Repeated pancreatic resection for pancreatic metastases from renal cell Carcinoma: A Spanish multicenter study (PANMEKID)

BACKGROUND AND OBJECTIVES

Recurrent isolated pancreatic metastasis from Renal Cell Carcinoma (RCC) after pancreatic resection is rare. The purpose of our study is to describe a series of cases of relapse of pancreatic metastasis from renal cancer in the pancreatic remnant and its surgical treatment with a repeated pancreatic resection, and to analyse the results of both overall and disease-free survival.

METHODS

Multicenter retrospective study of patients undergoing pancreatic resection for RCC pancreatic metastases, from January 2010 to May 2020. Patients were grouped into two groups depending on whether they received a single pancreatic resection (SPS) or iterative pancreatic resection. Data on short and long-term outcome after pancreatic resection were collected.

RESULTS

The study included 131 pancreatic resections performed in 116 patients. Thus, iterative pancreatic surgery (IPS) was performed in 15 patients. The mean length of time between the first pancreatic surgery and the second was 48.9 months (95 % CI: 22.2-56.9). There were no differences in the rate of postoperative complications. The DFS rates at 1, 3 and 5 years were 86 %, 78 % and 78 % vs 75 %, 50 % and 37 % in the IPS and SPS group respectively (p = 0.179). OS rates at 1, 3, 5 and 7 years were 100 %, 100 %, 100 % and 75 % in the IPS group vs 95 %, 85 %, 80 % and 68 % in the SPS group (p = 0.895).

CONCLUSION

Repeated pancreatic resection in case of relapse of pancreatic metastasis of RCC in the pancreatic remnant is justified, since it achieves OS results similar to those obtained after the first resection.

Incidence and risk factors of delayed development for stoma site incisional hernia after ileostomy closure in patients undergoing colorectal surgery with temporary ileostomy

BACKGROUND

Stoma site incisional hernias after ileostomy closure are complex hernias that can be associated with abdominal pain, discomfort, and a diminished quality of life. The aim of this study was to determine the incidence of incisional hernia (IH) following temporary ileostomy reversal in patients undergoing colorectal surgery, and the risk factors associated with its development.

METHODS

This was a prospective, single-centre, cohort study of patients undergoing ileostomy reversal between January 2010 and December 2016. Comorbidities, operative characteristics, comparison between early and late ileostomy closure and postoperative complications were analysed.

RESULTS

A total of 202 consecutive patients were prospectively evaluated (median follow-up 46 months; range: 12-109). Stoma site incisional hernia occurred in 23% of patients (n = 47), diagnosed by physical examination or imaging tests. The reasons for the primary surgery were colorectal cancer (n = 141, 69.8%), inflammatory bowel disease (n = 14, 6.9%), emergency surgery (n = 35, 17.3%), and other conditions (n = 12, 5.9%). Secondary outcomes: a statistically significant risk factors for developing an IH was obesity (higher BMI) (OR 1.15, 95% CI: 1.05-1.26) p = .003).

CONCLUSIONS

23% of patients developed surgical site IH, a higher BMI being the only risk factor found to be statistically significant in the development of an incisional hernia.

Pancreatic metastases from renal cell carcinoma. Postoperative outcome after surgical treatment in a Spanish multicenter study (PANMEKID)

BACKGROUND

Renal Cell Carcinoma (RCC) occasionally spreads to the pancreas. The purpose of our study is to evaluate the short and long-term results of a multicenter series in order to determine the effect of surgical treatment on the prognosis of these patients.

METHODS

Multicenter retrospective study of patients undergoing surgery for RCC pancreatic metastases, from January 2010 to May 2020. Variables related to the primary tumor, demographics, clinical characteristics of metastasis, location in the pancreas, type of pancreatic resection performed and data on short and long-term evolution after pancreatic resection were collected.

