Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, May 11, 2017
There is a lack of data on incidental hepatocellular carcinoma (iHCC) in the setting of liver tra... more There is a lack of data on incidental hepatocellular carcinoma (iHCC) in the setting of liver transplantation (LT) in HIV infected patients. This study aims to describe the frequency, histopathological characteristics and outcomes of HIV-infected LT recipients with iHCC from a Spanish, multicenter cohort in comparison with a matched cohort of LT patients without HIV infection. Fifteen (6%) out of 271 patients with HIV infection who received LT in Spain from 2002-2012 and 38 (5%) out of the 811 HIV-uninfected counterparts presented iHCC in liver explants (p=0.58). Patients with iHCC constitute the present study population. All patients also had HCV-related cirrhosis. There were no significant differences in histopathological features of iHCC between the two groups. Most patients showed a small number and size of tumoral nodules, and few patients had satellite nodules, microvascular invasion or poorly differentiated tumors. After a median follow-up of 49 months, no patient developed H...
RESECTION OF COLORECTAL LIVER METASTASES. RESECTABILITY RATE AND LONG TERM SURVIVAL. Introduction... more RESECTION OF COLORECTAL LIVER METASTASES. RESECTABILITY RATE AND LONG TERM SURVIVAL. Introduction. A multidisciplinary treatment is needed to obtain the best possible results of the treatment of hepatic metastases. Nevertheless, the only option for long term survival is based on the complete resection of all detectable tumoral disease on the preoperative study, that must be as accurate as possible to avoid unnecessary laparotomies. Objectives. To establish the efficacy of our preoperative work-up by studying the resectability rate and to know our results on long term survival. Patients and methods. From January 1991 till December 2000, we have performed 273 hepatectomies in 250 patients for metastases of colorectal carcinoma. Neither the number nor the size of the metastases or the locoregional invasion were considered to be exclusion criteria. The only predefined criteria of resectability was the presumption of a complete and macroscopically curative resection. Results. Resectabilitity rate was 91.3% (273/299) Postoperative mortality was 3.3%. In 37 cases simultaneous surgery of the primary tumour was perfor
Background: Surgical resection has been the treatment of choice for hepatocellular carcinoma (HCC... more Background: Surgical resection has been the treatment of choice for hepatocellular carcinoma (HCC), but the resection rate remains low in cirrhotic patients and recurrence is common. Unfavorable results compared with benign disease and the shortage of organ donors have led to a restricted indication for orthotopic liver transplantation (OLT) for HCC. Study Design: The aim of this study was to analyze the results of our surgical approach to HCC in patients with cirrhosis. The first treatment strategy indicated in these patients was OLT. From January 1990 to May 1999, 85 patients underwent OLT and the remaining 35 had surgical resection. Results: One-, 3-, and 5-year survival rates were 84%, 74%, and 60% versus 83%, 57%, and 51%, respectively, in the OLT and resection groups (p.)43.0؍ Hepatic tumor recurrence was much less frequent in the OLT group than in the resection group. The 1-, 3-, and 5-year disease-free survival rates were 83%, 72%, and 60% versus 70%, 44%, and 31%, respectively (p.)720.0؍ In the multivariate Cox regression analysis, macroscopic vascular invasion was the only factor independently associated with death or recurrence after OLT (p.)600.0؍ After partial liver resection, the tumors significantly associated with mortality and recurrence in the multivariate analysis were solitary or multiple tumors greater than 2cm with microscopic vascular invasion (pathologic pT3) (p.)10.0؍ No competing interests declared.
To outline the characteristics and define appropriate management of chronic hepatosplenic suppura... more To outline the characteristics and define appropriate management of chronic hepatosplenic suppurative brucellosis (CHSB), 905 patients with brucellosis were analyzed. Sixteen episodes of CHSB (14 in the liver and 2 in the spleen) were found in 15 patients. Six patients had had previous remote brucellosis. Twelve patients presented with systemic symptoms, and 12 with local symptoms. Cultures of blood samples yielded negative results in all cases except 1, and the results of cultures of pus specimens were positive for Brucella melitensis in only 2 cases. All patients showed calcium deposits surrounded by a hypodense area on computed tomography. Patients often had low titers of agglutinating antibody. In patients who were receiving conservative management, early response was successful in 50% and late response was successful in 33.3%. In the patients who underwent surgery and concomitant antibiotic therapy, early and late response was successful in 100%. Thus, CHSB mainly represents a local reactivation of previous brucellosis. Its diagnosis may be difficult to establish and surgery may be required to cure many patients.
