Revistas
Revista:
CANCERS
ISSN:
2072-6694
Año:
2023
Vol.:
15
N°:
3
Págs.:
733
Simple Summary Radioembolization is a locoregional therapy used in primary liver malignancies with different applications depending on the treatment goal. The aim of this retrospective study was to evaluate postoperative and long-term survival outcomes of patients with unresectable or high biological risk HCC and ICC treated with RE that were finally rescued to liver surgery with curative intent. In a cohort of 34 patients, we assessed that liver resection and transplantation after RE seem safe and feasible with adequate short-term outcomes. Moreover, long-term outcomes after RE and LR were optimal, with a 10-year OS rate greater than 50% for HCC and ICC patients. On the other hand, the 10-year OS rates from RE were also greater than 50% for patients with HCC downstaged or bridged to LT. Radioembolization (RE) may help local control and achieve tumor reduction while hypertrophies healthy liver and provides a test of time. For liver transplant (LT) candidates, it may attain downstaging for initially non-candidates and bridging during the waitlist. Methods: Patients diagnosed with HCC and ICC treated by RE with further liver resection (LR) or LT between 2005-2020 were included. All patients selected were discarded for the upfront surgical approach for not accomplishing oncological or surgical safety criteria after a multidisciplinary team assessment. Data for clinicopathological details, postoperative, and survival outcomes were retrospectively reviewed from a prospectively maintained database. Results: A total of 34 patients underwent surgery following RE (21 LR and 13 LT). Clavien-Dindo grade III-IV complications and mortality rates were 19.0% and 9.5% for LR and 7.7% and 0% for LT, respectively. After RE, for HCC and ICC patients in the LR group, 10-year OS rates were 57% and 60%, and 10-year DFS rates were 43.1% and 60%, respectively. For HCC patients in the LT group, 10-year OS and DFS rates from RE were 51.3% and 43.3%, respectively. Conclusion: Liver resection after RE is safe and feasible with optimal short-term outcomes. Patients diagnosed with unresectable or high biological risk HCC or ICC, treated with RE, and rescued by LR may achieve optimal global and DFS rates. On the other hand, bridging or downstaging strategies to LT with RE in HCC patients show adequate recurrence rates as well as long-term survival.
Revista:
CIRUGÍA ESPAÑOLA
ISSN:
2173-5077
Año:
2023
Vol.:
101
N°:
5
Págs.:
333 - 340
INTRODUCTION: Laparoscopic resection of the pancreas (LRP) has been implemented to a varying degree because it is technically demanding and requires a long learning curve. In the present study we analyze the risk factors for complications and hospital readmissions in a single center study of 105 consecutive LRPs.
METHODS: We conducted a retrospective study using a prospective database. Data were collected on age, gender, BMI, ASA score, type of surgery, histologic type, operative time, hospital stay, postoperative complications, degree of severity and hospital readmission.
RESULTS: The cohort included 105 patients, 63 females and 42 males with a median age and BMI of 58 (53-70) and 25.5 (22,2-27.9) respectively. Eighteen (17%) central pancreatectomies, 5 (4.8%) enucleations, 81 (77.6%) distal pancreatectomies and one total pancreatectomy were performed. Fifty-six patients (53.3%) experienced some type of complication, of which 13 (12.3%) were severe (Clavien-Dindo > IIIb) and 11 (10.5%) patients were readmitted in the first 30 days after surgery. In the univariate analysis, age, male gender, ASA score, central pancreatectomy and operative time were significantly associated with the development of complications (P <0.05). In the multivariate analysis, male gender (OR 7.97; 95% CI 1.08-58.88)), severe complications (OR 59.40; 95% CI, 7.69-458.99), and the development of intrabdominal collections (OR 8.97; 95% CI, 1.28-63.02)) were associated with hospital readmission.
CONCLUSIONS: Age, male gender, ASA score, operative time and central pancreatectomy are associated with a higher incidence of complications. Male gender, severe complications and intraabdominal collections are associated with more hospital readmissions.
