Analyze our results in the treatment of klatskin tumor since the use of more aggressive aproach w... more Analyze our results in the treatment of klatskin tumor since the use of more aggressive aproach with en bloc resection and extended hepatectomy. Methods: From 1998 to 2014, 45 patients underwent resection of klatskin tumor. 10 (22%) patients had right hepatectomy, 19 (42%) had left hepatectomy, 13 (29%) had extended right hemihepatectomy and 3 (7%) had extended lef hemihepatectomy. Of the 45, 13 patients underwent surgery before 2007(G1), with standard procedure, and 32 had surgery after 2007(G2), with en bloc resection (vascular reconstruction) and extended hemihepatectomy if required. We analyze the overall survival and evaluated important prognostic factors such as stage , nodal involvement and R0 resection (UICC TNM). Results: The postoperative stage were I in 1 patient (2,2%), II 12 (27%), IIIa 8 (18,2%), IIIb 10 (22,2%), IVa 4 (9%), IVb 8 (18%). The Clavien-Dindo after surgical resection was I in 5 patients (11%), II in 9 (20%), IIIa in 9 (20%), IIIb in 12 (27%), IVa in 2 (4%) and V in 8 (18%). Media follow up in the total group was 25,6 + 38 months. The overall 1-,3-, and 5-year survival was 69%, 61% and 38% respectively. Comparing both groups G2 had trend a better survival (54,5 vs 76,4%, 45,5 vs 71 and 27,3% vs 53 respectively). When prognostic factors were evaluated in the total group, only TNM stage (p = 0.023) and nodal involvement (p = 0.044) were statistically significant. Conclusions: Although with a short median follow up, there is a trend toward better survival with a similar morbidity and early outcome in the group of en bloc resection.
Introduction Intrahepatic cholangiocarcinoma (ICC) is a rare type of liver cancer. "Very early" I... more Introduction Intrahepatic cholangiocarcinoma (ICC) is a rare type of liver cancer. "Very early" ICC, defined as a solitary lesion of ≤ 2 cm in diameter, appears to have a favorable outcome. Purpose This study aimed to assess the outcome of patients with "very early" ICC treated with curative surgical resection in an intention-to-treat analysis. Methods All patients with ICC undergoing surgical resection at the Hospital Clínic of Barcelona (Spain) between April 2000 and December 2018 were reviewed, and those with evident "very early" ICC in preoperative imaging studies were selected. Results of histopathologic examination of the surgical specimen, postoperative complications, recurrence, and survival were assessed. Results Of the 89 patients operated for ICC during the study period, 7 (7.9%) met the "very early" criteria at preoperative imaging. Two (TNM 7th) and four (TNM 8th) patients were classified as stage I, following histological examination of their resected specimens. One patient presented with postoperative morbidity (grade II Clavien-Dindo). The median (IQR) hospital stay was 5 days (3-7). After a median follow-up of 23 months (IQR 11.9-80.6), recurrence was diagnosed in one case at 8.3 months after surgery. The overall survival at 1, 3, and 5 years was 85.7%, 68.6%, and 68.6%, respectively. Conclusion Intention-to-treat curative surgery in "very early" ICC is associated with good results in terms of survival and recurrence. However, most patients presented more advanced stages in the definitive pathological analysis, associated with a lower survival. Future prospective multicenter studies are required to validate these encouraging data.
Introduccio´n: Se analizan las resecciones hepá ticas mayores realizadas en 10 añ os, con el obje... more Introduccio´n: Se analizan las resecciones hepá ticas mayores realizadas en 10 añ os, con el objetivo principal de evaluar los resultados perioperatorios. Como objetivos secundarios, se evalú an los factores relacionados con las complicaciones mayores y el aná lisis comparativo de 2 periodos de 5 añ os. Me´todos: Aná lisis retrospectivo de pacientes intervenidos mediante una resecció n hepá tica mayor (3 o má s segmentos) desde enero de 2005 hasta diciembre de 2014, de los datos pre-, intra-y postoperatorios. Se utiliza la clasificació n de Clavien para el aná lisis de la morbilidad postoperatoria. Resultados: Se realizaron 416 hepatectomías mayores, con necesidad de transfusió n en 38 pacientes (9,1%) y maniobra de Pringle en el 47,7% de los casos. La mitad de los pacientes no presentaron ninguna complicació n y ú nicamente 96 pacientes (23%) presentaron una complicació n mayor. La fuga biliar fue la complicació n má s frecuente (n = 72; 17,3% de los pacientes), sobre todo, por enfermedad maligna y derivació n biliar, con ASA elevado (III-IV) y tiempo quirú rgico prolongado. Trece pacientes cumplían criterios de insuficiencia hepá tica, de los cuales 7 murieron (5 asociaban sobreinfecció n bacteriana). La estancia hospitalaria media fue de 12,5 días, con una tasa de reingreso del 11,8%. Al comparar 2 periodos de 5 añ os, se operan pacientes má s complejos, con menor incidencia de transfusiones y de complicaciones (ns). Conclusiones: La cirugía hepá tica ha aumentado de forma significativa en los ú ltimos añ os. El manejo quirú rgico del hígado permite en la actualidad ofrecer una cirugía segura y eficaz, con un índice de complicaciones muy bajo. El límite de la resecabilidad viene marcado por el volumen hepá tico residual.