Objective: To evaluate the efficacy, amount of hemorrhage, biliary leakage, complications, and po... more Objective: To evaluate the efficacy, amount of hemorrhage, biliary leakage, complications, and postoperative evolution after fibrin glue sealant application in patients undergoing liver resection. Summary Background Data: Fibrin sealants have become popular as a means of improving perioperative hemostasis and reducing biliary leakage after liver surgery. However, trials regarding its use in liver surgery remain limited and of poor methodologic quality. Patients and Methods: A total of 300 patients undergoing hepatic resection were randomly assigned to fibrin glue application or control groups. Characteristics and debit of drainage and postoperative complications were evaluated. The amount of blood loss, measurements of hematologic parameters liver test, and postoperative evolution (particularly involving biliary fistula and morbidity) was also recorded. Results: Postoperatively, no differences were observed in the amount of transfusion (0.15 Ϯ 0.66 vs. 0.17 Ϯ 0.63 PRCU; P ϭ 0.7234) or in the patients that required transfusion (18% vs. 12%; P ϭ 0.2), respectively, for the fibrin glue or control group. There were no differences in overall drainage volumes (1180 Ϯ 2528 vs. 960 Ϯ 1253 mL) or in days of postoperative drainage (7.9 Ϯ 5 vs. 7.1 Ϯ 4.7). Incidence of biliary fistula was similar in the fibrin glue and control groups, (10% vs. 11%). There were no differences regarding postoperative morbidity between groups (23% vs. 23%; P ϭ 1). Conclusions: Application of fibrin sealant in the raw surface of the liver does not seem justified. Blood loss, transfusion, incidence of biliary fistula, and outcome are comparable to patients without fibrin glue. Therefore, discontinuation of routine use of fibrin sealant would result in significant cost saving.
The aim of our study was to prospectively evaluate the accuracy of dualphase helical CT in the pr... more The aim of our study was to prospectively evaluate the accuracy of dualphase helical CT in the preoperative assessment of resectabiliy in patients with suspected pancreatic cancer using surgical and histopathologic correlation. SUBJECTS AND METHODS. Between January 1999 and December 2000, 76 patients with suspected pancreatic cancer underwent preoperative evaluation and staging with dualphase helical CT (3-mm collimation for pancreatic phase, 5-mm collimation for portal phase). Iodinated contrast material was injected IV (170 mL at a rate of 4 mL/sec); acquisition began at 40 sec during the pancreatic phase and at 70 sec during the portal phase. Three radiologists prospectively evaluated the imaging findings to determine the presence of pancreatic tumor and signs of unresectability (liver metastasis, vascular encasement, or regional lymph nodes metastasis). The degree of tumor-vessel contiguity was recorded for each patient (no contiguity with tumor, contiguity of <50%, or contiguity of ≥ 50%). RESULTS. Thirty-nine patients with pancreatic adenocarcinoma were surgically explored. Curative resections were attempted in 34 patients and were successful in 25. The positive predictive value for resectability was 73.5%. Nine patients considered resectable on the basis of CT findings were found to be unresectable at surgery because of liver metastasis (n = 5), vascular encasement (n = 2), or lymph node metastasis (n = 2). We found that the overall accuracy of helical CT as a tool for determining whether a pancreatic adenocarcinoma was resectable was 77% (30/39 patients). CONCLUSION. Dual-phase helical CT is a useful technique for preoperative staging of pancreatic cancer. The main limitation of CT is that it may not reveal small hepatic metastases.
