The Role of Systematic Lymphadenectomy in Low-Grade Serous Ovarian Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the role of systematic lymphadenectomy in low-grade serous ovarian cancer (LGSOC) and determine its impact on clinical outcomes in overall survival (OS) and disease-free survival (DFS) terms.

METHODS

A comprehensive, systematic computer literature search on PubMed was performed using the following Medical Subject Headings (MeSH) terms: "low grade serous ovarian cancer" AND/OR "lymphadenectomy" AND/OR "staging" AND/OR "ovarian cancer" AND/OR "cytoreduction". Separate searches were performed with MeSH terms on MEDLINE and EMBASE to extract all the relevant literature available. We included only patients with histologically confirmed LGSOC.

RESULTS

Three studies were considered in the quantitative analysis. Systematic lymphadenectomy in LGSOC failed to provide a significant OS or PFS benefit in LGSOC when compared to no lymphadenectomy in the entire (all the stages) population (for OS: HR = 1.15, 95% CI [0.42, 3.18] I2 = 84% and for PFS: HR = 1.46, 95% CI [0.63, 3.41], I2 = 71%), nor did it in the subtype analysis regarding FIGO stages. For FIGO early-stage I-II LGSOC, the DFS data were pooled (HR = 1.48, 95% CI [0.58, 3.78], I2 = 75%). In patients with advanced-stage (FIGO II-IV), we also failed to prove survival benefit for lymphadenectomy in OS (HR = 1.74, 95% CI [0.87, 3.48], I2 = 11%) or DFS (HR = 1.48, 95% CI [0.58, 3.78], I2 = 75%) compared to no lymphadenectomy.

CONCLUSION

More extensive prospective research is mandatory to understand the real impact of lymphadenectomy on survival in LGSOC. The existing literature does not provide strong evidence.

Standardizing Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer Treatment: Navigating Complexities and Charting the Path Forward

The incorporation of hyperthermic intraperitoneal chemotherapy (HIPEC) into the treatment landscape for ovarian cancer has invoked a spectrum of emotions, ranging from enthusiastic anticipation to cautious skepticism [...].

Antiperistaltic Transverse Coloplasty: A Salvage Procedure in Extensive Bowel and Colorectal Resections to Avoid Intestinal Failure

INTRODUCTION

After extensive small and colon resections, quality of life can be affected. We propose the antiperistaltic transverse coloplasty as a solution that allows for preservation of the transverse colon after both right and left colectomies while achieving a tension-free colorectal anastomosis slowing the transit and increasing the absorption time, resulting in better stool consistency and quality of life compared with an ileorectal anastomosis.

METHODS

This technique was performed in a 41-year-old woman with Goblet cell adenocarcinoma of the appendix with peritoneal metastasis. The transverse colon is rotated anticlockwise over the axis of the middle colic vessels toward the left parietocolic flank and relocated to the usual position of the descending colon.

RESULTS

After 1 year of follow-up, the patient led a normal life without parenteral nutrition with five bowel movements per day and a weight gain of 15%.

CONCLUSIONS

The use of an antiperistaltic transverse coloplasty may be worthwhile to perform in cases of extensive bowel resections during cytoreductive surgery leading to short-bowel syndrome to avoid a permanent stoma or intestinal failure and improve patient outcomes.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Simultaneous Surgical Approach with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Patients with Concurrent Peritoneal and Liver Metastases of Colon Cancer Origin

Background: Simultaneous liver resection and peritoneal cytoreduction with hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial today. The aim of the study was to analyze the postoperative outcomes and survival of patients with advanced metastatic colon cancer (peritoneal and/or liver metastases). Methods: Retrospective observational study from a prospective maintained data base. Patients who underwent a simultaneous peritoneal cytoreduction and liver resection plus HIPEC were studied. Postoperative outcomes and overall and disease free survival were analyzed. Univariate and multivariate analyses were performed. Results: From January 2010 to October 2022, 22 patients operated with peritoneal and liver metastasis (LR+) were compared with 87 patients operated with peritoneal metastasis alone (LR-). LR+ group presented higher serious morbidity (36.4 vs. 14.9%; p: 0.034). Postoperative mortality did not reach statistical difference. Median overall and disease free survival was similar. Peritoneal carcinomatosis index was the only predictive factor of survival. Conclusions: Simultaneous peritoneal and liver resection is associated with increased postoperative morbidity and hospital stay, but with similar postoperative mortality and OS and disease free survival. These results reflect the evolution of these patients, considered inoperable until recently, and justify the trend to incorporate this surgical strategy within a multimodal therapeutic plan in highly selected patients.