Revista:
HERNIA
ISSN:
1265-4906
Año:
2023
Vol.:
27
N°:
2
Págs.:
479 - 480
Revista:
ANNALS OF SURGICAL ONCOLOGY
ISSN:
1068-9265
Año:
2022
Vol.:
29
N°:
9
Págs.:
5545 - 5546
Revista:
ANNALS OF SURGICAL ONCOLOGY
ISSN:
1068-9265
Año:
2022
Vol.:
29
N°:
9
Págs.:
5547
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2022
Vol.:
114
N°:
6
Págs.:
317 - 322
Background and aim: fifty to 70 percent of pancreatic neuro-endocrine tumors are diagnosed incidentally. The objective of this study was to compare the phenotype and oncologi-cal outcomes of incidental versus symptomatic pancreatic neuroendocrine tumors. Methods: a retrospective study was performed, identifying all incidental and symptomatic tumors resected between 2000 and 2019. Baseline characteristics, symptoms, oper-ative variables and pathological stage were all recorded. Patterns of recurrence and overall and disease-free survival were analyzed in both groups. Results: fifty-one incidental and 45 symptomatic pancreat-ic tumor resections were performed. Symptomatic tumors were more frequent in females (29 vs 17; p = 0.005) and younger patients (median years; 50 vs 58; p = 0.012) and were detected at a more advanced stage (p = 0.027). There were no differences in location and most resections (n = 49; 51 %) were performed laparoscopically. There were no operative mortalities and 17 (17.7 %) severe com-plications (>_ IIIb on the Clavien-Dindo classification) were recorded with no differences between the two groups. With a median follow-up of 64.4 months (range 13.5-90), overall survival at five and ten years was 89.7 % and 72.8 % for the non-incidental tumors and 80.9 % and 54.6 % for the incidental tumors (p = ns), respectively. Disease-free survival in both groups (excluding M1a) was 71.2 % and 47.5 %, and 93.7 % and 78.1 %, respectively (p = ns). Conclusions: symptomatic tumors are more frequent in females and present at more advanced pathological stag-es. There were no significant differences in overall and disease-free survival between the two groups. Resection of incidental tumors >_ 1.5-2 cm seems advisable, although each case should be assessed on an individual basis.
Revista:
ANNALS OF SURGICAL ONCOLOGY
ISSN:
1068-9265
Año:
2022
Vol.:
29
N°:
9
Págs.:
5543 - 5544
Background: Laparoscopic liver surgery has progressively evolved. Consequently, liver procedures are increasingly performed laparoscopically, particularly in experienced centers. However, vascular resection and reconstruction still are considered a limitation for laparoscopy1 due to the risk of bleeding and the technical difficulty.
Methods: A 72-year-old woman with a history of colorectal cancer had a 10 cm metastasis diagnosed in the right hemiliver with tumoral invasion of the right portal branch and tumor thrombus advancing to the portal confluence. After adjuvant chemotherapy and with stable disease, surgical resection was planned.2,3 Tips to avoid portal stenosis were carefully followed.
Results: The operation was performed with a fully laparoscopic procedure. To minimize manipulation, an in situ right hepatectomy was performed.4 The right hepatic artery was dissected and ligated. The liver transection was guided with a caudal approach of the middle hepatic vein.5 The right biliary duct was then divided, achieving an excellent exposure of the portal bifurcation. The main and left portal trunks were occluded with vascular clamps, and the right portal vein was sharply divided with scissors. The stump was sutured to minimize backflow bleeding and to cover the tumor thrombus. Then, the portal opening was transversally sutured with a 5/0 running suture. The clamps were released, and the authors observed no bleeding and an adequate caliber with no stenosis. The procedure was completed in the standard fashion. The postoperative course was uneventful, and the woman was discharged on postoperative day 3. No early or late complications were observed.6 CONCLUSIONS: In selected cases, patients who require vascular resection and reconstruction during hepatectomies can benefit from the advantages of a laparoscopic approach.