RESULTS

The study included 116 patients. The mean time between nephrectomy and pancreatic metastases' resection was 87.35 months (ICR: 1.51-332.55). Distal pancreatectomy was the most performed technique employed (50 %). Postoperative morbidity was observed in 60.9 % of cases (Clavien-Dindo greater than IIIa in 14 %). The median follow-up time was 43 months (13-78). Overall survival (OS) rates at 1, 3, and 5 years were 96 %, 88 %, and 83 %, respectively. The disease-free survival (DFS) rate at 1, 3, and 5 years was 73 %, 49 %, and 35 %, respectively. Significant prognostic factors of relapse were a disease free interval of less than 10 years (2.05 [1.13-3.72], p 0.02) and a history of previous extrapancreatic metastasis (2.44 [1.22-4.86], p 0.01).

CONCLUSIONS

Pancreatic resection if metastatic RCC is found in the pancreas is warranted to achieve higher overall survival and disease-free survival, even if extrapancreatic metastases were previously removed. The existence of intrapancreatic multifocal compromise does not always warrant the performance of a total pancreatectomy in order to improve survival.

Update on the management of uncomplicated acute diverticulitis at our centre. Equally effective, more efficient

GOALS

The current trend in the treatment of non-complicated diverticulitis is the outpatient management with antibiotic or even anti-inflammatory regimens in selected cases. We present a comparison of the results in our hospital with different protocols applied in 2016 and 2017.

MATERIAL AND METHODS

All patients selected for this study were diagnosed with diverticulitis grade Ia of Hinchey's classification according to radiological findings on abdominal CT. We have analyzed two retrospective cohorts: 100 patients treated in 2016 according to the old protocol and 104 patients treated in 2017 with a new protocol. In 2016, the candidates for ambulatory treatment remained under observation for 24 hours before being discharged. The treatment consisted of 14 days of ciprofloxacin and metronidazole. In 2017, only patients with more acute symptoms were observed 24 hours and amoxicillin-clavulanic acid was prescribed for only 5 days.

RESULTS

The persistence of the disease in 2016 was 6% and in 2017 was only 5.77% (p = 0.944). Recurrence during the first year was 13% in the first group, while in the second it was 5.7%, although this difference was not statistically significant. Likewise, a significant reduction in health costs was achieved.

CONCLUSIONS

Outpatient treatment of acute uncomplicated diverticulitis with oral treatment seems to be a safe and effective therapeutic strategy in selected patients with low comorbidity.

Normothermic regional perfusion vs. super-rapid recovery in controlled donation after circulatory death liver transplantation

BACKGROUND & AIMS

Although there is increasing interest in its use, definitive evidence demonstrating a benefit for postmortem normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation is lacking. The aim of this study was to compare results of cDCD liver transplants performed with postmortem NRP vs. super-rapid recovery (SRR), the current standard for cDCD.

METHODS

This was an observational cohort study including all cDCD liver transplants performed in Spain between June 2012 and December 2016, with follow-up ending in December 2017. Each donor hospital determined whether organ recovery was performed using NRP or SRR. The propensity scores technique based on the inverse probability of treatment weighting (IPTW) was used to balance covariates across study groups; logistic and Cox regression models were used for binary and time-to-event outcomes.

RESULTS

During the study period, there were 95 cDCD liver transplants performed with postmortem NRP and 117 with SRR. The median donor age was 56 years (interquartile range 45-65 years). After IPTW analysis, baseline covariates were balanced, with all absolute standardised differences <0.15. IPTW-adjusted risks were significantly improved among NRP livers for overall biliary complications (odds ratio 0.14; 95% CI 0.06-0.35, p <0.001), ischaemic type biliary lesions (odds ratio 0.11; 95% CI 0.02-0.57; p = 0.008), and graft loss (hazard ratio 0.39; 95% CI 0.20-0.78; p = 0.008).

CONCLUSIONS

The use of postmortem NRP in cDCD liver transplantation appears to reduce postoperative biliary complications, ischaemic type biliary lesions and graft loss, and allows for the transplantation of livers even from cDCD donors of advanced age.