Objectives: to highlight an infrequent occurrence using a series of clinical cases with symptoms ... more Objectives: to highlight an infrequent occurrence using a series of clinical cases with symptoms and signs, and specific radiological findings allowing its diagnosis and treatment, which is in most cases successful. Patients and methods: a descriptive and retrospective study of patients diagnosed by computed tomography scanning and then treated with surgery in the Pancreas and Biliary Unit of a University Hospital from March 1999 to September 2005. Results: there were 6 female patients with a mean age of 33.5 years (range 11-72). Most common signs included pain and a palpable mass in the abdomen. Three patients were diagnosed by computed tomography scanning, and a differential diagnosis with a neuroendocrine tumor was performed for the remaining three subjects. Surgical treatment was adapted to each patient according to the findings and images seen in their computed tomography scans. Biopsy results confirmed the presumed diagnoses, and showed one case of solid pseudopapillary carcinoma of the pancreas. Average hospital stay was of 18.16 days (range 8-30). Mortality rate was 0%. No recurrences occurred during follow-up for 46.3 months on average (range 12-76). Conclusions: the presence of a huge mass in the pancreas of a young female should prompt suspicion for a solid pseudopapillary tumor. Given its low malignant potential, and the presence of specific radiographic patterns, its diagnosis should be accurate, as radical surgical treatment is effective.
Revista española de enfermedades digestivas : organo oficial de la Sociedad Española de Patología Digestiva, 1992
Carcinomatous ascites (CA) is not an uncommon manifestation of a metastatic neoplasia. The aim of... more Carcinomatous ascites (CA) is not an uncommon manifestation of a metastatic neoplasia. The aim of this study was to evaluate the utility of peritoneovenous shunt (PVS) in patients with CA refractory to conventional management. Twelve patients in whom a PVS was placed with palliative intention were studied. One patient died in the postoperative period. Permanent control of the ascites was achieved in 7 (63.6%) of the remaining patients. PVS obstruction occurred in 4 patients (36.4%) and no other complications related to the shunt were seen. Results were better in CA of gynecological origin but without reaching significant statistical differences. We conclude that PVS can be useful for palliation of CA with a low complication rate.
Teniendo presente la escasa disponibilidad de órganos para todos los potenciales candidatos a tra... more Teniendo presente la escasa disponibilidad de órganos para todos los potenciales candidatos a trasplante, es imprescindible una utilización óptima de los injertos disponibles. A pesar de que las mejoras en la selección preope-17
ABSTRACT The treatment of bile duct calculi associated with cholelithiasis is controversial. The ... more ABSTRACT The treatment of bile duct calculi associated with cholelithiasis is controversial. The hospital costs could be a decisive factor in choosing between the different therapeutic options. To compare the effectiveness and costs of two options in the treatment of common bile duct calculi: 1) One-stage: Laparoscopic cholecystectomy and bile duct exploration, and 2) Two-stage: sequential endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. A retrospective, observational study was performed on 49 consecutive patients with bile duct calculi and gallbladder in situ, treated consecutively and simultaneously over a two year period. The post-operate complication, hospital stay, number of procedures per patient, conversion to laparotomy, efficacy of removing the calculi, and hospital costs. There were no differences as regards the patient clinical features or morbidity. The mean post-surgical hospital stay for the One-stage group was less than that in the Two-stage group. Three patients of the Two-stage group required conversion to laparotomy. The median costs per patient were less for the One-stage strategy, representing an overall saving of 37,173€ during the period studied. No significant differences were found between the two treatment options as regards efficacy or post-surgical morbidity and mortality, but there were differences in hospital stay and costs. The management of patients with gallstones in one-stage surgery represents a saving of 3 days hospital stay and 1,008€ per patient.