Challenges in precision medicine in pancreatic cancer: A focus in cancer stem cells and microbiota

Pancreatic cancer adenocarcinoma (PDAC) is a lethal disease, with the lowest 5-years survival rate of all cancers due to late diagnosis. Despite the advance and success of precision oncology in gastrointestinal cancers, the frequency of molecular-informed therapy decisions in PDAC is currently neglectable. The reasons for this dismal situation are mainly the absence of effective early diagnostic biomarkers and therapy resistance. PDAC cancer stem cells (PDAC-SC), which are regarded as essential for tumor initiation, relapse and drug resistance, are highly dependent on their niche i.e. microanatomical structures of the tumor microenvironment. There is an altered microbiome in PDAC patients embedded within the highly desmoplastic tumor microenvironment, which is known to determine therapeutic responses and affecting survival in PDAC patients. We consider that understanding the communication network that exists between the microbiome and the PDAC-SC niche by co-culture of patient-derived organoids (PDOs) with TME microbiota would recapitulate the complexity of PDAC paving the way towards a precision oncology treatment-response prediction.

Insights behind the Relationship between Colorectal Cancer and Obesity: Is Visceral Adipose Tissue the Missing Link?

Colorectal cancer (CRC) is a major health problem worldwide, with an estimated 1.9 million new cases and 915,880 deaths in 2020 alone. The etiology of CRC is complex and involves both genetic and lifestyle factors. Obesity is a major risk factor for CRC, and the mechanisms underlying this link are still unclear. However, the generalized inflammatory state of adipose tissue in obesity is thought to play a role in the association between CRC risk and development. Visceral adipose tissue (VAT) is a major source of proinflammatory cytokines and other factors that contribute to the characteristic systemic low-grade inflammation associated with obesity. VAT is also closely associated with the tumor microenvironment (TME), and recent evidence suggests that adipocytes within the TME undergo phenotypic changes that contribute to tumor progression. In this review, we aim to summarize the current evidence linking obesity and CRC, with a focus on the role of VAT in tumor etiology and progression.

Abdominal metastatic melanoma invading transverse colon and stomach

Gastrointestinal melanoma metastases are not uncommon, with jejunum and ileum being the most common locations (58%), followed by gastric (26%), colonic (22%), duodenal (12%) and rectum metastases (5%).

Prophylactic HIPEC with oxaliplatin might be of benefit in T4 and perforated colon cancer: another possible interpretation of the COLOPEC results

The COLOPEC trial failed to show evidence for improved relapse-free survival (RFS) between the two study groups: 80,9% (95% CI 73.3-88.5) in the experimental group and 76.2 % (68.0-84.4) in the control group (one-sided log-rank p = 0.28). Nevertheless only 87 patients received the adjuvant HIPEC treatment in the experimental arm (n = 100). This group had a peritoneal relapse of 19 %, but only 10 % had a truly peritoneal relapse as 9 of them had stablished peritoneal carcinomatosis and 1 case was a peritoneal recurrence but did not receive adjuvant HIPEC. We conducted a per-protocol analysis comparing the 87 patients which truly received the adjuvant HIPEC to the 102 patients in the control arm and obtained an OR 0.396 (95 % CI 0.17-0.91) with a (Pearson Chi-Square p = 0.026, two-tailed Fisher exact test p = 0.032). This contradicts the COLOPEC reported conclusions and shows that adjuvant HIPEC could have an important protective role against peritoneal recurrence.