Revista:
CIRUGIA ESPAÑOLA
ISSN:
0009-739X
Año:
2022
Vol.:
100
N°:
4
Págs.:
241 - 241
Revista:
LANGENBECKS ARCHIVES OF SURGERY
ISSN:
1435-2443
Año:
2022
Vol.:
407
N°:
3
Págs.:
1099 - 1111
Background Liver surgery after radioembolization (RE) entails highly demanding and challenging procedures due to the frequent combination of large tumors, severe RE-related adhesions, and the necessity of conducting major hepatectomies. Laparoscopic liver resection (LLR) and its associated advantages could provide benefits, as yet unreported, to these patients. The current study evaluated feasibility, morbidity, mortality, and survival outcomes for major laparoscopic liver resection after radioembolization. Material and methods In this retrospective, single-center study patients diagnosed with hepatocellular carcinoma, intrahepatic cholangiocarcinoma or metastases from colorectal cancer undergoing major laparoscopic hepatectomy after RE were identified from institutional databases. They were matched (1:2) on several pre-operative characteristics to a group of patients that underwent major LLR for the same malignancies during the same period but without previous RE. Results From March 2011 to November 2020, 9 patients underwent a major LLR after RE. No differences were observed in intraoperative blood loss (50 vs. 150 ml; p = 0.621), operative time (478 vs. 407 min; p = 0.135) or pedicle clamping time (90.5 vs 74 min; p = 0.133) between the post-RE LLR and the matched group. Similarly, no differences were observed on hospital stay ( median 3 vs. 4 days; p = 0.300), Clavien-Dindo = III complications (2 vs. 1 cases; p = 0.250), specific liver morbidity (1 vs. 1 case p = 1.000), or 90 day mortality (0 vs. 0; p = 1.000). Conclusion The laparoscopic approach for post radioembolization patients may be a feasible and safe procedure with excellent surgical and oncological outcomes and meets the current standards for laparoscopic liver resections. Further studies with larger series are needed to confirm the results herein presented.
Revista:
JOURNAL OF SURGICAL ONCOLOGY
ISSN:
0022-4790
Año:
2020
Vol.:
122
N°:
7
Págs.:
1426 - 1427
Revista:
EUROPEAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY
ISSN:
0392-2936
Año:
2020
Vol.:
41
N°:
6
Págs.:
906 - 912
Introduction: We aimed to analyze the outcome in a series of women with primary advanced ovarian cancer in an Intermediate Volume Hospital where new surgical and chemotherapy treatments were implemented over a period of 14 years. Material and Methods: One hundred and twenty-seven women with stage IIIB-IV disease underwent primary (76.4%) or interval debulking surgery (23.6%). Fifty-seven were operated on from 2000 to 2005 (Group 1) and 70 from 2006 to 2014 (Group 2). Results: No gross residual disease was achieved in 51.5% and 43.3% of women who underwent primary and interval surgery, respectively. For no gross and < 1cm residual disease, median overall and progression-free survival were 94.7 vs. 60.6 months (p = 0.001) and 25.3 vs. 20.0 months, respectively (p = 0.02). The rate of no gross residual (36.8 to 60.0%) and 5-yr median overall survival (56.3 to 73.7 months) increased between 2000-2005 (Group 1) and from 2006 to 2014 (Group 2). On multivariate analysis, interval surgery, multiple peritoneal implants and residual disease were predictive of overall and progression-free survival. Conclusions: Survival after primary and interval debulking surgery progressively correlates with decrease in residual disease. Increasing rates of successful primary surgery are possible through standardization and adoption of best practices without increasing morbidity.
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2020
Vol.:
112
N°:
2
Págs.:
85 - 89
Objective: the objective of the present study was to analyze the characteristics of resected incidental lesions of the pancreas.
Material and methods: a retrospective study was performed of pancreatectomies due to incidentalomas between 1995 and 2018.