LAY SUMMARY

This is a propensity-matched nationwide observational cohort study performed using livers recovered from donors undergoing cardiac arrest provoked by the intentional withdrawal of life support (controlled donation after circulatory death, cDCD). Approximately half of the livers were recovered after a period of postmortem in situ normothermic regional perfusion, which restored warm oxygenated blood to the abdominal organs, whereas the remainder were recovered after rapid preservation with a cold solution. The study results suggest that the use of postmortem normothermic regional perfusion helps reduce rates of post-transplant biliary complications and graft loss and allows for the successful transplantation of livers from older cDCD donors.

Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation

INTRODUCTION

The prevalence of portal vein thrombosis (PVT) in patients that have undergone liver transplantation (LT) is 9.7% (SD 4.5). The aim of our study was to determine the prevalence, assess the factors that are associated with PVT and clarify their association with prognosis in patients with liver cirrhosis (LC) and LT.

AIMS AND METHODS

From 2005 to 2014, laboratory, radiological and surgical data were collected from patients with LC in our center who had undergone LT for the first time.

RESULTS

One hundred and ninety-one patients were included. The mean age was 55 (SD 9), 75.4% of patients were male and 48.7% had HCV. The Child-Pugh scores were A/B/C 41.9%/35.9%/25.5% and the MELD score was 15 (SD 6). Previous decompensations were: ascites (61.4%), hepatic encephalopathy (34.4%), variceal bleeding (25.4%), hepatocellular carcinoma (48.9%) and spontaneous bacterial peritonitis (SPB) (14.3%). The mean post-transplant follow-up was 42 months (0-113). PVT was diagnosed at LT in 18 patients (9.4%). Six patients were previously diagnosed using imaging tests (33.3%): 2 patients (11.1%) by DU and 4 patients (22.2%) by CT scan. All patients with PVT had DU in a mean time of 6 months before LT (0-44) and 90 patients (47.1%) had a CT scan in a median time of 6 months before LT (0-45). PVT was significantly related to the presence of SBP (33.3% vs 12.6%; p = 0.02) and lower levels of albumin (3.1g/dl vs 3.4g/dl; p = 0.05). MELD was higher in patients with PVT (16.6 vs 14.9; p = 0.3). There were no significant differences with regard to the need for transfusion of blood components. Moreover, the surgery time was similar in both groups. PVT correlated with a higher mortality in the first 30 days (8.8% vs 16.7%; p = 0.2).

CONCLUSION

Prior history of SBP and lower levels of albumin were identified as factors associated with PVT. The pre-transplant diagnosis rate is very low and the presence of PVT may have implications for short-term mortality.

Right adrenal metastases of hepatocarcinoma after liver transplantation: case report and literature review

BACKGROUND

Hepatocellular carcinoma (HCC) represents one of the most common malignancies globally, accounting for nearly one million new cases per year. Although the treatment of extrahepatic metastases from primary liver tumors is essentially palliative, a solitary metastasis from such tumors offers a possibility of cure by surgical resection. The adrenal gland is an uncommon site for metastasis from primary liver tumors.

METHODS

We report a liver transplantation case of HCC and hepatitis B virus in a 23-year-old man with an excellent postoperative result. However, because an increased alpha-fetoprotein was evident and complete radiologic and blood tests were performed, all of which were normal. Three years posttransplantation, a right adrenal mass was identified by CT. PAAF was performed as well as adrenalectomy for a solitary adrenal metastasis from hepatocellular carcinoma.

RESULTS

The patient underwent adrenalectomy for the right adrenal metastasis at 3 years following liver transplantation for HCC. He is presently alive and disease-free 24 months after adrenalectomy.

CONCLUSION

Carefully selected patients with solitary metastasis from HCC may be considered for resection.