A review of the diagnosis and management of liver hydatid cyst

Hydatidosis is a zoonosis caused by Echinococcus in the larval stage. Humans are accidental intermediary hosts where cystic lesions develop, primarily in the liver and lungs. It is usually asymptomatic, hence it is usually incidentally identified. Symptoms result from cyst expansion and/or host inflammatory reaction. Hepatomegaly is the most common sign. Hydatidosis induces no specific changes in lab tests, but immunodiagnostics are available that may complement its study, with antibody detection being the method of choice. While ultrasound is the main diagnostic technique, tomography offers more accurate information regarding characteristics and anatomical relations. A number of therapy options are presently available. Treatment with albendazole, whether combined or not with praziquantel, is useful for smaller, uncomplicated cysts (< 5 cm). Only 30 % of cysts disappear with medical treatment alone. Surgery is indicated for bigger liver cysts (> 10 cm), at risk for rupture and/or complicated; the laparoscopic approach is scarcely widespread. The radical technique (total cystopericystectomy) is preferable because o its lower risk for postoperative abdominal infection, biliary fistula, and overall morbidity. Conservative techniques are appropriate in endemic areas where surgery is performed by nonspecialist surgeons. PAIR (puncture-aspiration-injection-reaspiration) is an innovative technique representing an alternative to surgery. It is indicated for inoperable cases and/or patients who reject surgery, for recurrence after surgery, and for lack of response to medical treatment. Active surveillance without treatment may be indicated for quiescent or inactive, uncomplicated liver cysts.

Laparoscopy technique in the setting of peritoneal metastases to avoid port site relapse

BACKGROUND

Laparoscopy is indicated in many patients with abdominal and pelvic malignancy. If cancer cells are present within the peritoneal space, there is a possibility for port site metastases to develop.

METHODS

The pathophysiology for occurrence of port site metastases was reviewed. Technical modifications to reduce the incidence of these abdominal wall sites for disease progression were suggested.

RESULTS

Evacuation of all gases and all fluid from the peritoneal space through the trocars prior to their removal will reduce the contamination of the tissue surrounding the port site by intraperitoneal cancer cells. If port sites are confined to the midline, they can be removed as part of a midline abdominal incision if metastases occur. If port site metastases occur through lateral port sites, the rectus abdominus muscle may need to be widely excised to achieve negative margins.

CONCLUSION

Technical modifications of laparoscopy in patients with peritoneal metastases may reduce incidence of this iatrogenic dissemination of cancer.

Diaphragmatic Peritonectomy and Full-Thickness Resection in CRS/HIPEC May Allow Higher Completeness of Cytoreduction Rates with a Low Rate of Respiratory Complications

BACKGROUND

Cytoreductive surgery (CRS) provides a survival benefit when achieved without residual disease. As diaphragm is frequently affected in peritoneal malignancies, complete cytoreduction often requires surgical techniques over the diaphragm. The purpose of the study was to assess diaphragmatic resection impact on cytoreduction completeness, morbidity and mortality compared to less aggressive diaphragmatic peritonectomy in CRS and hyperthermic intraperitoneal chemotherapy (HIPEC) settings.

MATERIALS AND METHODS

Patients with peritoneal carcinomatosis and supramesocolic disease undergoing CRS/HIPEC from 2011 to 2019 were included in a prospectively collected database. We compared patients who underwent full-thickness diaphragmatic resection (DR) and diaphragmatic peritonectomy (DP). Epidemiological and clinical data, morbidity, and mortality within 90 days of surgery were documented.

RESULTS

232 patients were initially selected. Inclusion criteria were met by 88 procedures. DR was performed on 32 patients and DP on 56. Number of resected organs was 5.21 in the DR cohort vs. 3.57 in the DP cohort (p<0.0001). Rate of Peritoneal Cancer Index (PCI) score >14 was higher in the DR group (75%) than in the DP group (50.9%) (p=0.027). Tumor invasion of diaphragmatic muscle after DR was confirmed in 89.3% patients. Postoperative pleural effusion was observed in 28 patients (50%) in the DP group and in 17 (53.1%) in the DR group.

CONCLUSIONS

CRS/HIPEC requires specific surgical techniques over the diaphragm to achieve complete cytoreduction. As diaphragmatic muscle invasion is frequent, full-thickness resection may allow a cytoreduction completeness increase without an increased morbidity. Pleural drains are not systematically required as these procedures show low incidence of major respiratory complications.

Secondary surgical cytoreduction needs to be assessed taking into account surgical technique, completeness of cytoreduction, and extent of disease

Recent evidence suggested that secondary surgical cytoreduction followed by chemotherapy does not result in longer overall survival in patients with platinum-sensitive recurrent ovarian cancer.