Results: one hundred pancreatectomies were performed due to incidental lesions; 64 (64%) were solid and 36 (36%) were cystic lesions. The cytological analysis agreed with the diagnosis in 67/71 (88.7%) cases. Thirty-six tumors were cystic, 48 were neuroendocrine and 16 were adenocarcinomas. Disease-free survival for patients with cystic, neuroendocrine tumors and adenocarcinomas was 100%, 79% and 57.7% (p < 0.04).
Conclusion: pancreatic incidentalomas have a heterogeneous phenotype and should be treated in experienced centers
Revista:
JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES
ISSN:
1868-6974
Año:
2020
Vol.:
27
N°:
1
Págs.:
E7 - E8
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2019
Vol.:
111
N°:
2
Págs.:
87 - 93
Background: the aim of the present study was to analyze the clinicopathological features of patients undergoing pancreatic surgical resections due to cystic neoplasms of the pancreas. Material and methods: demographic data, form of presentation, radiologic images and location of the tumors within the pancreas were analyzed. Data was also collected on the type of surgery (open/laparoscopic), postoperative complications and their severity and oncologic outcomes. Results: eighty-two pancreatic resections were performed. The mean age of patients was 57 years and 49 (59%) were female. Forty-one tumors (50%) were incidental and the most frequent symptoms in the group of symptomatic patients were abdominal pain (63.4%) and weight loss (36.5%). Thirty-two tumors (39%) were located in the tail of the pancreas, 25 (30.5%) in the head and 20 (24.4%) in the body. Thirty-nine (47.5%) distal pancreatectomies, 16 central, ten duodenal pancreatectomies and one enucleation were performed; 40 (48.5%) were carried out laparoscopically. Mean hospital stay was ten days and eight patients (7%) experienced severe complications, one was a pancreatic fistula. Sixty-six tumors (80.5%) were recorded as non-invasive and 16 (19.5%) as invasive: seven intraductal mucinous papillary tumors, one cystic mucinous tumor, four solid pseudopapillary tumors and four cystic neuroendocrine tumors. There was a median follow-up of 64 months; disease-free survival at five and ten years was 97.4% in the patients with non-invasive tumors and 84.6% and 70.5% in the invasive tumors group (p < 0.01). Conclusions: fifty percent of cystic neoplasms of the pancreas are incidental. Two phenotypes exist, invasive and non-invasive.
Autores:
Manzanedo, I. (Autor de correspondencia); Pereira, F. ; Caro, C. R.; et al.
Revista:
ANNALS OF SURGICAL ONCOLOGY
ISSN:
1068-9265
Año:
2019
Vol.:
26
N°:
8
Págs.:
2615 - 2621
BackgroundGastric cancer (GC) with peritoneal carcinomatosis (PC) is traditionally considered a terminal stage of the disease. The use of a multimodal treatment, including cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), can benefit these patients. Our goal was to evaluate the morbidity and survival outcomes of these patients.MethodsThis is a retrospective, multicenter study from a prospective national database of patients diagnosed with PC secondary to GC treated with CRS and HIPEC from June 2006 to October 2017.ResultsEighty-eight patients from seven specialized Spanish institutions were treated with CRS and HIPEC, with median age of 53years; 51% were women. Median Peritoneal Cancer Index (PCI) was 6, and complete cytoreduction was achieved in 80 patients (90.9%). HIPEC was administered in 85 cases with 4 different regimens (Cisplatin+Doxorubicin, Mitomycin-C+Cisplatin, Mitomycin-C and Oxaliplatin). Twenty-seven cases (31%) had severe morbidity (grade III-IV) and 3 patients died in the postoperative period (3.4%). Median follow-up was 32months. Median overall survival (OS) was 21.2months, with 1-year OS of 79.9% and 3-year OS of 30.9%. Median disease-free survival (DFS) was 11.6months, with 1-year DFS of 46.1% and 3-year DFS of 21.7%. After multivariate analysis, the extent of peritoneal disease (PCI >= 7) was identified as the only independent factor that influenced OS (hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.26-4.46, p=0.007).ConclusionsThe multimodal treatment, including CRS and HIPEC, for GC with PC can improve the survival results in selected patients (PCI<7) and in referral centers.