BACKGROUND & AIMS Defining optimum management of patients progressing beyond Milan criteria o... more BACKGROUND & AIMS Defining optimum management of patients progressing beyond Milan criteria on the waiting list is a controversial topic. Our aim was to determine whether the policy of allowing a limited progression beyond enlistment criteria permits acceptable outcomes in terms of survival and recurrence. METHODS Patients with hepatocellular carcinoma included on the waiting list for liver transplantation (OLT) between January 1989 and December 2016 were analyzed. Tumour features were assessed at inclusion on the waiting list, before OLT and at explant pathology. Patients were retained on the waiting list despite exceeding enlistment criteria if not presenting macrovascular invasion, extrahepatic spread or cancer-related symptoms. RESULTS A total of 495 patients constituted the target population. Comparison between Milan-in (n=434) and Milan-out group (n=61) whilst transplanted showed statistically significant differences in: largest tumour size; BCLC stage; patients treated before OLT; α-fetoprotein, and time on waiting list. Milan-out patients showed a significantly higher number of poorly differentiated nodules, satellitosis and microscopic vascular invasion. The 1,3,5 and 10-year survival rate was 89.6%, 82.5%, 75%, and 55.5%, vs. 83.6%, 70.5%, 65.5%, and 53.9% for Milan-in/Milan-out patients, respectively. Recurrence rate at 1,3,5 and 10 years was 1.2%, 3.3%, 5.5%, and 10.8% vs. 7.1% 14.5%, 23%, and 23% for Milan-in and Milan-out patients, respectively (p<0.01). CONCLUSION This study shows that although limited tumour progression without reaching major adverse predictors (vascular invasion, extrahepatic spread, cancer symptoms) has an expected impact on recurrence rate, overall survival remains above the minimum proposed benchmark of 65% at five years. The clinically relevant increase in tumour recurrence must be taken into account when analysing the benefit of this approach in the case of a limited organ supply. LAY SUMMARY Optimum results are indeed obtained for hepatocellular carcinoma (HCC) patients following orthotopic liver transplantation (OLT) when the Milan criteria (MC) are used. However, the most appropriate strategy in cases of progression beyond MC while on the waiting list is still unclear. Herein, we present 27 years' experience in OLT for HCC, using a conservative approach for those who progress beyond MC while still continuing enlistment for OLT. Although the survival in Milan-out patients is in accordance with previous published studies, the recurrence rate was notably higher. Therefore, the assessment of transplantation viability in those patients has to take into account the availability of organs and the impact on other patient categories.
Pylorus-preserving pancreatoduodenectomy with gastric partition (PPPD-GP) seems to be associated ... more Pylorus-preserving pancreatoduodenectomy with gastric partition (PPPD-GP) seems to be associated to a better postoperative outcome than conventional pancreaticojejunostomy in the setting of a prospective-randomized study. The aim of this study is to further evaluate the surgical outcome in a series of 129 consecutive patients. Between 2007 and June 2013, 129 patients with periampullary tumors surgically treated with PPPD-GP were retrospectively analyzed. Surgical complications (Clavien-Dindo score), as well as pancreatic and non-pancreas related complications were analyzed. Overall postoperative complication rate was 77%, although 50% of complications were graded I-II by the Clavien-Dindo classification. Incidence of clinically relevant pancreatic fistula was 18%: ISGFP type B: 12%, and type C: 6%. Other pancreas specific complications such as delayed gastric emptying and pospancreatectomy haemorrhage were 27 and 15%, respectively, similar to results published in the literature. Overall perioperative mortality rate was 4.6%. PPPD-GP results show that it is a technique with an acceptable morbidity, low mortality and pancreatic fistula rate similar to other techniques currently described of pancreaticoenteric reconstruction.
Surgical Endoscopy and Other Interventional Techniques, Apr 10, 2015
Laparoscopic resection is considered the treatment of choice for gastric subepithelial tumors. Oc... more Laparoscopic resection is considered the treatment of choice for gastric subepithelial tumors. Occasionally, it is necessary to perform an intraoperative gastroscopy to localize the lesion. There are no data in the literature addressing the factors that can predict when a combined laparoscopic-endoscopic approach will be needed. A retrospective cohort study using a prospectively collected database was conducted. From January 2005 to December 2013, all the patients undergoing a laparoscopic gastric resection for subepithelial tumors irresectable by endoscopy were reviewed. Potential predictive factors for the need of an intraoperative endoscopy were analyzed. Thirty-eight consecutive patients (22 men and 16 women) with a mean age of 67 (41-86) years underwent laparoscopic gastric resection for subepithelial tumors. Fourteen (36.8 %) patients required intraoperative endoscopic assessment. The only significant factors related to the need of endoscopic assessment during surgery were tumor growth pattern (P = 0.002) and size (P = 0.001). An accurate description of tumor growth pattern and size by EUS is recommended in the preoperative assessment of gastric subepithelial tumors. Small tumors (≤18 mm) with an intraluminal growth may need a combined endoscopic-assisted laparoscopic management.