This statement is based on a phase III multicenter, randomized clinical trial that lacks a description of the surgical protocol, the surgical technique, and the surgical variables. In a study that evaluates surgical cytoreduction, it is mandatory to assess the grade of cytoreductive surgery achieved (Sugarbaker PH, Langenbeck’s Arch Surg 384:576–87, 1999), the extent of disease using PCI (Peritoneal Cancer Index), the technique itself, and the existence of a multidisciplinary approach with extensive upper abdominal procedures in experienced centers (Ren et al, BMC Cancer 15:1-12, 2015). There is evidence proving that the quality of cytoreduction (Al Rawahi et al, Cochrane Database Syst Rev 2013, 2013), the measurement of the amount of disease by PCI (Elzarkaa et al, J Gynecol Oncol 29, 2018), and a multidisciplinary approach with supramesocolic procedures (Ren et al, BMC Cancer 15:1-12, 2015) impact overall survival.

This study fails to compare chemotherapy with secondary cytoreductive surgery since, due to the lack of variables, we can assess neither the performed surgery nor its criteria. This study should not be taken into account to recommend chemotherapy alone over a surgical approach in this group of patients.

Results of a national survey on the use of stents for the treatment of colonic obstruction

INTRODUCTION

We distributed a survey in order to determine the current indications for the use of colonic stents to treat colonic obstruction in Spain and its compliance with international guidelines.

METHODS

Descriptive study of a survey distributed by the Spanish Association of Surgeons (Asociación Española de Cirujanos), the Catalan Society of Surgery (Societat Catalana de Cirurgia) and the Spanish Society of Digestive Endoscopy (Sociedad Española de Endoscopia Digestiva).

RESULTS

340 valid responses were received: 25% from gastrointestinal specialists, and 75% from general surgeons. During the last year, 44.4% of respondents assessed between 10 and 20 COC. Of these, 52.2% indicated less than 5 stents/year, 75% of which were indicated as a prior step to preferential surgery and only 25% were performed with palliative intent. 55.3% of the participants reported knowing the official guidelines, and 64% of respondents would use the stent as a step prior to surgery in elderly patients with localized disease. 75.9% would place stents as palliative therapy in young patients with carcinomatosis, and 61.8% would use them in stage IV malignancies under treatment with chemotherapy. Only 18.1% knew of the risk of colon perforation after stent placement in patients undergoing treatment with antiangiogenics.

CONCLUSIONS

In Spain, the indication for colonic stents is reserved for selected cases and varies according to the specialty and the years of experience of the respondent. The compliance with international guidelines of most respondents is moderate. It is important to insist on the high risk of perforation after angiogenics, which is unknown to most surgeons.

New hemostatic device for grade IV-V liver injury in porcine model: a proof of concept

Background

The liver is the most injured organ following abdominal trauma. Uncontrolled bleeding remains the main cause of early liver injury-related death, with a mortality rate of 50–54% in the first 24 h after admission and with 80% of operative deaths. Packing and reoperation account for the increased survival in severe liver trauma, and they are recommended for severe liver injuries (grades IV–V).

Perihepatic packing can lead to several potential complications. An excessive packing can cause complications due to abdominal compartment syndrome, while a soft packing may be ineffective, and thus, bleeding can continue inadvertently with the consequent hypovolemic shock and potentially death.

Methods

We designed a new vacuum-based device to perform perihepatic packing without the negative side-effects of the classic technique. We conducted a prospective pilot feasibility study in a porcine model. We compared the traditional perihepatic packing (PHP) (n = 2) with the new VacBagPack device (VBP) (n = 2).

Results

Both pigs survived with the new device and showed an equivalent outcome to the one that survived in the traditional technique group. Blood tests were similar too. This suggests that VBP could be at least as effective as traditional PHP.

Conclusions

We establish a first step towards the development of a new packing device. A new study with a bigger sample size still in pigs will be conducted. Also, an industrial model of the device is currently in production.

From utopia to reality: increased survival in peritoneal carcinomatosis treated with cytoreduction and hyperthermic intraperitoneal chemotherapy

We have read with great interest the article by Illán et al.1 entitled "Long survival in a patient with metastatic colorectal carcinoma: reality or utopia?" This article describes the case of a 42 year old patient with mucinous-type colon adenocarcinoma who had tumor recurrence with peritoneal metastases 18 months after resection of the primary tumor and adjuvant chemotherapy. After multiple metastasectomies and several lines of chemotherapy, the patient died 27 months after the recurrence.