Apelin effects in human splanchnic arteries. Role of nitric oxide and prostanoids

Apelin effects were examined in human splanchnic arteries from liver donors (normal arteries) and from liver recipients. Segments 3 mm long were obtained from mesenteric arteries taken from liver donors (normal arteries), and from hepatic arteries taken from cirrhotic patients undergoing liver transplantation (liver recipients), and the segments were mounted in organ baths for isometric tension recording. In arteries under resting conditions, apelin (10(-10)-10(-6) M) caused no effect in any of the arteries tested. In arteries precontracted with the thromboxane A(2) analogue U46619 (10(-7)-10(-6) M), apelin (10(-10)-10(-6) M) produced concentration-dependent relaxation that was lower in hepatic than in mesenteric arteries, whereas sodium nitroprusside (10(-8)-10(-4) M) produced a similar relaxation in both types of arteries. The inhibitor of nitric oxide synthesis N(w)-nitro-L-arginine methyl ester (L-NAME, 10(-4) M) diminished the relaxation to apelin in mesenteric but not in hepatic arteries. The inhibitor of cyclooxygenase meclofenamate (10(-5) M) did not affect the relaxation provoked by apelin in both types of arteries. Therefore, apelin may produce relaxation in normal human splanchnic arteries, and this relaxation may be mediated in part by nitric oxide without involvement of prostanoids. This relaxation as well as the role of nitric oxide may be decreased in splanchnic arteries from cirrhotic patients.

Liver transplantation for peripheral cholangiocarcinoma: Spanish experience

INTRODUCTION

Palliative treatment for nondisseminated unresectable peripheral cholangiocarcinoma (PCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than with other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for PCC to identify prognostic factors for survival.

METHODS

We retrospectively reviewed 23 patients undergoing OLT in Spain for PCC over a period of 13 years.

RESULTS

The actuarial survival rates were 77%, 65%, and 42% at 1, 3, and 5 years, respectively. The main cause of death was tumor recurrence (35%). Prognotic factors for an adverse outcome were pTNM classification (P<.05) in the univariate analysis and perineural invasion (P<.05) and stages III or IVA (P<.05) in the multivariate analysis.

CONCLUSIONS

OLT for nondisseminated irresectable PCC displays higher survival rates at 3 and 5 years than palliative treatments, especially for tumors in the initial stages, which means that more information is needed to help better select PCC patients for transplantation.

Chronic renal dysfunction after liver transplantation in adult patients: prevalence, risk factors, and impact on mortality

INTRODUCTION

Although chronic renal dysfunction (CRD) is a common complication among patients undergoing liver transplantation (OLT) its prevalence, risk factors, and impact on outcome have not been well defined. We aimed to assess the incidence of CRD, its associated risk factors and its impact on outcome.

PATIENTS AND METHODS

The cohort of 289 consecutive adult first liver transplant patients with posttransplant follow-up longer than 6 months received cyclosporine in 230 patients (153 oil-based and 81 microemulsion formulation), tacrolimus in 55. CRD was defined as serum creatinine levels greater than 1.3 mg/dL for more than 6 months.

RESULTS

After a mean follow-up of 67 months, 138 patients (47.8%) displayed CRD. The prevalence of CRD was 30.9%, 41.5%, and 38.9% at 1, 5, and 13 years after OLT, respectively. Twelve patients (4.1%) developed end-stage renal failure. Male gender, older recipient age, pretransplant renal dysfunction and hyperuricemia, posttransplant in-hospital renal dysfunction and hyperuricemia, and renal dysfunction during the first 6 months after OLT were each significantly associated with the development of CRD. Survival was significantly lower (63%) among liver transplant patients with CRD than those without this complication (71%, P=.024).

CONCLUSIONS

CRD is an important cause of morbidity after OLT, although end-stage renal disease is infrequent. Because early renal dysfunction is associated with the development of CRD, and decreased long-term patient survival, efforts should be made to avoid early renal dysfunction after liver transplantation.