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2018
Vol.:
110
N°:
3
Págs.:
138 - 144
Purpose: The objective of the study was to analyze the clinico-pathological differences and the oncologic outcomes between right and left-sided colon cancer. Patients and methods: The patients cohort was identified from a prospective register of colon cancer, 950 patients underwent surgery (stages I, II and III), of which 431 had right-sided colon cancer and 519 had left-sided colon cancer. Results: More laparoscopic resections were performed (101 vs 191; p < 0.001) and operating times were longer (146 min vs 165 min; p < 0.001) in the left-sided colon group. Patients with right-sided colon cancer more frequently received transfusions (18.8% vs 11.3%; p < 0.001) and experienced a greater number of complications (28.5% vs 20.9%, p = 0.004), although severity and operative mortality were similar in both groups (1.2% vs 0.2%). Mucinous adenocarcinomas and undifferentiated tumors were more frequent in the right-sided group (12% vs 6.5%; p < 0.001). Early stage was predominant in the left-sided colon tumors (28.2% vs 34.5%, p = 0.02). There were no differences in disease-free survival (DFS) in stages I and II after a median follow-up of 103 months. However, a greater survival at five and ten years in left-sided, stage III tumors was observed, with a trend towards statistical significance (p = 0.06). No differences were found with regard to the patterns of recurrence. Conclusions: Right-sided colon cancer exhibits phenotypical differences with regard to left-sided colon cancer. In stage III disease, left-sided colon cancer has a greater survival with a trend towards statistical significance. Overall, tumor location is a variable that should be taken into consideration in clinical studies of colon cancer.
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2018
Vol.:
110
N°:
12
Págs.:
768 - 774
Objective: the objective of this study was to analyze the anatomical and clinical features and long-term oncologic outcomes of 25 patients that underwent surgery due to intraductal papillary mucinous neoplasm of the pancreas.
Material and methods: patients undergoing surgery for intraductal papillary mucinous neoplasm of the pancreas were identified from a prospective database of pancreatic resections. Demographic data, symptoms, type of surgery and type of lesion (branch type, main duct or mixed) were recorded. The lesions were classified into invasive (high grade dysplasia and carcinoma) and noninvasive (low- or intermediate-grade dysplasia). Postoperative complications were analyzed as well as the pattern of recurrence and disease-free survival at five and ten years.
Results: the most common symptoms in the 25 patients (14 males and eleven females) were abdominal pain and weight loss. Eight (32%) cases were diagnosed incidentally. Twelve (48%) of the lesions were of the branch type, three affected the main duct and ten (40%) were mixed. Twelve cephalic duodenopancreatectomies and seven total pancreatectomies were performed; three were central; two, distal; and one, enucleation. Seven cases (32%) had an invasive phenotype. Three patients had locoregional and distant recurrence at six, 16 and 46 months after surgery with a median follow-up of 7.7 years. Disease-free survival at five and ten years for the noninvasive type was 94% and 57% for invasive phenotypes (p < 0.05).
Conclusions: intraductal papillary mucinous neoplasm is a heterogeneous entity with well differentiated phenotypes, which requires a tailored strategy and treatment, as established in the current consensus guidelines due to its malignant potential.