Treatment of transsphincteric fistula-in-ano with growth factors from autologous platelets: results of a phase II clinical trial

PURPOSE

The aim of this paper is to evaluate to the safety, feasibility and efficacy of a novel treatment for transsphincteric cryptoglandular fistula: injection of autologous plasma rich in growth factors (PRGF) into the fistula tract accompanied by sealing using a fibrin plug created from the activated platelet-poor fraction of the same plasma.

METHOD

This article is a prospective, phase II clinical trial. The procedure was externally audited. Thirty-six patients diagnosed with transsphincteric fistula-in-ano were included. All patients underwent follow-up examinations at 1 week and again at 3, 6 and 12 months after discharge. Main outcome measures safety (number of adverse events), feasibility and effectiveness of the treatment.

RESULTS

A total of 36 patients received the study treatment, with the procedure found to be feasible in all patients. A total of seven adverse events (AE) related to the injected product or surgical procedure were identified in 4 of 36 patients. At the end of the follow-up period (12 months), 33.3% of patients (12/36) had achieved complete fistula healing and 11.1% of patients (4/36) had achieved partial healing. In total, this amounted to 44.4% of patients (16/36) being asymptomatic at final follow-up. In successfully healed patients, a gradual reduction in pain was observed, as measured using a Visual Analog Scale (VAS) (p = 0.0278). Compared to baseline, a significant improvement in Wexner score was seen in patients achieving total or partial healing of the fistula (p = 0.0195).

CONCLUSIONS

The study treatment was safe and feasible, with apparently modest efficacy rates. Continence and pain improvement following treatment may be considered predictive factors for healing.

Feasibility and safety of surgical wound remote follow-up by smart phone in appendectomy: A pilot study

INTRODUCTION

The objective of the present study is to assess the safety and feasibility of the use of telemedicine-based services for surgical wound care and to measure patient satisfaction with telemedicine-based follow-up.

MATERIAL AND METHODS

24 patients were included, they were provided with a corporate mail address. On day 7 after surgery patients sent, via email, an image of their surgical wound together with a completed questionnaire in order to obtain an early diagnosis. Two independent physicians studied this information and the histologic analysis of the specimen. On day 8, all patients underwent face-to-face office examination by a third physician and all of them completed a satisfaction questionnaire at the end of the study.

RESULTS

The use of telemedicine-based services showed a sensitivity of 100%, a specificity of 91.6%, a positive predictive value of 75% and a negative predictive value of 100%. Degree of concordance between the two physicians, as regards the necessity of face-to-face follow-up yielded a kappa coefficient of 0.42 (standard error 0.25 and confidence interval 95% (0.92-0.08), which means a moderate agreement between the two evaluations. 94% of patients were satisfied with telemedicine-based follow-up and 93% showed their preference for this procedure over conventional methods.

CONCLUSIONS

The telemedicine-based follow-up, has proven to be feasible and safe for the evaluation of early postoperative complications. Patients reported high levels of satisfaction with the procedure. Telemedicine-based follow-up could become standard practice with the development of a specific mobile application.

Dorsal inflammatory mass secondary to lost stones after laparoscopic cholecystectomy

The most frequent intraabdominal complication after lost stones are abscesses, which account for 65% of complications. The main risk factors are: old age, male gender, surgical difficulty, leakage of lithiasis of more than 1.5 cm or more than 15 stones, perihepatic location and pigmented gallstones. We report the case of a 73-year-old man with a medical history of hypertension, diabetes, chronic kidney failure and laparoscopic cholecystectomy.

Is the interval from surgery to ileostomy closure a risk factor for low anterior resection syndrome?

AIM

Low anterior resection syndrome (LARS) comprises a collection of symptoms affecting patients after restorative surgery for rectal cancer. The aim of the present study was to analyse the incidence of LARS in patients undergoing rectal cancer surgery with and without subsequent ileostomy and to determine whether the interval to ileostomy closure is a factor associated with its occurrence.

METHOD

All patients undergoing curative anterior resection for rectal cancer from 2008 to 2012 in our institution were included in the study. They were divided into two groups according to whether or not a defunctioning ileostomy had been performed. Patients were assessed for LARS at a median interval of 23.60 ± 16.73 (12-48) months from anterior resection in those who did not have an ileostomy and at an interval of 11.31 ± 14.24 (12-60) months from closure of the ileostomy in those who did. They underwent a structured telephone interview based on a validated LARS score questionnaire. Univariate and multivariate analysis was carried out to assess possible associations between LARS and the variables studied.

