Safety and Efficacy of Ultrasound-Guided Radiofrequency Ablation of Recurrent Colorectal Cancer Liver Metastases after Hepatectomy

INTRODUCTION

To assess the results and outcome of radiofrequency ablation in the treatment of recurrent colorectal liver metastases.

PATIENTS AND METHODS

Between January 2005 and September 2012, we treated 59 patients with recurrent colorectal metastases not amenable to surgery with 77 radiofrequency ablation procedures. Radiofrequency was indicated if oncologic resection was technically not possible or the patient was not fit for major surgery. A total of 91 lesions were treated. The mean number of liver tumors per patient was 1.5, and the mean tumor diameter was 2.3 cm. In 37.5% of the cases, lesions had a subcapsular location, and 34% were close to a vascular structure.

RESULTS

The morbidity rate was 18.7%, and there were no post-procedural deaths. Distant extrahepatic recurrence appeared in 50% of the patients. Local recurrence at the site of ablation appeared in 18% of the lesions. Local recurrence rate was 6% in lesions less than 3 cm and 52% in lesions larger than 3 cm. The size of the lesions (more than 3 cm) was an independent risk factor for local recurrence (p < 0.05). Survival rates at 1, 3, and 5 years were 94.5%, 65.3%, and 21.7%, respectively.

DISCUSSION

Radiofrequency ablation is a safe procedure and allows local tumor control in lesions less than 30 mm (local recurrence of 6%) and provides survival benefits in patients with recurrent colorectal liver metastases.

Outcome of HCV/HIV-coinfected liver transplant recipients: a prospective and multicenter cohort study

Eighty-four HCV/HIV-coinfected and 252-matched HCV-monoinfected liver transplant recipients were included in a prospective multicenter study. Thirty-six (43%) HCV/HIV-coinfected and 75 (30%) HCV-monoinfected patients died, with a survival rate at 5 years of 54% (95% CI, 42-64) and 71% (95% CI, 66 to 77; p = 0.008), respectively. When both groups were considered together, HIV infection was an independent predictor of mortality (HR, 2.202; 95% CI, 1.420-3.413 [p < 0.001]). Multivariate analysis of only the HCV/HIV-coinfected recipients, revealed HCV genotype 1 (HR, 2.98; 95% CI, 1.32-6.76), donor risk index (HR, 9.48; 95% CI, 2.75-32.73) and negative plasma HCV RNA (HR, 0.14; 95% CI, 0.03-0.62) to be associated with mortality. When this analysis was restricted to pretransplant variables, we identified three independent factors (HCV genotype 1, pretransplant MELD score and centers with <1 liver transplantation/year in HIV-infected patients) that allowed us to identify a subset of 60 (71%) patients with a similar 5-year prognosis (69%[95% CI, 54-80]) to that of HCV-monoinfected recipients. In conclusion, 5-year survival in HCV/HIV-coinfected liver recipients was lower than in HCV-monoinfected recipients, although an important subset with a favorable prognosis was identified in the former.

Preoperative gastric conditioning in cervical gastroplasty

To determine if ischemic conditioning of the stomach improves the morbidity, mortality, and the anastomotic failure in gastroplasties with cervical anastomosis. Analysis of all patients with indication for cervical gastroplasty during the period of study. In all cases, ischemic conditioning was performed by selective embolization. Anastomotic failure, morbidity, and mortality rates were studied. Thirty-nine consecutive patients were included. Angiography and selective embolization of the left gastric, right gastric, and splenic arteries were performed. Surgery was performed 2 weeks later. Four patients did not have a complete embolization; median hospital stay after conditioning was 1.24 ± 0.6 days. In two patients, surgery could not be completed. Of the 33 remaining, 29 had a posterior mediastinic gastroplasty and four through the anterior mediastinum. The most common morbidity was respiratory. Five patients had a reoperation and the mortality was 6%. One case of anastomotic leak was found (3%). The mean hospital stay was 17.5 days. Preoperative embolization is a technique with acceptable morbidity and a short hospital stay. In our experience it can reduce the incidence of the morbidity, mortality, and anastomotic leak in gastroplasties with cervical anastomosis. Prospective studies will be necessary to demonstrate the validity of this approach.