Revista:
JOURNAL OF GASTROINTESTINAL SURGERY
ISSN:
1091-255X
Año:
2018
Vol.:
22
N°:
4
Págs.:
713 - 721
Laparoscopic arcuate ligament release has been demonstrated a valid therapeutic option for arcuate ligament syndrome. Nevertheless, long-term follow-up and predictive factors have not been described for this treatment. Clinical and surgical data and short- and long-term outcomes together with the impact of the degree of stenosis of the celiac trunk were analyzed in 13 consecutive patients who underwent laparoscopic arcuate ligament release between 2001 and 2013. Thirteen patients (12 F/1 M) underwent surgery. The median age was 32 years old, and their mean body mass index was 20.7 (range 14.7-25). The 13 patients presented with intense postprandial abdominal pain. Ten cases were associated with weight loss. The median duration of symptoms was 24 months (range 2-240). Three patients presented symptoms associated with superior mesenteric artery syndrome. Median operative time was 120 min (range 90-240), and there were no conversions to open surgery. Median hospital stay was 3 days (range 2-14). Over a median follow-up of 117 months (range 45-185), nine patients had excellent results although two required endovascular procedures at 70 and 24 months after surgery. Four patients (30.7%) experienced poor outcomes. When we analyzed the impact of the degree of occlusion of the celiac trunk, we observed that in patients with severe occlusion (> 70%), better results were obtained, with complete resolution of symptoms in 71% of cases. Laparoscopic arcuate ligament release constitutes an excellent treatment for arcuate ligament syndrome. The degree of occlusion of the celiac trunk may be a factor predictive of long-term outcomes.
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2018
Vol.:
110
N°:
11
Págs.:
684 - 690
Purpose: the aim of this study was to compare overall and disease-free survival among patients with colorectal cancer detected via a screening program as compared to those with symptomatic cancer.
Material and methods: patients diagnosed via colonoscopy (screening group) and those with clinical symptoms (non-screening) were identified from 1995 to 2014. Demographic, clinical, surgical and pathologic variables were recorded. Stage I, II and III cancers were included. Overall and disease-free survival were calculated at five and ten years after tumor resection and survival was calculated by matching both groups for cancers at stage I, II and III.
Results: two hundred and fifty patients were identified as a result of screening procedures and 1,330 patients presented with symptomatic cancers.There were no significant differences in the baseline characteristics between the two groups. Pathologic stage, degree of differentiation, perineural invasion and lymphovascular invasion were lower in the screening group (p < 0.01). Overall and disease-free survival at five and ten years were higher in the screening group (p < 0.01). However, when the subjects were matched for pathologic stage, significant differences were found between the two groups with regard to stage I and III tumors. Disease-free survival in stage III at five years (79.1 vs 61.7%; p < 0.001) and ten years (79.1% vs 58.5%; p < 0.001) were significantly higher in the screening group.
Conclusions: patients with stage I and III tumors that were diagnosed via a screening program have a higher overall and disease-free survival at five and ten years.
Revista:
INTERNATIONAL JOURNAL OF SURGERY
ISSN:
1743-9191
Año:
2018
Vol.:
52
Págs.:
303 - 308
Purpose: The objective is to analyze the impact of severe postoperative complications in patients undergoing curative surgery for colon cancer. Material and methods: From a prospective database, we identified patients with stage I-III disease (AJCC) who underwent surgery between 2000 and 2014. Patients were selected with major complications (IIIb on the Clavien-Dindo classification) and with no major complications. Variables were analyzed in both groups. Local, peritoneal and distant recurrence together with overall survival and disease-free survival were analyzed. Results: Of a total of 950 patients, 51 (5.3%) experienced major complications. Operative mortality was 2.6%. Age, ASA grade, urgent surgery, pre-operative hemoglobin, right-sided location, operative time, transfusion, conversion to open surgery, were all associated with major complications (all P < 0.05). With a median follow-up of 84.8 and 40 months in both groups, there was greater incidence of local recurrences in patients experiencing complications (2.4% vs 7.8%; P=0.03 OR 3.39, 95% CI 1.12-10.24), being more marked in stage III patients (4.2% vs 21%; P=0.005, OR 6.13 95% CI 1.74-21.56). In the stage III group, peritoneal recurrence was significantly greater in patients with complications (13.6% vs 31.6%; P=0.04 OR 2.92 95% CI 1.04-8.18). Patients with major complications had a significantly lower overall survival (P=0.024) than patients with no complications both at 5 years (78.9% vs 68.8%) and 10 years (74.6% vs 32.1%). The same trend was observed for disease-free survival (71.6% vs 48.3% and 69.8% vs 32.2%; P=0.013). Conclusion: The development of major complications following colectomy for colon cancer has a negative impact on long-term oncologic outcomes, especially in stage III disease.