Background/Purpose Surgery can offer the only chance for a cure in patients with perihilar cholan... more Background/Purpose Surgery can offer the only chance for a cure in patients with perihilar cholangiocarcinoma, and a growing number of elderly patients are undergoing resection. The purpose of this study was to evaluate the impact of patient age on surgery for perihilar cholangiocarcinoma. Methods From 2001 to 2011, 431 consecutive patients underwent a potentially curative resection for perihilar cholangiocarcinoma at the
Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our... more Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.
Conclusion: Our study suggests a similar effectiveness of these procedures, but the subgroup anal... more Conclusion: Our study suggests a similar effectiveness of these procedures, but the subgroup analysis, following the BCLC stages, showed differences on survival. A more comprehensive study, with a prospective design and an adequate follow-up, could clarify further differences producing objective data on the clinical indications.
To investigate the long-term oncologic outcome of patients with hepatocellular carcinoma (HCC) un... more To investigate the long-term oncologic outcome of patients with hepatocellular carcinoma (HCC) undergoing sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE). Material and methods: From 2006 and 2012, the characteristics and survivals of all HCC patients who underwent sequential TACE-PVE before major liver resection were retrospectively analyzed according to whether or not they underwent surgical resection as planned. Results: A total of 54 patients (50 males, 93%, mean age 68 AE 10.5 years) were included. Resection was performed in 39 patients (72%), including 19/25 (76%), 16/23 (70%), and 4/6 (67%) with BCLC A, B, and C HCC, respectively (p = 0.839). Tumor recurrence occurred in 22 resected patients (56%) at a mean delay of 15.5 AE 5 months, including 9/19 (47%), 11/16 (69%), and 2/4 (50%) patients with BCLC A, B, and C HCC, respectively (p = 0.430). In non-resected patients, TACE was performed during the follow-up of 8 patients (53%) and was not associated with significant adverse effects or toxicity. Survival was significantly better in resected patients than in non-resected ones (median overall survival (OS): 44 vs. 18 months; p < 0.0001), but was not influenced by the BCLC stage (p = 0.13). Conclusion: In patients with large unilobar HCC, sequential TACE-PVE allows surgical resection in the majority of cases, with good oncological outcome regardless of the tumor burden. When the strategy fails, nonresected patients present with a poorer outcome but can be managed with TACE despite a previous PVE.
Hiliar cholangiocarcinoma is the most common type of cholangiocarcinoma, an represent around 10% ... more Hiliar cholangiocarcinoma is the most common type of cholangiocarcinoma, an represent around 10% of all hepatobiliary tumors. It is an aggressive malignancy, resectable in around 47% of the patients at diagnosis. Complete resection is the most effective and only potentially curative therapy, with a survival rate of less than 12 months in unresectable cases. Axial computerized tomography and magnetic resonance are the most useful image techniques to determine the surgical resectability. Clinically, jaundice and pruritus are the most common symptoms at diagnosis;preoperative biliary drainage is recommended using endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography. Surgery using extended liver resections with an en bloc resection of the liver with vascular reconstruction is the technique with the highest survival. Complete resection with histologically negative resection margins (R0), nodal involvement and metastases are the most important prognostic factors.
Gastroenterología y Hepatología (English Edition), 2021
Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our... more Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.
operation was 66. Mean operative time was 309mins with a median estimated blood loss of 550mls. R... more operation was 66. Mean operative time was 309mins with a median estimated blood loss of 550mls. Results: The median hospital stay was 15days. 16(25%) had no post-operative complications; 32(51%) had a ClavienDindo grade of 1 or 2; and 14(22%) had a grade 3 or higher, with many patients suffering more than one complication. Pancreatic leak was present in 17(27%) patients of which 7(11.1%) were grade A; and 10(15.9%) had a clinically relevant grade B or C pancreatic fistula. Post pancreatectomy haemorrhage was found in 6(9.5%) patients while 8(13%) suffered delayed gastric emptying. The perioperative mortality was 6.3%. Conclusion: The results presented in this study are in concordance with international standards. Pancreatoduodenectomy remains to be the only potentially curative procedure for ampullary carcinoma. However, it does results in significant morbidity and mortality. Thus, these procedures should be performed in specialist centres under the full support of a multidisciplinary team.
Introduccio´n: Se analizan las resecciones hepá ticas mayores realizadas en 10 añ os, con el obje... more Introduccio´n: Se analizan las resecciones hepá ticas mayores realizadas en 10 añ os, con el objetivo principal de evaluar los resultados perioperatorios. Como objetivos secundarios, se evalú an los factores relacionados con las complicaciones mayores y el aná lisis comparativo de 2 periodos de 5 añ os. Me´todos: Aná lisis retrospectivo de pacientes intervenidos mediante una resecció n hepá tica mayor (3 o má s segmentos) desde enero de 2005 hasta diciembre de 2014, de los datos pre-, intra-y postoperatorios. Se utiliza la clasificació n de Clavien para el aná lisis de la morbilidad postoperatoria. Resultados: Se realizaron 416 hepatectomías mayores, con necesidad de transfusió n en 38 pacientes (9,1%) y maniobra de Pringle en el 47,7% de los casos. La mitad de los pacientes no presentaron ninguna complicació n y ú nicamente 96 pacientes (23%) presentaron una complicació n mayor. La fuga biliar fue la complicació n má s frecuente (n = 72; 17,3% de los pacientes), sobre todo, por enfermedad maligna y derivació n biliar, con ASA elevado (III-IV) y tiempo quirú rgico prolongado. Trece pacientes cumplían criterios de insuficiencia hepá tica, de los cuales 7 murieron (5 asociaban sobreinfecció n bacteriana). La estancia hospitalaria media fue de 12,5 días, con una tasa de reingreso del 11,8%. Al comparar 2 periodos de 5 añ os, se operan pacientes má s complejos, con menor incidencia de transfusiones y de complicaciones (ns). Conclusiones: La cirugía hepá tica ha aumentado de forma significativa en los ú ltimos añ os. El manejo quirú rgico del hígado permite en la actualidad ofrecer una cirugía segura y eficaz, con un índice de complicaciones muy bajo. El límite de la resecabilidad viene marcado por el volumen hepá tico residual.