Cardiovascular morbidity and obesity in adult liver transplant recipients

There is a direct relationship between the grade of obesity and mortality based on the increased cardiovascular diseases, cancer, etc. However, the results of studies in renal and liver allograft recipients relating obesity to morbidity and mortality are contradictory. A retrospective cohort study of 170 patients transplanted between March 1987 and July 1997 showed obesity to be identified in 77 (45.3%) patients. During the mean follow-up of 5 years posttransplantation, 16 (9.4%) patients experienced cardiovascular complications, including 10 patients with ischemic cardiac syndromes (five acute infarctions and five angina), five patients with acute cerebrovascular accidents, and one patient with intermittent lower limbs claudication. The prevalence of obesity at 1, 3, 5, 7, and 9 years after transplantation was 58.2%, 56.9%, 60.3%, 59.5%, and 66.4%, respectively. Compared with the baseline value, the BMI was increased at 1 year posttransplantation (25.78), a significant difference. No significant differences were found between the mean BMI values of patients with and without cardiovascular diseases, or overweight and morbidly obese patients compared to the normal weight population. Among liver transplant recipients, obesity was a frequent complication after transplantation, but it was not clearly associated with increased morbidity and mortality secondary to cardiovascular disease.

Liver transplantation for hilar cholangiocarcinoma: Spanish experience

INTRODUCTION

Palliative treatment for nondisseminated irresectable hilar cholangiocarcinoma (HCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than that for other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for HCC and identify prognostic factors for survival.

METHODS

We retrospectively reviewed 36 patients undergoing OLT for HCC over 13 years.

RESULTS

The actuarial survival rate at 1, 3, and 5 years was 82%, 53%, and 30%, respectively. The main cause of death was tumor recurrence (53%). In the univariate analysis, the factors for a poor prognosis were vascular invasion (P<.001) namely 0% survival at 3 years when present versus 63% and 35% at 3 and 5 years, respectively, when it was not; and stages III to IVA (P<.05), namely 15% survival at 5 years versus 47% for stages I to II. Lymph node and perineural invasion also reduce survival. In the multivariate analysis, the factors for poor prognosis included vascular invasion (P<.01) and stages III to IVA (P<.01).

CONCLUSION

OLT for nondisseminated irresectable HCC has higher survival rates at 3 and 5 years than palliative treatments, especially with initial stage tumors, which means that more information is needed to better select cholangiocarcinoma patients for transplantation.

De novo malignancies and liver transplantation

INTRODUCTION

De novo tumors (DNTs) are the leading cause of late death among liver transplant recipients with an incidence of 5% to 15%, which is significantly greater than the general population. In this retrospective study, we compared this complication in liver transplant recipients to sex- and age-matched controls.

PATIENTS

Among 410 patients who received liver allografts between March 1986 and December 2000, 32 (7.8%) developed a DNT. Epidermoid tumors were the most frequent histologic lineage. A complete response was observed in 19 patients (59.4%), a partial response in eight (25%), and no response in five (15%). Survival was lower among liver transplant recipients than controls, a difference that was statistically significant. Treatment consisted of surgery in 76.7%, radiotherapy in 16.7%, chemotherapy in 13.3%, and reduction of immunosuppression in 10%.

RESULTS

The mean survival time in transplant patients of 122.97 months (95% CI; range 98-147 months) was significantly shorter than controls, 156.5 months (95% CI; range 141-171 months). About 50% of patients were smokers (active or ex-smokers), compared to 20.7% of controls (P=.049). Significant differences were also found when the three subgroups (smokers, previous smokers, and nonsmokers) were analyzed separately (P=.013). Patients were smokers (active or nonactive) among 45% of cases of skin tumors; 60% of hematological tumors; 71.4% of epidermoids; and 33% of sarcomas.

CONCLUSIONS

DNTs, a complication of long-term immunosuppression in patients after liver transplantation, most frequently presented as skin tumors and PTLD. Occurrence of a DNT was an adverse prognostic factor for survival. Smoking represents an independent risk factor for these tumors.