lo largo de su evolución la mitad de estos pacientes van a presentar metástasis hepáticas (MH) 1.... more lo largo de su evolución la mitad de estos pacientes van a presentar metástasis hepáticas (MH) 1. Aunque la cirugía está considerada como el mejor tratamiento de los pacientes con MH de CCR, las indicaciones son limitadas y sólo un 25% de pacientes se van a beneficiar de este tratamiento por diversos motivos 2. Los factores pronósticos de supervivencia y, por tanto, las indicaciones quirúrgicas que están basadas en los mismos son variables 3-6. Un mejor conocimiento de la anatomía hepática, la mejora de los cuidados perioperatorios y la concentración de la cirugía del hígado 309
Background: APACHE II is a multifactorial scoring system for predicting severity in acute pancrea... more Background: APACHE II is a multifactorial scoring system for predicting severity in acute pancreatitis (AP). Organ failure (OF) has been correlated with mortality in AP. Objectives: to evaluate the usefulness of APACHE II as an early predictor of severity in AP, its correlation with OF, and the relevance of an early establishment of OF during the course of AP. Patients and methods: from January 1999 to November 2001, 447 consecutive cases of AP were studied. APACHE II scores and Atlanta criteria were used for defining severity and OF. Results: twenty-five percent of patients had severe acute pancreatitis (SAP). APACHE II at 24 h after admission showed a sensitivity, specificity, and positive and negative predictive value of 52, 77, 46, and 84%, respectively, for predicting severity. Mortality for SAP was 20.5%. Seventy percent of patients who developed OF did so within the first 24 hours of admission, and their mortality was 52%. Mortality was statistically significant (p < 0.01) if OF was established within the first 24 hours after admission. Conclusions: APACHE II is not reliable for predicting outcome within the first 24 hours after admission and should therefore be used together with other methods. OF mostly develops within the first days after admission, if ever. The time of onset of OF is the most accurate and reliable method for predicting death risk in AP.
Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2001
This study aims to determine whether the use of a temporary portocaval shunt (PCS) improves hemod... more This study aims to determine whether the use of a temporary portocaval shunt (PCS) improves hemodynamic and metabolic evolution during orthotopic liver transplantation (OLT). Preservation of the vena cava during OLT has gained wide acceptance. However, benefits of adding a temporary PCS to the piggyback technique during the anhepatic phase in patients with cirrhosis have not been shown. Eighty patients with cirrhosis were studied prospectively. They were randomly distributed into two groups: patients with a temporary PCS (n = 40) and those without a PCS (n = 40). In all cases, the piggyback technique was used. Hemodynamic profiles and biochemical data during OLT and clinical evolution after OLT were evaluated. Preoperative data were similar in both groups. Surgical time also was similar (403 +/- 77 v 387 +/- 56 minutes; P = .3). Red blood cell requirements were lower in the PCS group (2.3 +/- 2.5 v 3.3 +/- 2.9 units), although differences were not significant. In the PCS group, 45% ...
ABSTRACT Objective To analyse the results obtained after cephalic pancreatoduodenectomy in patien... more ABSTRACT Objective To analyse the results obtained after cephalic pancreatoduodenectomy in patients with severe chronic pancreatitis. Design Retrospective study of indications and results of the intervention. Patients The inclusion criteria were severe anatomic alteration of the head of the pancreas associated with refractory pain. Pancreatoduodenectomy was performed in 19 patients. Results Four patients had postoperative morbidity, and the mean hospital stay was 15 days. One patient died in the postoperative period. The pain evolution after surgery was: total control in 72% and satisfactory control in the remaining patients. During follow-up, de novo diabetes was detected in two patients, difficulty in maintaining weight in one patient, and de novo steatorrhea in four patients. Conclusions Cephalic pancreatoduodenectomy is a good therapeutic alternative for the treatment of patients with chronic pancreatitis, refractory pain, and severe involvement of the pancreas head. Pain control is excellent and sequelae, such as diabetes or steatorrhea, are easily amenable to medical treatment.
Introduction: Surgery is the accepted treatment for infected acute pancreatitis, although mortali... more Introduction: Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centers in Spain have published their results of surgery for acute pancreatitis. Objective: To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality. Materials and methods: We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyze the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed. Results: A total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery (<7 days). The only risk factor for mortality in the multivariant analysis was the time from the start of symptoms to surgery of <7 days; furthermore, 50% of these patients presented infection in one of the intraoperative cultures. Conclusions: Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.
Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, May 11, 2017
There is a lack of data on incidental hepatocellular carcinoma (iHCC) in the setting of liver tra... more There is a lack of data on incidental hepatocellular carcinoma (iHCC) in the setting of liver transplantation (LT) in HIV infected patients. This study aims to describe the frequency, histopathological characteristics and outcomes of HIV-infected LT recipients with iHCC from a Spanish, multicenter cohort in comparison with a matched cohort of LT patients without HIV infection. Fifteen (6%) out of 271 patients with HIV infection who received LT in Spain from 2002-2012 and 38 (5%) out of the 811 HIV-uninfected counterparts presented iHCC in liver explants (p=0.58). Patients with iHCC constitute the present study population. All patients also had HCV-related cirrhosis. There were no significant differences in histopathological features of iHCC between the two groups. Most patients showed a small number and size of tumoral nodules, and few patients had satellite nodules, microvascular invasion or poorly differentiated tumors. After a median follow-up of 49 months, no patient developed H...
RESECTION OF COLORECTAL LIVER METASTASES. RESECTABILITY RATE AND LONG TERM SURVIVAL. Introduction... more RESECTION OF COLORECTAL LIVER METASTASES. RESECTABILITY RATE AND LONG TERM SURVIVAL. Introduction. A multidisciplinary treatment is needed to obtain the best possible results of the treatment of hepatic metastases. Nevertheless, the only option for long term survival is based on the complete resection of all detectable tumoral disease on the preoperative study, that must be as accurate as possible to avoid unnecessary laparotomies. Objectives. To establish the efficacy of our preoperative work-up by studying the resectability rate and to know our results on long term survival. Patients and methods. From January 1991 till December 2000, we have performed 273 hepatectomies in 250 patients for metastases of colorectal carcinoma. Neither the number nor the size of the metastases or the locoregional invasion were considered to be exclusion criteria. The only predefined criteria of resectability was the presumption of a complete and macroscopically curative resection. Results. Resectabilitity rate was 91.3% (273/299) Postoperative mortality was 3.3%. In 37 cases simultaneous surgery of the primary tumour was perfor
Background: Surgical resection has been the treatment of choice for hepatocellular carcinoma (HCC... more Background: Surgical resection has been the treatment of choice for hepatocellular carcinoma (HCC), but the resection rate remains low in cirrhotic patients and recurrence is common. Unfavorable results compared with benign disease and the shortage of organ donors have led to a restricted indication for orthotopic liver transplantation (OLT) for HCC. Study Design: The aim of this study was to analyze the results of our surgical approach to HCC in patients with cirrhosis. The first treatment strategy indicated in these patients was OLT. From January 1990 to May 1999, 85 patients underwent OLT and the remaining 35 had surgical resection. Results: One-, 3-, and 5-year survival rates were 84%, 74%, and 60% versus 83%, 57%, and 51%, respectively, in the OLT and resection groups (p.)43.0؍ Hepatic tumor recurrence was much less frequent in the OLT group than in the resection group. The 1-, 3-, and 5-year disease-free survival rates were 83%, 72%, and 60% versus 70%, 44%, and 31%, respectively (p.)720.0؍ In the multivariate Cox regression analysis, macroscopic vascular invasion was the only factor independently associated with death or recurrence after OLT (p.)600.0؍ After partial liver resection, the tumors significantly associated with mortality and recurrence in the multivariate analysis were solitary or multiple tumors greater than 2cm with microscopic vascular invasion (pathologic pT3) (p.)10.0؍ No competing interests declared.
To outline the characteristics and define appropriate management of chronic hepatosplenic suppura... more To outline the characteristics and define appropriate management of chronic hepatosplenic suppurative brucellosis (CHSB), 905 patients with brucellosis were analyzed. Sixteen episodes of CHSB (14 in the liver and 2 in the spleen) were found in 15 patients. Six patients had had previous remote brucellosis. Twelve patients presented with systemic symptoms, and 12 with local symptoms. Cultures of blood samples yielded negative results in all cases except 1, and the results of cultures of pus specimens were positive for Brucella melitensis in only 2 cases. All patients showed calcium deposits surrounded by a hypodense area on computed tomography. Patients often had low titers of agglutinating antibody. In patients who were receiving conservative management, early response was successful in 50% and late response was successful in 33.3%. In the patients who underwent surgery and concomitant antibiotic therapy, early and late response was successful in 100%. Thus, CHSB mainly represents a local reactivation of previous brucellosis. Its diagnosis may be difficult to establish and surgery may be required to cure many patients.