Analyze our results in the treatment of klatskin tumor since the use of more aggressive aproach w... more Analyze our results in the treatment of klatskin tumor since the use of more aggressive aproach with en bloc resection and extended hepatectomy. Methods: From 1998 to 2014, 45 patients underwent resection of klatskin tumor. 10 (22%) patients had right hepatectomy, 19 (42%) had left hepatectomy, 13 (29%) had extended right hemihepatectomy and 3 (7%) had extended lef hemihepatectomy. Of the 45, 13 patients underwent surgery before 2007(G1), with standard procedure, and 32 had surgery after 2007(G2), with en bloc resection (vascular reconstruction) and extended hemihepatectomy if required. We analyze the overall survival and evaluated important prognostic factors such as stage , nodal involvement and R0 resection (UICC TNM). Results: The postoperative stage were I in 1 patient (2,2%), II 12 (27%), IIIa 8 (18,2%), IIIb 10 (22,2%), IVa 4 (9%), IVb 8 (18%). The Clavien-Dindo after surgical resection was I in 5 patients (11%), II in 9 (20%), IIIa in 9 (20%), IIIb in 12 (27%), IVa in 2 (4%) and V in 8 (18%). Media follow up in the total group was 25,6 + 38 months. The overall 1-,3-, and 5-year survival was 69%, 61% and 38% respectively. Comparing both groups G2 had trend a better survival (54,5 vs 76,4%, 45,5 vs 71 and 27,3% vs 53 respectively). When prognostic factors were evaluated in the total group, only TNM stage (p = 0.023) and nodal involvement (p = 0.044) were statistically significant. Conclusions: Although with a short median follow up, there is a trend toward better survival with a similar morbidity and early outcome in the group of en bloc resection.
To investigate the long-term oncologic outcome of patients with hepatocellular carcinoma (HCC) un... more To investigate the long-term oncologic outcome of patients with hepatocellular carcinoma (HCC) undergoing sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE). Material and methods: From 2006 and 2012, the characteristics and survivals of all HCC patients who underwent sequential TACE-PVE before major liver resection were retrospectively analyzed according to whether or not they underwent surgical resection as planned. Results: A total of 54 patients (50 males, 93%, mean age 68 AE 10.5 years) were included. Resection was performed in 39 patients (72%), including 19/25 (76%), 16/23 (70%), and 4/6 (67%) with BCLC A, B, and C HCC, respectively (p = 0.839). Tumor recurrence occurred in 22 resected patients (56%) at a mean delay of 15.5 AE 5 months, including 9/19 (47%), 11/16 (69%), and 2/4 (50%) patients with BCLC A, B, and C HCC, respectively (p = 0.430). In non-resected patients, TACE was performed during the follow-up of 8 patients (53%) and was not associated with significant adverse effects or toxicity. Survival was significantly better in resected patients than in non-resected ones (median overall survival (OS): 44 vs. 18 months; p < 0.0001), but was not influenced by the BCLC stage (p = 0.13). Conclusion: In patients with large unilobar HCC, sequential TACE-PVE allows surgical resection in the majority of cases, with good oncological outcome regardless of the tumor burden. When the strategy fails, nonresected patients present with a poorer outcome but can be managed with TACE despite a previous PVE.
European surgical research. Europaische chirurgische Forschung. Recherches chirurgicales europeennes, Jan 4, 2016
Living donor liver transplantation (LDLT) entails a significant number of bile duct complications... more Living donor liver transplantation (LDLT) entails a significant number of bile duct complications. We aimed to diminish the biliary complication rate with the use of a resorbable biliary stent (RBS) during LDLT. The objective of this study is to describe the surgical techniques and the associated outcomes, especially in terms of safety, of RBS use in LDLT. From 2011 to 2014, 12 LDLT recipients were enrolled in a clinical trial with the use of a specifically designed RBS. These patients were followed according to the clinical protocol. Specific complications derived from RBS as well as biliary complications were recorded. One patient underwent early retransplantation due to a small-for-size syndrome. None of the patients had a complication attributable to the placement, remaining in place, or degradation of the stent. Four of the remaining patients presented with a biliary complication: 1 (9.1%) with a biliary leak alone, 1 (9.1%) with a biliary stenosis alone, and 2 (18.2%) with bot...