Preservation of the recipient inferior vena cava in liver transplantation

Twenty piggy-back (PB) liver transplantations (LT) were compared with 20 LT performed by the standard technique in order to evaluate whether or not the theoretical haemodynamic advantages of the preservation of the inferior vena cava (IVC) have any impact on the final results of the LT. Statistically significant differences were observed in the duration of the hepatectomy, which was longer for PB LT (192 min vs. 146 min), and in the duration of the anhepatic phase, which was shorter in that group (52 min vs. 76 min). There were no differences in the duration of the complete surgical procedure, consumption of blood products, incidence of postoperative acute renal failure, number of reoperations or survival.

Randomized trial of fluconazole versus nystatin for the prophylaxis of Candida infection following liver transplantation

A prospective, randomized, multicenter study addressed the safety and efficacy of fluconazole therapy in 143 liver transplant patients. Seventy-six patients received daily oral fluconazole (100 mg), and 67 received nystatin (4 X 10(6) U) during the first 28 days after transplantation. Candida colonization occurred in 25% and 53% of patients in the fluconazole and nystatin groups, respectively (P = .04), and 13% and 34% of patients in the respective groups had Candida infections (P = .022). Of these patients, 10.5% in the fluconazole group and 25.3% in the nystatin group had superficial candidal infections (P = .024). Invasive candidiasis developed in 2 patients in the fluconazole group (2.6%) and 6 in the nystatin group (9.0%) (P = .12). There was no increased hepatotoxicity, cyclosporine interaction, or emergence of clinically relevant resistant Candida strains attributable to fluconazole. Thus, oral fluconazole (100 mg) is safe and reduces Candida colonization and infection after liver transplantation.

[Hepatic artery thrombosis in the pediatric liver transplant]

The hepatic artery thrombosis (HAT) is the most serious complication after pediatric liver transplantation. Most of the cases will need a retransplantation. Multiple factors are keeping in discussion as causes of this complication: Rejection, two or more arteries, complex vascular reconstruction, etc. This article describes our experience with this complication and the prophylactic treatment. From January 1986 through April 1991, 62 orthotopic liver transplants were performed on 48 pediatric patients with a mean age of seven years. The incidence of hepatic artery thrombosis was 19 per 100, increasing when recipients were less than three years and less than 15 kg (23.8 per 100). Forty six cases were rearterialized with end-to-end anastomoses, ten were rearterialized by directly anastomosing them to the recipient aorta and six with iliac artery graft. We use in the last 38 consecutive patients prophylactic heparin during two weeks after transplantation (300 u/kg/d) following with antiaggregants. There were eleven patients with hepatic artery thrombosis, one of them had two episodes in both grafts. We perform a retransplantation in eight patients, two died waiting a new graft and one exceptional patient is out of the clinic with normal liver function and without regraft. Seventeen grafts had two or more arteries from aorta, ten with branches from superior mesenteric artery and five from gastric artery. One graft had a triple hepatic artery and another one was a common hepatic artery from superior mesenteric artery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aspects related to extraction and preservation in 60 cases of liver transplant]

Extraction and preservation are of special interest in any liver transplant program. The viability and correct early function of the graft are determinant factors of the success or failure of the transplant. Application of a restrictive criterion in the acceptance of donor livers has allowed us to achieve an optimal viability (96.7%) in our first 60 cases of liver transplant.

Special operative events in the first case of liver grafting after heart transplantation

Combined heart-liver transplantation is the only therapeutic possibility for patients with familial hypercholesterolemia IIa. A 12-year-old boy with this metabolopathy underwent a double transplant in two steps (different donors). This original alternative was chosen to assure a safer procedure in this critical situation. Details of intraoperative events are described. Cholesterol and LDL decreased to physiologic levels after liver transplantation. The child's condition is optimal 1.5 years after surgery.