Objective: To evaluate the efficacy, amount of hemorrhage, biliary leakage, complications, and po... more Objective: To evaluate the efficacy, amount of hemorrhage, biliary leakage, complications, and postoperative evolution after fibrin glue sealant application in patients undergoing liver resection. Summary Background Data: Fibrin sealants have become popular as a means of improving perioperative hemostasis and reducing biliary leakage after liver surgery. However, trials regarding its use in liver surgery remain limited and of poor methodologic quality. Patients and Methods: A total of 300 patients undergoing hepatic resection were randomly assigned to fibrin glue application or control groups. Characteristics and debit of drainage and postoperative complications were evaluated. The amount of blood loss, measurements of hematologic parameters liver test, and postoperative evolution (particularly involving biliary fistula and morbidity) was also recorded. Results: Postoperatively, no differences were observed in the amount of transfusion (0.15 Ϯ 0.66 vs. 0.17 Ϯ 0.63 PRCU; P ϭ 0.7234) or in the patients that required transfusion (18% vs. 12%; P ϭ 0.2), respectively, for the fibrin glue or control group. There were no differences in overall drainage volumes (1180 Ϯ 2528 vs. 960 Ϯ 1253 mL) or in days of postoperative drainage (7.9 Ϯ 5 vs. 7.1 Ϯ 4.7). Incidence of biliary fistula was similar in the fibrin glue and control groups, (10% vs. 11%). There were no differences regarding postoperative morbidity between groups (23% vs. 23%; P ϭ 1). Conclusions: Application of fibrin sealant in the raw surface of the liver does not seem justified. Blood loss, transfusion, incidence of biliary fistula, and outcome are comparable to patients without fibrin glue. Therefore, discontinuation of routine use of fibrin sealant would result in significant cost saving.
The aim of our study was to prospectively evaluate the accuracy of dualphase helical CT in the pr... more The aim of our study was to prospectively evaluate the accuracy of dualphase helical CT in the preoperative assessment of resectabiliy in patients with suspected pancreatic cancer using surgical and histopathologic correlation. SUBJECTS AND METHODS. Between January 1999 and December 2000, 76 patients with suspected pancreatic cancer underwent preoperative evaluation and staging with dualphase helical CT (3-mm collimation for pancreatic phase, 5-mm collimation for portal phase). Iodinated contrast material was injected IV (170 mL at a rate of 4 mL/sec); acquisition began at 40 sec during the pancreatic phase and at 70 sec during the portal phase. Three radiologists prospectively evaluated the imaging findings to determine the presence of pancreatic tumor and signs of unresectability (liver metastasis, vascular encasement, or regional lymph nodes metastasis). The degree of tumor-vessel contiguity was recorded for each patient (no contiguity with tumor, contiguity of <50%, or contiguity of ≥ 50%). RESULTS. Thirty-nine patients with pancreatic adenocarcinoma were surgically explored. Curative resections were attempted in 34 patients and were successful in 25. The positive predictive value for resectability was 73.5%. Nine patients considered resectable on the basis of CT findings were found to be unresectable at surgery because of liver metastasis (n = 5), vascular encasement (n = 2), or lymph node metastasis (n = 2). We found that the overall accuracy of helical CT as a tool for determining whether a pancreatic adenocarcinoma was resectable was 77% (30/39 patients). CONCLUSION. Dual-phase helical CT is a useful technique for preoperative staging of pancreatic cancer. The main limitation of CT is that it may not reveal small hepatic metastases.