Analyze our results in the treatment of klatskin tumor since the use of more aggressive aproach w... more Analyze our results in the treatment of klatskin tumor since the use of more aggressive aproach with en bloc resection and extended hepatectomy. Methods: From 1998 to 2014, 45 patients underwent resection of klatskin tumor. 10 (22%) patients had right hepatectomy, 19 (42%) had left hepatectomy, 13 (29%) had extended right hemihepatectomy and 3 (7%) had extended lef hemihepatectomy. Of the 45, 13 patients underwent surgery before 2007(G1), with standard procedure, and 32 had surgery after 2007(G2), with en bloc resection (vascular reconstruction) and extended hemihepatectomy if required. We analyze the overall survival and evaluated important prognostic factors such as stage , nodal involvement and R0 resection (UICC TNM). Results: The postoperative stage were I in 1 patient (2,2%), II 12 (27%), IIIa 8 (18,2%), IIIb 10 (22,2%), IVa 4 (9%), IVb 8 (18%). The Clavien-Dindo after surgical resection was I in 5 patients (11%), II in 9 (20%), IIIa in 9 (20%), IIIb in 12 (27%), IVa in 2 (4%) and V in 8 (18%). Media follow up in the total group was 25,6 + 38 months. The overall 1-,3-, and 5-year survival was 69%, 61% and 38% respectively. Comparing both groups G2 had trend a better survival (54,5 vs 76,4%, 45,5 vs 71 and 27,3% vs 53 respectively). When prognostic factors were evaluated in the total group, only TNM stage (p = 0.023) and nodal involvement (p = 0.044) were statistically significant. Conclusions: Although with a short median follow up, there is a trend toward better survival with a similar morbidity and early outcome in the group of en bloc resection.
Introduction Intrahepatic cholangiocarcinoma (ICC) is a rare type of liver cancer. "Very early" I... more Introduction Intrahepatic cholangiocarcinoma (ICC) is a rare type of liver cancer. "Very early" ICC, defined as a solitary lesion of ≤ 2 cm in diameter, appears to have a favorable outcome. Purpose This study aimed to assess the outcome of patients with "very early" ICC treated with curative surgical resection in an intention-to-treat analysis. Methods All patients with ICC undergoing surgical resection at the Hospital Clínic of Barcelona (Spain) between April 2000 and December 2018 were reviewed, and those with evident "very early" ICC in preoperative imaging studies were selected. Results of histopathologic examination of the surgical specimen, postoperative complications, recurrence, and survival were assessed. Results Of the 89 patients operated for ICC during the study period, 7 (7.9%) met the "very early" criteria at preoperative imaging. Two (TNM 7th) and four (TNM 8th) patients were classified as stage I, following histological examination of their resected specimens. One patient presented with postoperative morbidity (grade II Clavien-Dindo). The median (IQR) hospital stay was 5 days (3-7). After a median follow-up of 23 months (IQR 11.9-80.6), recurrence was diagnosed in one case at 8.3 months after surgery. The overall survival at 1, 3, and 5 years was 85.7%, 68.6%, and 68.6%, respectively. Conclusion Intention-to-treat curative surgery in "very early" ICC is associated with good results in terms of survival and recurrence. However, most patients presented more advanced stages in the definitive pathological analysis, associated with a lower survival. Future prospective multicenter studies are required to validate these encouraging data.
Introduccio´n: Se analizan las resecciones hepá ticas mayores realizadas en 10 añ os, con el obje... more Introduccio´n: Se analizan las resecciones hepá ticas mayores realizadas en 10 añ os, con el objetivo principal de evaluar los resultados perioperatorios. Como objetivos secundarios, se evalú an los factores relacionados con las complicaciones mayores y el aná lisis comparativo de 2 periodos de 5 añ os. Me´todos: Aná lisis retrospectivo de pacientes intervenidos mediante una resecció n hepá tica mayor (3 o má s segmentos) desde enero de 2005 hasta diciembre de 2014, de los datos pre-, intra-y postoperatorios. Se utiliza la clasificació n de Clavien para el aná lisis de la morbilidad postoperatoria. Resultados: Se realizaron 416 hepatectomías mayores, con necesidad de transfusió n en 38 pacientes (9,1%) y maniobra de Pringle en el 47,7% de los casos. La mitad de los pacientes no presentaron ninguna complicació n y ú nicamente 96 pacientes (23%) presentaron una complicació n mayor. La fuga biliar fue la complicació n má s frecuente (n = 72; 17,3% de los pacientes), sobre todo, por enfermedad maligna y derivació n biliar, con ASA elevado (III-IV) y tiempo quirú rgico prolongado. Trece pacientes cumplían criterios de insuficiencia hepá tica, de los cuales 7 murieron (5 asociaban sobreinfecció n bacteriana). La estancia hospitalaria media fue de 12,5 días, con una tasa de reingreso del 11,8%. Al comparar 2 periodos de 5 añ os, se operan pacientes má s complejos, con menor incidencia de transfusiones y de complicaciones (ns). Conclusiones: La cirugía hepá tica ha aumentado de forma significativa en los ú ltimos añ os. El manejo quirú rgico del hígado permite en la actualidad ofrecer una cirugía segura y eficaz, con un índice de complicaciones muy bajo. El límite de la resecabilidad viene marcado por el volumen hepá tico residual.
