with HCC, reducing time on the waiting list. We report our experience with patients transplanted for HCC associated with hepatic cirrhosis using livers from donors >75 years of age. Our preliminary results supported the use of elderly suboptimal donors making it possible to give priority to these patients. All patients in the series achieved good graft function after a follow-up of 2 years with a 100% disease-free survival rate. More extensive long-term studies are needed to confirm these findings.

Tolerancia y quimerismo en el trasplante hepático / Tolerance and chimerism in liver transplantation

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[Fulminant hepatic failure and liver transplantation. Experience of the Hospital Virgen de la Arrixaca]. / Fracaso hepático fulminante y trasplante hepático. Experiencia del Hospital Virgen de la Arrixaca.

INTRODUCTION: Medical treatment for fulminat hepatic failure seeks spontaneous recovery of the liver function, but the results are very discouraging (50-80% mortality). Liver transplantation is an option in patients with a poor evolution despite medical treatment, with survival rates of > 50%. The ideal moment for performing the transplant is controversial, as it should not be done too soon, when the liver disease is still reversible, or tool late, when the patient is in an irreversible clinical situation. PATIENTS AND METHOD: A retrospective review was made of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure, of whom 26 underwent transplantation. The most frequent cause was viral, with 10 cases (38%); no aetiology at all could be established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of ABO/DR compatibility, 13 cases were identical (40%), 17 compatible (51%) and the other 3 incompatible (9%). RESULTS: Thirty-three transplants were performed in 26 patients: 4 were retransplants due to chronic rejection, 2 for primary graft failure and 1 for hyperacute rejection. The overall mortality rate was 46% (12 patients), the most frequent cause of death being infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years and 59% at 5 years. The factors of poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the latter being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the latter being the only prognostic factor identified in the multivariate analysis. CONCLUSIONS: The achievement of good results with the use of transplantation in the management of fulminant hepatic failure depends on an optimum selection of transplant candidates, which means identifying them early, i.e. early indication for transplant, reduction in mean waiting time and exclusion of factors of poor prognosis.

Reparación de la iatrogenia biliar poscirugía laparoscópica en centros con experiencia en cirugía hepatobiliar / Repair of iatrogenic lesions of the biliary tract after laparoscopic surgery in centers with experience in hepatobiliary surgery

Introducción. La colecistectomía realizada por vía laparoscópica se acompaña de una incidencia de lesiones iatrogénicas de la vía biliar principal mayor que cuando se realiza por vía abierta. Estas lesiones son más graves, al ser más altas en su localización, afectando a la vía biliar intrahepática y con frecuente desaparición de tramos completos de la misma, lo que dificulta su diagnóstico y tratamiento quirúrgico. Pacientes y método. Se presentan 10 casos de lesiones iatrogénicas de la vía biliar principal tras colecistectomía laparoscópica intervenidos en nuestro servicio, tres de ellos con afectación de la vía biliar intrahepática. En los 7 casos de localización extrahepática se practicó una hepaticoyeyunostomía en "Y" de Roux en 4 casos, una coledococoledocostomía terminoterminal sobre tubo en "T" de Kehr en otros 2 casos (en ambos hubo que realizar posteriormente una hepaticoyeyunostomía en "Y" de Roux) y, en el restante, un cierre de una sección parcial del colédoco sobre un tubo en "T" de Kehr. En los 3 casos de lesión intrahepática fracasó una primera reconstrucción en "Y" de Roux, precisando un abordaje intrahepático con tutores múltiples y nueva hepaticoyeyunostomía en "Y" de Roux. Resultados. Todos los enfermos se encuentran asintomáticos y con unas analíticas normales tras un seguimiento medio de 39,2 meses. Conclusión. Las lesiones iatrogénicas de la vía biliar principal tras colecistectomía laparoscópica pueden requerir cirugía compleja para su tratamiento, por lo que deben ser referidas a centros con experiencia en cirugía hepatobiliar, sobre todo si son de localización intrahepática (AU)