Revista:
SURGICAL ONCOLOGY-OXFORD
ISSN:
0960-7404
Año:
2017
Vol.:
26
N°:
1
Págs.:
71 - 72
Background: Liver surgery after selective internal radiation therapy (SIRT) has been scarcely reported. The combination of laparoscopic approach in post-SIRT major liver surgery is a complex scenario to our knowledge not reported so far. Method: From July' 2007-July' 2016, 40 patients underwent post-SIRT R0 resections in our center: 30 resections and 10 liver transplants. From March'2011, 5 (out of those 30) were full-laparoscopic resections: Three patients underwent laparoscopic right hepatectomy (LRH) after previous right hemiliver radiation lobectomy: two cirrhotic patients with HCC and one with colorectal cancer liver metastasis; one segment-VI resection in a cirrhotic patient, due to HCC and finally, a patient with a Budd-Chiari Syndrome and an infiltrating HCC in segment-III underwent left lateral seccionectomy. In all cases, the procedure was uneventfully completed full-laparoscopic and none required transfusion. Hospital stay was 3, 2, 5, 3 and 3 days respectively. We herein present a LRH in a 71 year-old patient after right hemiliver radiation lobectomy (due to a 7 cm unresectable HCC in a HCV cirrhotic liver). Case presentation, surgical findings and technique are detailed in this video, which also demonstrates the comparative hypoperfusion of the treated hemiliver revealed with ICG fluorescence, a hitherto undescribed finding. Results: Hospital stay was 3 days. No early or late morbidity occurred. At this writing, 18 months after the resection and 43 months after the initial diagnosis the patient is alive and free of disease. Conclusion: This experience suggests that laparoscopic liver resection after SIRT is feasible and safe, even in major hepatectomies. (C) 2017 Elsevier Ltd. All rights reserved.
Revista:
LANGENBECKS ARCHIVES OF SURGERY
ISSN:
1435-2443
Año:
2017
Vol.:
402
N°:
1
Págs.:
181 - 185
The purpose of this study is to describe a technical modification that facilitates right liver mobilization in laparoscopic right hepatectomy (LRH). In the supine position, an inflatable device is placed under the patient's right chest. For right hemiliver mobilization, the table is placed in 30A degrees anti-Trendelenburg and full-left tilt. Balloon inflation offers an additional 30A degrees left inclination that places the patient in an almost left lateral position. Foot and lateral supports are placed to prevent patient slippage during changes in the patient positioning. From December 2013 to October 2015, this technique has been used in 10 consecutive LRH. The indications for these procedures were as follows: four donor hepatectomies for living donor liver transplant, three hepatocellular carcinomas and one peripheral cholangiocarcinoma in cirrhotic patients, one hepatocellular carcinoma in a non-cirrhotic patient, and one case of colorectal cancer metastases. In this period, it has also been used to facilitate mobilization and resection in the posterior segments of the liver in seven patients. In every case, right hemiliver mobilization was easily performed in a maximum time of 15 min and placement of a tape or plastic tube for liver hanging was prepared. We have not observed any complication directly attributable to the technique herein described (i.e. right brachialgia; arms, back or left flank pain) in the early or late postoperative follow-up. The additional left inclination obtained with the inflation of a balloon under the right chest facilitates right hemiliver mobilization. Its use may help in the performance and adoption of LRH.