BACKGROUND & AIMS Defining optimum management of patients progressing beyond Milan criteria o... more BACKGROUND & AIMS Defining optimum management of patients progressing beyond Milan criteria on the waiting list is a controversial topic. Our aim was to determine whether the policy of allowing a limited progression beyond enlistment criteria permits acceptable outcomes in terms of survival and recurrence. METHODS Patients with hepatocellular carcinoma included on the waiting list for liver transplantation (OLT) between January 1989 and December 2016 were analyzed. Tumour features were assessed at inclusion on the waiting list, before OLT and at explant pathology. Patients were retained on the waiting list despite exceeding enlistment criteria if not presenting macrovascular invasion, extrahepatic spread or cancer-related symptoms. RESULTS A total of 495 patients constituted the target population. Comparison between Milan-in (n=434) and Milan-out group (n=61) whilst transplanted showed statistically significant differences in: largest tumour size; BCLC stage; patients treated before OLT; α-fetoprotein, and time on waiting list. Milan-out patients showed a significantly higher number of poorly differentiated nodules, satellitosis and microscopic vascular invasion. The 1,3,5 and 10-year survival rate was 89.6%, 82.5%, 75%, and 55.5%, vs. 83.6%, 70.5%, 65.5%, and 53.9% for Milan-in/Milan-out patients, respectively. Recurrence rate at 1,3,5 and 10 years was 1.2%, 3.3%, 5.5%, and 10.8% vs. 7.1% 14.5%, 23%, and 23% for Milan-in and Milan-out patients, respectively (p<0.01). CONCLUSION This study shows that although limited tumour progression without reaching major adverse predictors (vascular invasion, extrahepatic spread, cancer symptoms) has an expected impact on recurrence rate, overall survival remains above the minimum proposed benchmark of 65% at five years. The clinically relevant increase in tumour recurrence must be taken into account when analysing the benefit of this approach in the case of a limited organ supply. LAY SUMMARY Optimum results are indeed obtained for hepatocellular carcinoma (HCC) patients following orthotopic liver transplantation (OLT) when the Milan criteria (MC) are used. However, the most appropriate strategy in cases of progression beyond MC while on the waiting list is still unclear. Herein, we present 27 years' experience in OLT for HCC, using a conservative approach for those who progress beyond MC while still continuing enlistment for OLT. Although the survival in Milan-out patients is in accordance with previous published studies, the recurrence rate was notably higher. Therefore, the assessment of transplantation viability in those patients has to take into account the availability of organs and the impact on other patient categories.
Pylorus-preserving pancreatoduodenectomy with gastric partition (PPPD-GP) seems to be associated ... more Pylorus-preserving pancreatoduodenectomy with gastric partition (PPPD-GP) seems to be associated to a better postoperative outcome than conventional pancreaticojejunostomy in the setting of a prospective-randomized study. The aim of this study is to further evaluate the surgical outcome in a series of 129 consecutive patients. Between 2007 and June 2013, 129 patients with periampullary tumors surgically treated with PPPD-GP were retrospectively analyzed. Surgical complications (Clavien-Dindo score), as well as pancreatic and non-pancreas related complications were analyzed. Overall postoperative complication rate was 77%, although 50% of complications were graded I-II by the Clavien-Dindo classification. Incidence of clinically relevant pancreatic fistula was 18%: ISGFP type B: 12%, and type C: 6%. Other pancreas specific complications such as delayed gastric emptying and pospancreatectomy haemorrhage were 27 and 15%, respectively, similar to results published in the literature. Overall perioperative mortality rate was 4.6%. PPPD-GP results show that it is a technique with an acceptable morbidity, low mortality and pancreatic fistula rate similar to other techniques currently described of pancreaticoenteric reconstruction.
Surgical Endoscopy and Other Interventional Techniques, Apr 10, 2015
Laparoscopic resection is considered the treatment of choice for gastric subepithelial tumors. Oc... more Laparoscopic resection is considered the treatment of choice for gastric subepithelial tumors. Occasionally, it is necessary to perform an intraoperative gastroscopy to localize the lesion. There are no data in the literature addressing the factors that can predict when a combined laparoscopic-endoscopic approach will be needed. A retrospective cohort study using a prospectively collected database was conducted. From January 2005 to December 2013, all the patients undergoing a laparoscopic gastric resection for subepithelial tumors irresectable by endoscopy were reviewed. Potential predictive factors for the need of an intraoperative endoscopy were analyzed. Thirty-eight consecutive patients (22 men and 16 women) with a mean age of 67 (41-86) years underwent laparoscopic gastric resection for subepithelial tumors. Fourteen (36.8 %) patients required intraoperative endoscopic assessment. The only significant factors related to the need of endoscopic assessment during surgery were tumor growth pattern (P = 0.002) and size (P = 0.001). An accurate description of tumor growth pattern and size by EUS is recommended in the preoperative assessment of gastric subepithelial tumors. Small tumors (≤18 mm) with an intraluminal growth may need a combined endoscopic-assisted laparoscopic management.