Objectives: to highlight an infrequent occurrence using a series of clinical cases with symptoms ... more Objectives: to highlight an infrequent occurrence using a series of clinical cases with symptoms and signs, and specific radiological findings allowing its diagnosis and treatment, which is in most cases successful. Patients and methods: a descriptive and retrospective study of patients diagnosed by computed tomography scanning and then treated with surgery in the Pancreas and Biliary Unit of a University Hospital from March 1999 to September 2005. Results: there were 6 female patients with a mean age of 33.5 years (range 11-72). Most common signs included pain and a palpable mass in the abdomen. Three patients were diagnosed by computed tomography scanning, and a differential diagnosis with a neuroendocrine tumor was performed for the remaining three subjects. Surgical treatment was adapted to each patient according to the findings and images seen in their computed tomography scans. Biopsy results confirmed the presumed diagnoses, and showed one case of solid pseudopapillary carcinoma of the pancreas. Average hospital stay was of 18.16 days (range 8-30). Mortality rate was 0%. No recurrences occurred during follow-up for 46.3 months on average (range 12-76). Conclusions: the presence of a huge mass in the pancreas of a young female should prompt suspicion for a solid pseudopapillary tumor. Given its low malignant potential, and the presence of specific radiographic patterns, its diagnosis should be accurate, as radical surgical treatment is effective.
Revista española de enfermedades digestivas : organo oficial de la Sociedad Española de Patología Digestiva, 1992
Carcinomatous ascites (CA) is not an uncommon manifestation of a metastatic neoplasia. The aim of... more Carcinomatous ascites (CA) is not an uncommon manifestation of a metastatic neoplasia. The aim of this study was to evaluate the utility of peritoneovenous shunt (PVS) in patients with CA refractory to conventional management. Twelve patients in whom a PVS was placed with palliative intention were studied. One patient died in the postoperative period. Permanent control of the ascites was achieved in 7 (63.6%) of the remaining patients. PVS obstruction occurred in 4 patients (36.4%) and no other complications related to the shunt were seen. Results were better in CA of gynecological origin but without reaching significant statistical differences. We conclude that PVS can be useful for palliation of CA with a low complication rate.
Teniendo presente la escasa disponibilidad de órganos para todos los potenciales candidatos a tra... more Teniendo presente la escasa disponibilidad de órganos para todos los potenciales candidatos a trasplante, es imprescindible una utilización óptima de los injertos disponibles. A pesar de que las mejoras en la selección preope-17
ABSTRACT The treatment of bile duct calculi associated with cholelithiasis is controversial. The ... more ABSTRACT The treatment of bile duct calculi associated with cholelithiasis is controversial. The hospital costs could be a decisive factor in choosing between the different therapeutic options. To compare the effectiveness and costs of two options in the treatment of common bile duct calculi: 1) One-stage: Laparoscopic cholecystectomy and bile duct exploration, and 2) Two-stage: sequential endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. A retrospective, observational study was performed on 49 consecutive patients with bile duct calculi and gallbladder in situ, treated consecutively and simultaneously over a two year period. The post-operate complication, hospital stay, number of procedures per patient, conversion to laparotomy, efficacy of removing the calculi, and hospital costs. There were no differences as regards the patient clinical features or morbidity. The mean post-surgical hospital stay for the One-stage group was less than that in the Two-stage group. Three patients of the Two-stage group required conversion to laparotomy. The median costs per patient were less for the One-stage strategy, representing an overall saving of 37,173€ during the period studied. No significant differences were found between the two treatment options as regards efficacy or post-surgical morbidity and mortality, but there were differences in hospital stay and costs. The management of patients with gallstones in one-stage surgery represents a saving of 3 days hospital stay and 1,008€ per patient.