El desarrollo de seroma poslinfadenectomía axilar por cáncer de mama y su relación con determinados parámetros del drenaje aspirativo / Development of axillary seroma after lymphadenectomy for breast cancer and its relationship with several parameters of suction drainage

Objetivos. La aparición de seromas axilares es la complicación más frecuente tras la linfadenectomía axilar. En este trabajo estudiamos algunos parámetros relacionados con el uso de drenajes quirúrgicos que podrían resultar predictivos del desarrollo de dichos seromas. Pacientes y método. Se han estudiado, de forma prospectiva, 100 pacientes intervenidas de manera consecutiva por cáncer de mama y en las que se realizó linfadenectomía axilar de los tres niveles como parte de su tratamiento. En todas se colocó en la intervención un drenaje axilar, y se registraron datos sobre el débito y duración de dicho drenaje en el postoperatorio. Estos parámetros se compararon según desarrollaran las pacientes seromas que precisasen punciones evacuadoras. Resultados. Sólo se encontraron diferencias significativas en el débito medio de los tres últimos días de drenaje, encontrándose una relación entre el desarrollo de seromas y más de 50 ml del citado débito. No encontramos diferencias en el resto de parámetros, incluyendo la técnica utilizada. Conclusiones. La retirada del drenaje axilar cuando el débito medio de los tres últimos días es menor de 50 ml, es una medida eficaz a la hora de tratar de evitar el desarrollo de seromas axilares postoperatorios tras linfadenectomías por cáncer de mama (AU)

[Prognostic factors in gallbladder cancer]. / Factores pronósticos del cáncer de vesícula.

BACKGROUND AND AIM: Carcinoma of the gallbladder is the most frequent biliary tract lesion but the 5-year survival is less than 5%. The aim of this study was to analyze the influence of several clinico-pathological variables on survival in a series of 226 carcinomas of the gallbladder. PATIENTS AND METHODS: The results were retrospectively analyzed and prognostic factors were identified by univariate statistical analysis and Cox regression model. All patients underwent surgery and in 67 of these (29.6%), surgery was potentially curative. In 63 patients (27.9%) diagnosis was made when the resected gallbladder was studied for benign disease. Tumor node metastasis (TNM) stage was 0 in 7 patients (3.1%), stage I in 19 patients (8.4%), stage II in 21 patients (9.3%), stage III in 61 patients (27%) and stage IV in 118 patients (52%). RESULTS: Overall 5-year survival was 17.3%. In the univariate analysis, significant variables were the presence of jaundice, weight loss, palpation of abdominal tumors at diagnosis, surgical technique, TNM stage and the three variables of this system (T: size, N: adenopathies; M: distant metastasis). In the multivariate analysis, the three variables of the TNM system and surgical technique were significantly associated with survival. CONCLUSIONS: The most important prognostic factor was TNM stage. Currently, radical cholecystectomy in stages II and III has become another important prognostic factor.

Carcinoma no medular familiar de tiroides / Familial nonmedullary thyroid carcinoma

Introducción. A pesar de la frecuencia epidemiológica del carcinoma no medular de tiroides, sobre todo del papilar, son excepcionales los casos descritos de asociación familiar. Presentamos 8 casos de esta enfermedad pertenecientes a 3 familias. Pacientes y método. De los pacientes intervenidos en nuestro hospital por carcinoma no medular, se seleccionaron aquellos en los que existía asociación familiar sin relación con los síndromes de Gardner, de Coluden ni el MEN-1 y no habrán tenido exposición previa a la radiación. Resultados. La edad media de los pacientes fue de 46 años, siendo 7 mujeres (87,5 por ciento). Excepto en uno de los casos, que consultó por hipercalcemias y fue intervenido con el diagnóstico de hiperparatiroidismo primario, en los demás la palpación cervical y la ecografía demostraban la presencia de un nódulo tiroideo. En estos 7 casos se realizó punción del nódulo, que en seis de ellos fue indicativa de carcinoma papilar. En todos se realizó tiroidectomía total, y en 4 casos en los que se objetivaron adenopatías, ésta se completó con un vaciamiento ganglionar funcional. Todos los carcinomas papilares eran de la variedad bien diferenciado, con un tamaño medio de 1,5 ñ 0,9 cm, siendo en 4 casos (50 por ciento) un microcarcinoma. Tres pacientes presentaron adenopatías positivas (37,5 por ciento). Todos fueron tratados posquirúrgicamente con yodo-131, excepto la paciente con hiperparatiroidismo, que presentaba un microcarcinoma de 0,5 cm. Con un seguimiento medio de 2,5 años, los controles son normales, excepto en un caso, en el que se ha detectado una tiroglobulina elevada, con exploración clínica y rastreo morfológico normales, a los 7 años de la cirugía, por lo que ha recibido tratamiento con 100 mCi de yodo-131. Conclusiones. El carcinoma no medular familiar de tiroides es una enfermedad inusual, con frecuente afectación ganglionar en el momento del diagnóstico, que presenta un relativo buen pronóstico con un tratamiento acorde con el estadio de la enfermedad (AU)