RESULTS

There were 150 patients (93 men) of whom 54.7% had no evidence of LARS, 17.3% had minor symptoms and 28% major symptoms of LARS. Univariate analysis showed that male gender, the presence of a temporary ileostomy and neoadjuvant therapy were predisposing factors for LARS. The interval from construction of the ileostomy to its closure did not appear to be a factor associated with LARS. In multivariate analysis, male gender and preoperative neoadjuvant therapy were significant predisposing factors for LARS.

CONCLUSION

Male gender and preoperative neoadjuvant therapy are risk factors for LARS. The presence of ileostomy or time to ileostomy closure is not associated with the development of this syndrome.

Small bowel obstruction due to laparoscopic barbed sutures: an unknown complication?

BACKGROUND

In recent years there has been an increasing uptake in the use of barbed sutures, particularly in minimally invasive and laparoscopic procedures where they may reduce operating time and improve surgical efficiency. However, little is known about the adverse events associated with these new materials and concerns have arisen regarding their safety in certain procedures.

METHODS

We performed a search of electronic databases (PubMed, EMBASE, and Cochrane Database). We reveal up to 15 cases of small bowel obstruction (SBO) complicating laparoscopic pelvic surgery that have been reported to date adding two cases of SBO in our own practice following the use of barbed sutures in laparoscopic operations, both requiring surgical re-intervention in the early post-operative period.

RESULTS

Fifteen similar cases of small bowel obstruction were identified, all of which occurred in patients undergoing surgery below the transverse colon . Surgical re-intervention was required in all cases although 60% of these were performed laparoscopically.

CONCLUSIONS

These cases highlight that although barbed sutures provide an attractive means to allow easier and faster laparoscopic suturing, they should be used carefully in inframesocolic surgery and the suture end cut and buried to avoid inadvertent attachment to the small bowel or its mesentery. Barbed suture entanglement should be considered as an uncommon yet potentially serious differential cause for SBO presenting in the early period after laparoscopic surgery where a barbed suture has been used.

Outcomes of Liver Transplantation During Adulthood After Kasai Portoenterostomy Due to Biliary Atresia

Biliary atresia (BA) is a neonatal progressive cholangiopathy of unknown etiology and one of the most common reasons for liver transplantation (LT) in children. Kasai portoenterostomy (KP) improves survival of the native liver, although LT remains the only ultimate treatment. In some cases KP makes it possible to defer the ultimate LT until adulthood. We report our experience regarding 5 cases of BA treated with LT during adulthood. KP was performed in all patients at an average age of 176 days (range, 60-280), which allowed an average survival of the native liver of 19.01 years (range, 14.06-22.32). Five-year survival rate was 100%. Ten-year survival rate did not reach 100% because of a death 9.55 years after LT due to chronic graft rejection, in a patient who was already prepared for a new LT. Our results corroborate that KP remains the first-line treatment of BA. Early performance of the KP provides children with the best chance of survival, allowing the delay of the LT to adulthood. LT during adulthood in these patients achieves good post-LT survival rate; we have not found any data regarding this group of patients in the literature.

Unnoticed biloma due to liver puncture after Veress needle insertion

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

Gallbladder leiomyoma in absence of immune system disorders: an unusual diagnosis

Mesenchymal neoplasms of the gallbladder are rare and in particular leiomyomas of the gallbladder have been rarely reported, all of them in patients with immune system disorders.This is the first report in Spanish of a 23-year-old female patient with a gallbladder leiomyoma without associated immunodeficiency. The patient lacks a previous history of uterine leiomyoma or any other form of neoplasm. She refers several episodes of epygastralgia. A hydatic cyst led to an initial diagnosis and the gallbladder was removed by means of simple cholecystectomy. The abnormal macroscopic aspect of the sample prompted intraoperative biopsy which revealed a benign gallbladder angiomyoma. Subsequent immunohistochemical analysis of the resected sample yielded the diagnosis of intramural endocavitary leiomyoma negative for EBV and C-kit / CD-117. The patient has good general condition and remains asymptomatic 15 months after surgery.