Background/Purpose Surgery can offer the only chance for a cure in patients with perihilar cholan... more Background/Purpose Surgery can offer the only chance for a cure in patients with perihilar cholangiocarcinoma, and a growing number of elderly patients are undergoing resection. The purpose of this study was to evaluate the impact of patient age on surgery for perihilar cholangiocarcinoma. Methods From 2001 to 2011, 431 consecutive patients underwent a potentially curative resection for perihilar cholangiocarcinoma at the
Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our... more Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.
Conclusion: Our study suggests a similar effectiveness of these procedures, but the subgroup anal... more Conclusion: Our study suggests a similar effectiveness of these procedures, but the subgroup analysis, following the BCLC stages, showed differences on survival. A more comprehensive study, with a prospective design and an adequate follow-up, could clarify further differences producing objective data on the clinical indications.
To investigate the long-term oncologic outcome of patients with hepatocellular carcinoma (HCC) un... more To investigate the long-term oncologic outcome of patients with hepatocellular carcinoma (HCC) undergoing sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE). Material and methods: From 2006 and 2012, the characteristics and survivals of all HCC patients who underwent sequential TACE-PVE before major liver resection were retrospectively analyzed according to whether or not they underwent surgical resection as planned. Results: A total of 54 patients (50 males, 93%, mean age 68 AE 10.5 years) were included. Resection was performed in 39 patients (72%), including 19/25 (76%), 16/23 (70%), and 4/6 (67%) with BCLC A, B, and C HCC, respectively (p = 0.839). Tumor recurrence occurred in 22 resected patients (56%) at a mean delay of 15.5 AE 5 months, including 9/19 (47%), 11/16 (69%), and 2/4 (50%) patients with BCLC A, B, and C HCC, respectively (p = 0.430). In non-resected patients, TACE was performed during the follow-up of 8 patients (53%) and was not associated with significant adverse effects or toxicity. Survival was significantly better in resected patients than in non-resected ones (median overall survival (OS): 44 vs. 18 months; p < 0.0001), but was not influenced by the BCLC stage (p = 0.13). Conclusion: In patients with large unilobar HCC, sequential TACE-PVE allows surgical resection in the majority of cases, with good oncological outcome regardless of the tumor burden. When the strategy fails, nonresected patients present with a poorer outcome but can be managed with TACE despite a previous PVE.
Hiliar cholangiocarcinoma is the most common type of cholangiocarcinoma, an represent around 10% ... more Hiliar cholangiocarcinoma is the most common type of cholangiocarcinoma, an represent around 10% of all hepatobiliary tumors. It is an aggressive malignancy, resectable in around 47% of the patients at diagnosis. Complete resection is the most effective and only potentially curative therapy, with a survival rate of less than 12 months in unresectable cases. Axial computerized tomography and magnetic resonance are the most useful image techniques to determine the surgical resectability. Clinically, jaundice and pruritus are the most common symptoms at diagnosis;preoperative biliary drainage is recommended using endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography. Surgery using extended liver resections with an en bloc resection of the liver with vascular reconstruction is the technique with the highest survival. Complete resection with histologically negative resection margins (R0), nodal involvement and metastases are the most important prognostic factors.
Gastroenterología y Hepatología (English Edition), 2021
Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our... more Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.
operation was 66. Mean operative time was 309mins with a median estimated blood loss of 550mls. R... more operation was 66. Mean operative time was 309mins with a median estimated blood loss of 550mls. Results: The median hospital stay was 15days. 16(25%) had no post-operative complications; 32(51%) had a ClavienDindo grade of 1 or 2; and 14(22%) had a grade 3 or higher, with many patients suffering more than one complication. Pancreatic leak was present in 17(27%) patients of which 7(11.1%) were grade A; and 10(15.9%) had a clinically relevant grade B or C pancreatic fistula. Post pancreatectomy haemorrhage was found in 6(9.5%) patients while 8(13%) suffered delayed gastric emptying. The perioperative mortality was 6.3%. Conclusion: The results presented in this study are in concordance with international standards. Pancreatoduodenectomy remains to be the only potentially curative procedure for ampullary carcinoma. However, it does results in significant morbidity and mortality. Thus, these procedures should be performed in specialist centres under the full support of a multidisciplinary team.
Introduccio´n: Se analizan las resecciones hepá ticas mayores realizadas en 10 añ os, con el obje... more Introduccio´n: Se analizan las resecciones hepá ticas mayores realizadas en 10 añ os, con el objetivo principal de evaluar los resultados perioperatorios. Como objetivos secundarios, se evalú an los factores relacionados con las complicaciones mayores y el aná lisis comparativo de 2 periodos de 5 añ os. Me´todos: Aná lisis retrospectivo de pacientes intervenidos mediante una resecció n hepá tica mayor (3 o má s segmentos) desde enero de 2005 hasta diciembre de 2014, de los datos pre-, intra-y postoperatorios. Se utiliza la clasificació n de Clavien para el aná lisis de la morbilidad postoperatoria. Resultados: Se realizaron 416 hepatectomías mayores, con necesidad de transfusió n en 38 pacientes (9,1%) y maniobra de Pringle en el 47,7% de los casos. La mitad de los pacientes no presentaron ninguna complicació n y ú nicamente 96 pacientes (23%) presentaron una complicació n mayor. La fuga biliar fue la complicació n má s frecuente (n = 72; 17,3% de los pacientes), sobre todo, por enfermedad maligna y derivació n biliar, con ASA elevado (III-IV) y tiempo quirú rgico prolongado. Trece pacientes cumplían criterios de insuficiencia hepá tica, de los cuales 7 murieron (5 asociaban sobreinfecció n bacteriana). La estancia hospitalaria media fue de 12,5 días, con una tasa de reingreso del 11,8%. Al comparar 2 periodos de 5 añ os, se operan pacientes má s complejos, con menor incidencia de transfusiones y de complicaciones (ns). Conclusiones: La cirugía hepá tica ha aumentado de forma significativa en los ú ltimos añ os. El manejo quirú rgico del hígado permite en la actualidad ofrecer una cirugía segura y eficaz, con un índice de complicaciones muy bajo. El límite de la resecabilidad viene marcado por el volumen hepá tico residual.