Evolución de la categoría del cirujano que realiza la apendicectomía laparoscópica en nuestro servicio / Changes in category of surgeons performing laparoscopic appendectomy in our service

Introducción. Desde que se introdujo la laparoscopia en nuestro hospital ha ido variando la categoría del cirujano que realiza la apendicectomía laparoscópica. El objetivo de nuestro trabajo es analizar la evolución de la categoría del cirujano que efectúa esta técnica. Pacientes y método. Hemos estudiado las 400 apendicecto mías laparoscópicas realizadas entre junio de 1991 y diciembre de 1997, dividiéndolas en 4 grupos de 100. Analizamos los hallazgos operatorios, el tiempo quirúrgico, la tasa de conversiones, las complicaciones, la estancia hospitalaria y la categoría del cirujano en cada grupo. Resultados. Inicialmente, los adjuntos realizaban casi la totalidad de intervenciones, siendo actualmente los residentes los que llevan a cabo más del 85 por ciento de las apendicectomías laparoscópicas. No existen diferencias en el tiempo quirúrgico, complicaciones y estancia hospitalaria en los 4 grupos. Ha aumentado de forma significativa la tasa de conversiones y ha disminuido el número de apendicitis perforadas conforme avanza la serie. Conclusiones. La apendicectomía laparoscópica es una técnica ampliamente asimilada por los residentes de nuestro servicio, que realizan en estos momentos la mayoría de intervenciones (AU)

El cirujano como factor pronóstico en la apendicectomía laparoscópica / The surgeon as a prognostic factor in laparoscopic appendectomy

Introducción. La apendicectomía laparoscópica se introdujo en nuestro servicio de manos de cirujanos con experiencia previa en colecistectomía laparoscópica. Progresivamente, los residentes se iniciaron en la técnica, realizando hoy día la mayor parte de estas intervenciones. El objetivo del estudio es analizar si el grado de experiencia del cirujano influye en el pronóstico del paciente con apendicitis aguda intervenido por laparoscopia. Pacientes y método. Se estudian 400 pacientes con sospecha de apendicitis aguda intervenidos por laparoscopia. Analizamos los hallazgos, el tiempo quirúrgico, las conversiones, las complicaciones y la estancia hospitalaria según el cirujano (adjunto o residente, y año de formación). Resultados. No existen diferencias en cuanto al tiempo quirúrgico, tasa de conversión, complicaciones y estancia hospitalaria entre los pacientes intervenidos por adjuntos o residentes. No obstante, los adjuntos han operado un mayor porcentaje de apendicitis complicadas que los residentes. Conclusión. Los residentes de cirugía deben iniciarse en laparoscopia a través de la apendicectomía laparoscópica, aunque las formas complicadas deben ser operadas por cirujanos con experiencia (AU)

Renal vein thrombosis caused by laparoscopic cholecystectomy.

A 48-year-old woman was diagnosed with right renal vein thrombosis (RVT) 2 weeks after a laparoscopic cholecystectomy. The patient had none of the major risk factors for RVT or deep vein thrombosis. She was treated with long-term anticoagulation. Complete dissolution of the thrombi was reached 1 month after diagnosis.