lo largo de su evolución la mitad de estos pacientes van a presentar metástasis hepáticas (MH) 1.... more lo largo de su evolución la mitad de estos pacientes van a presentar metástasis hepáticas (MH) 1. Aunque la cirugía está considerada como el mejor tratamiento de los pacientes con MH de CCR, las indicaciones son limitadas y sólo un 25% de pacientes se van a beneficiar de este tratamiento por diversos motivos 2. Los factores pronósticos de supervivencia y, por tanto, las indicaciones quirúrgicas que están basadas en los mismos son variables 3-6. Un mejor conocimiento de la anatomía hepática, la mejora de los cuidados perioperatorios y la concentración de la cirugía del hígado 309
Background: APACHE II is a multifactorial scoring system for predicting severity in acute pancrea... more Background: APACHE II is a multifactorial scoring system for predicting severity in acute pancreatitis (AP). Organ failure (OF) has been correlated with mortality in AP. Objectives: to evaluate the usefulness of APACHE II as an early predictor of severity in AP, its correlation with OF, and the relevance of an early establishment of OF during the course of AP. Patients and methods: from January 1999 to November 2001, 447 consecutive cases of AP were studied. APACHE II scores and Atlanta criteria were used for defining severity and OF. Results: twenty-five percent of patients had severe acute pancreatitis (SAP). APACHE II at 24 h after admission showed a sensitivity, specificity, and positive and negative predictive value of 52, 77, 46, and 84%, respectively, for predicting severity. Mortality for SAP was 20.5%. Seventy percent of patients who developed OF did so within the first 24 hours of admission, and their mortality was 52%. Mortality was statistically significant (p < 0.01) if OF was established within the first 24 hours after admission. Conclusions: APACHE II is not reliable for predicting outcome within the first 24 hours after admission and should therefore be used together with other methods. OF mostly develops within the first days after admission, if ever. The time of onset of OF is the most accurate and reliable method for predicting death risk in AP.
Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2001
This study aims to determine whether the use of a temporary portocaval shunt (PCS) improves hemod... more This study aims to determine whether the use of a temporary portocaval shunt (PCS) improves hemodynamic and metabolic evolution during orthotopic liver transplantation (OLT). Preservation of the vena cava during OLT has gained wide acceptance. However, benefits of adding a temporary PCS to the piggyback technique during the anhepatic phase in patients with cirrhosis have not been shown. Eighty patients with cirrhosis were studied prospectively. They were randomly distributed into two groups: patients with a temporary PCS (n = 40) and those without a PCS (n = 40). In all cases, the piggyback technique was used. Hemodynamic profiles and biochemical data during OLT and clinical evolution after OLT were evaluated. Preoperative data were similar in both groups. Surgical time also was similar (403 +/- 77 v 387 +/- 56 minutes; P = .3). Red blood cell requirements were lower in the PCS group (2.3 +/- 2.5 v 3.3 +/- 2.9 units), although differences were not significant. In the PCS group, 45% ...
ABSTRACT Objective To analyse the results obtained after cephalic pancreatoduodenectomy in patien... more ABSTRACT Objective To analyse the results obtained after cephalic pancreatoduodenectomy in patients with severe chronic pancreatitis. Design Retrospective study of indications and results of the intervention. Patients The inclusion criteria were severe anatomic alteration of the head of the pancreas associated with refractory pain. Pancreatoduodenectomy was performed in 19 patients. Results Four patients had postoperative morbidity, and the mean hospital stay was 15 days. One patient died in the postoperative period. The pain evolution after surgery was: total control in 72% and satisfactory control in the remaining patients. During follow-up, de novo diabetes was detected in two patients, difficulty in maintaining weight in one patient, and de novo steatorrhea in four patients. Conclusions Cephalic pancreatoduodenectomy is a good therapeutic alternative for the treatment of patients with chronic pancreatitis, refractory pain, and severe involvement of the pancreas head. Pain control is excellent and sequelae, such as diabetes or steatorrhea, are easily amenable to medical treatment.
Introduction: Surgery is the accepted treatment for infected acute pancreatitis, although mortali... more Introduction: Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centers in Spain have published their results of surgery for acute pancreatitis. Objective: To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality. Materials and methods: We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyze the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed. Results: A total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery (<7 days). The only risk factor for mortality in the multivariant analysis was the time from the start of symptoms to surgery of <7 days; furthermore, 50% of these patients presented infection in one of the intraoperative cultures. Conclusions: Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.
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Papers by Juan Fabregat