Disseminated adiaspiromycosis: case report of a liver transplant patient with human immunodeficiency infection, and literature review

Disseminated adiaspiromycosis is a rare infection that is sometimes associated with immunocompromised situations. We report the case of a patient, infected with human immunodeficiency virus and receiving highly active antiretroviral therapy, who had a liver transplant for hepatocellular carcinoma. The patient presented skin and pulmonary lesions due to adiaspiromycosis during immunosuppressive therapy. A review of >60 cases in the literature shows that adiaspiromycosis is a rare infection and Emmonsia is a dimorphic fungus that is difficult to grow. It should be considered a possible diagnosis in case of fungal infection and pulmonary granulomatosis. We should be aware of emerging adiaspiromycosis in patients with risk factors of immunosuppression, particularly transplant recipients. In these patients in particular, liposomal amphotericin B therapy should be considered.

Time course of necrosis/apoptosis and neovascularization during experimental gastric conditioning

Apoptosis, necrosis and neovascularization are three processes that occur during ischemic preconditioning in a range of organs. In the stomach, the effect of this preconditioning (the delay phenomenon) has helped to improve gastric vascularization prior to esophagogastric anastomosis after esophagectomy. Here we present a sequential study of the histological recovery of the gastric fundus and the phenomena of apoptosis, necrosis and neovascularization in an experimental model of partial gastric ischemia. Partial gastric devascularization was performed by ligature of the left gastric vessels in Sprague-Dawley rats. Rats were assigned to groups in accordance with their evaluation period: control, 1, 3, 6, 10, 15 and 21 days. Histological analysis, caspase-3 activity, DNA fragmentation and vascular endothelial cell proliferation (Ki-67) were measured in tissue samples after sacrifice. After 24 h of partial gastric ischemia, rates of apoptosis and necrosis were higher in the experimental groups than in controls. Tissue injury was higher 3 and 6 days post-ischemia. From day 10 after partial gastric ischemia, apoptosis and necrosis started to decrease, and on days 15 and 21 showed no differences in relation to controls. Neovascularization began between days 1 and 3, reaching its peak at 15 days after ischemia and coinciding with complete histological recovery. Both necrosis and apoptosis play a role in tissue injury during the first days after partial gastric ischemia. After 15 days, the evolution of both the histology and the neovascularization suggested that this is the optimal time for performing gastric transposition.

Efficacy of enteral decontamination in the prevention of anastomotic dehiscence and pulmonary infection in esophagogastric surgery

Our aim in this study is to evaluate the efficacy of decontamination of the high digestive tract in reducing the incidence of anastomotic dehiscence, pulmonary infection and mortality after resective gastro-esophageal surgery. A prospective randomized and double-blinded study was conducted in patients undergoing total gastrectomy for gastric cancer and esophagectomy for esophageal cancer. Two groups were studied: group A patients were given erythromycin + gentamicine + nistatine sulfate orally; group B patients were given placebo. Mortality, incidence of anastomotic dehiscence and incidence of pulmonary infection were the end points evaluated. One hundred and nine consecutive patients were randomized. Eighteen (16.5%) were excluded. From the 91 patients who were evaluated, 42 (46.2%) received an esophagectomy and 49 (53.8%) had a total gastrectomy. Esophagectomies showed: a 0% rate of anastomotic dehiscence in group A and 12.5% in group B, P = 0.176; a pulmonary infection rate of 22.2% in group A and 29.1% in group B, P = 0.443; and mortality rate was 0% in group A and 12.5% in group B, P = 0.176. After gastrectomy, anastomotic dehiscence rate was 4.5% in group A and 0% in group B, P = 0.449; pulmonary infection rate was 4.5% in group A and 11.1% in group B, P = 0.387 and mortality was 9% in group A and 0% in group B, P = 0.196. Decontamination protocol does not help in decreasing the incidence of anastomotic dehiscence, pulmonary infection and mortality in the present study. Nevertheless, there seems to be a tendency to low pulmonary infection after gastrectomy and esophagectomy and to improve the incidence of anastomotic dehiscence after esophagectomy. Further studies are needed to re-evaluate these findings.

Surgical treatment of liver metastases from colorectal carcinoma in elderly patients. When is it worthwhile?

BACKGROUND

The elderly are under-represented in series of patients operated on for colorectal liver metastases (LM).

OBJECTIVE

To analyse the influence of age on surgery of colorectal LM, and the identification of factors that could be used as exclusion criteria.