Analyze our results in the treatment of klatskin tumor since the use of more aggressive aproach w... more Analyze our results in the treatment of klatskin tumor since the use of more aggressive aproach with en bloc resection and extended hepatectomy. Methods: From 1998 to 2014, 45 patients underwent resection of klatskin tumor. 10 (22%) patients had right hepatectomy, 19 (42%) had left hepatectomy, 13 (29%) had extended right hemihepatectomy and 3 (7%) had extended lef hemihepatectomy. Of the 45, 13 patients underwent surgery before 2007(G1), with standard procedure, and 32 had surgery after 2007(G2), with en bloc resection (vascular reconstruction) and extended hemihepatectomy if required. We analyze the overall survival and evaluated important prognostic factors such as stage , nodal involvement and R0 resection (UICC TNM). Results: The postoperative stage were I in 1 patient (2,2%), II 12 (27%), IIIa 8 (18,2%), IIIb 10 (22,2%), IVa 4 (9%), IVb 8 (18%). The Clavien-Dindo after surgical resection was I in 5 patients (11%), II in 9 (20%), IIIa in 9 (20%), IIIb in 12 (27%), IVa in 2 (4%) and V in 8 (18%). Media follow up in the total group was 25,6 + 38 months. The overall 1-,3-, and 5-year survival was 69%, 61% and 38% respectively. Comparing both groups G2 had trend a better survival (54,5 vs 76,4%, 45,5 vs 71 and 27,3% vs 53 respectively). When prognostic factors were evaluated in the total group, only TNM stage (p = 0.023) and nodal involvement (p = 0.044) were statistically significant. Conclusions: Although with a short median follow up, there is a trend toward better survival with a similar morbidity and early outcome in the group of en bloc resection.
To investigate the long-term oncologic outcome of patients with hepatocellular carcinoma (HCC) un... more To investigate the long-term oncologic outcome of patients with hepatocellular carcinoma (HCC) undergoing sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE). Material and methods: From 2006 and 2012, the characteristics and survivals of all HCC patients who underwent sequential TACE-PVE before major liver resection were retrospectively analyzed according to whether or not they underwent surgical resection as planned. Results: A total of 54 patients (50 males, 93%, mean age 68 AE 10.5 years) were included. Resection was performed in 39 patients (72%), including 19/25 (76%), 16/23 (70%), and 4/6 (67%) with BCLC A, B, and C HCC, respectively (p = 0.839). Tumor recurrence occurred in 22 resected patients (56%) at a mean delay of 15.5 AE 5 months, including 9/19 (47%), 11/16 (69%), and 2/4 (50%) patients with BCLC A, B, and C HCC, respectively (p = 0.430). In non-resected patients, TACE was performed during the follow-up of 8 patients (53%) and was not associated with significant adverse effects or toxicity. Survival was significantly better in resected patients than in non-resected ones (median overall survival (OS): 44 vs. 18 months; p < 0.0001), but was not influenced by the BCLC stage (p = 0.13). Conclusion: In patients with large unilobar HCC, sequential TACE-PVE allows surgical resection in the majority of cases, with good oncological outcome regardless of the tumor burden. When the strategy fails, nonresected patients present with a poorer outcome but can be managed with TACE despite a previous PVE.
European surgical research. Europaische chirurgische Forschung. Recherches chirurgicales europeennes, Jan 4, 2016
Living donor liver transplantation (LDLT) entails a significant number of bile duct complications... more Living donor liver transplantation (LDLT) entails a significant number of bile duct complications. We aimed to diminish the biliary complication rate with the use of a resorbable biliary stent (RBS) during LDLT. The objective of this study is to describe the surgical techniques and the associated outcomes, especially in terms of safety, of RBS use in LDLT. From 2011 to 2014, 12 LDLT recipients were enrolled in a clinical trial with the use of a specifically designed RBS. These patients were followed according to the clinical protocol. Specific complications derived from RBS as well as biliary complications were recorded. One patient underwent early retransplantation due to a small-for-size syndrome. None of the patients had a complication attributable to the placement, remaining in place, or degradation of the stent. Four of the remaining patients presented with a biliary complication: 1 (9.1%) with a biliary leak alone, 1 (9.1%) with a biliary stenosis alone, and 2 (18.2%) with bot...
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Papers by Jaime Sampson