PATIENTS AND METHODS

Six hundred and forty-eight patients underwent liver resection between 1990 and 2006. Demographic data, primary tumour related variables, stage of the disease, morbidity, mortality, survival and recurrence were prospectively recorded.

RESULTS

One hundred and sixty of 648 patients (25%) were 70 years old or older. Postoperative mortality was significantly higher in elderly patients (8% vs. 3%, p=0.008). Morbidity was also higher (41% vs. 34%, p=0.008). Survival rate at 1, 3 and 5 years was 88%, 62% and 45% respectively in patients younger than 70 years, and 82%, 48% and 36% in the elderly (p=0.007). Excluding the postoperative mortality, the figures were 90%, 64% and 46%. 90%, 53% and 38% (p=0.061). Disease-free survival rates at 1, 3 and 5 years excluding postoperative mortality were 68%, 32% and 25% in younger patients, compared to 68%, 34% and 30% (p=0.71) in the elderly. Major liver resections increased mortality in the elderly. In the multivariate analyses only a tumour size equal to or more than 10 cm significantly increased the postoperative mortality risk in elderly patients.

CONCLUSIONS

The elderly have a higher mortality. In recent years that difference has been markedly reduced. Excluding the postoperative mortality, the overall survival and disease-free survival are similar between both groups. The criteria to indicate surgery must be the same in both groups.

[Factors related to renal dysfunction after liver transplantation in patients with normal preoperative function]

OBJECTIVE

To determine perioperative factors related to postoperative renal dysfunction in patients receiving liver transplants who had normal renal function before surgery.

PATIENTS AND METHODS

We analyzed the cases of 189 consecutive patients. Patients with hepatorenal syndrome and previously diagnosed renal insufficiency were excluded, as were patients undergoing a second transplant operation. Postoperative renal dysfunction was diagnosed when creatinine levels exceeded 1.5 mg x dL(-1) in the first postoperative week. Multivariate analysis of preoperative variables (patient characteristics; Child-Pugh score; status with the United Network for Organ Sharing; and sodium, coagulation, hemoglobin, and creatinine levels); intraoperative variables (blood product units required, duration of surgery, reperfusion syndrome, surgical technique, and crystalloids required); and postoperative variables (hemodialysis or filtration, reoperation, mortality, creatinine levels at 6 and 12 months).

RESULTS

One hundred fifty patients with normal kidney function were included. Postoperative renal dysfunction developed in 45 (30%). Differences between patients with and without postoperative renal dysfunction were found for weight; sex; Child-Pugh score; blood transfusion requirements (mean [SD] of 2.36 [2.4] units of packed red cells in the group of patients with renal dysfunction vs 1.3 [1.8] in the patients with normal function); and reperfusion syndrome (26 [66.7%] patients with renal dysfunction and 35 [21.5%] without). The last 2 variables continued to be significantly correlated with renal dysfunction in the multivariate analysis with a relative risk of 1.25, (95% confidence interval [CI], 1.01-1.55) for units of blood transfusion and 2.41 (95% CI, 1.04-5.57) for reperfusion syndrome. Renal replacement therapy was used in 4 patients (2.7%). Mortality rates were similar. At 6 and 12 months, 26 (17.3%) and 18 (12%) patients had renal dysfunction.

CONCLUSIONS

Acute renal dysfunction is a frequent complication following a liver transplant and it is associated with transfusion of more units of blood products even when the average transfusion amount is not large.

[Domino or sequential liver transplantation. Is it a feasible technique?]

BACKGROUND

In domino liver transplantation (LT), the explanted liver of a patient with familial amyloidotic polyneuropathy (FAP) is donated to another patient.

PATIENTS AND METHOD

Between February 1999 and March 2001 we performed 131 LT with 121 cadaveric donors in our unit. Ten domino LTs were performed.

RESULTS

Patients with FAP were younger (37 years) than recipients of the second LT (64 years). The evolution of patients undergoing transplantation for FAP was excellent and all are currently alive and without complications. Among recipients of the second LT, one patient died in the postoperative period. A further two patients died from tumoral recurrence and hepatitis C virus recurrence 18 months and 9 months after transplantation, respectively. The remaining patients have shown no symptoms of FAP during the follow-up.

CONCLUSION

The results of this study show that domino LT is technically feasible. The technique increases the number of grafts without apparent risk either to the recipient with FAP or to the recipient of the latter's explanted liver.