Revista:
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
ISSN:
0930-2794
Año:
2017
Vol.:
31
N°:
10
Págs.:
3847 - 3857
Laparoscopic organ-sparing pancreatectomy (LOSP) is an ideal therapeutic option in selected cases of pancreatic neuroendocrine tumors (PNETs). Nevertheless, given the low frequency of PNETs, there is scarce evidence regarding short and particularly long-term outcomes of LOSP in this clinical setting. All patients with PNETs who underwent surgery (under a LOSP policy) were retrospectively reviewed from a prospective database maintained at our center. Preoperative characteristics, operative data, pathological features and postoperative outcomes were analyzed. Between December 2003 and December 2015, 36 patients with PNETs underwent laparoscopic resections. Ten were functional tumors, 26 non-functional and 16 were "incidental" cases. The following procedures were performed: one enucleation, eight central pancreatectomies (LCP), one resection of the uncinate process and 26 distal pancreatectomies (DP) (15 of them laparoscopic vessels-preserving). There were no conversions to open surgery, and no drains were routinely left. Mean operative time was 288 min (SD 99). Hospital stay was 6 days. Eighteen patients (50%) experienced some complication of which most were mild (Clavien-Dindo I/II). Three postoperative bleedings occurred: two grade B/one grade C; two required laparoscopic reoperation. Thirteen (36.1%) patients developed peripancreatic fluid collections: two were symptomatic and were managed with transgastric drainage (one presented post-puncture abscesification requiring surgical drainage and splenectomy). Four patients (11%)-one DP and three LCP-developed new-onset pancreatogenic diabetes mellitus (NODM) in the long term. According to the European Neuroendocrine Tumor Society, 19 cases were stage I, seven IIA, two IIIA, one IIIB and seven stage IV. Over a mean follow-up of 51 months, two patients died, one due to recurrence of the tumor and another due to cirrhosis. The existing different surgical options must be individually considered according to the location and particular characteristics of every tumor. Results from this single-center study document the effectiveness of LOSP in selected cases of PNETs.
Revista:
TRANSPLANTATION
ISSN:
0041-1337
Año:
2017
Vol.:
101
N°:
3
Págs.:
548 - 554
Background. The pure laparoscopic approach in right hepatectomy (LRH) for living donor liver transplantation (LDLT) is a controversial issue. Some authors have reported the procedure to be feasible but surgical outcomes and impact on short and longterm morbidity rates are yet to be determined. The aim of this study is to present the results of a preliminary 5 consecutive cases series of LRH for LDLT and to compare it with a successive cohort of open right hepatectomies (ORH) for LDLT. Methods. From May 2013 to October 2015, 5 consecutive donors underwent LRH for LDLT in our center. The previous last 10 ORH for LDLT were selected for comparison. Special care was taken to include all adverse events. Each patient's complications were graded with the Clavien-Dindo Classification and scored with the Comprehensive Complication Index. Results. All 5 consecutive donors completed a pure laparoscopic procedure. All allografts (open and laparoscopically procured) were successfully transplanted with no primary graft failures. Only 2 Clavien-Dindo Grade-I complications occurred in the LRH donors, while ORH donors had 10 Grade I, 2 Grade II and 1 Grade IIIa complications in the short term (< 3 months). In the long term (6-12 months follow-up), LRH donors had a significant lower incidence of complications (Comprehensive Complication Index: 1.74; SD, 3891 vs 15.2 SD; 8.618; P = 0.006). Conclusions. In our experience, LRH for LDLT is a feasible procedure. Further comparative series may support our preliminary findings of reduced incidence and severity of complications as compared with the open approach.
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2016
Vol.:
108
N°:
11
Págs.:
689 - 696
Background: Pancreatic neuroendocrine tumors (pNETs) comprise a heterogeneous group of tumors with a varied biological behavior. In the present study, we analyzed the experience of 79 pNETs resected between 1993 and 2015. The pathologic prognostic factors (European Neuroendocrine Tumor Society, ENETS; and AJCC) classification, vascular invasion (VI), proliferation index (ki-67) and the presence of necrosis were retrospectively reviewed. Methods: The clinical data of 79 patients with pNETs who underwent surgery were retrospectively analyzed. Mortality rates and Kaplan-Meier estimates were used to evaluate survival over time for pathologic stages, tumor functionality, and vascular invasion. Cox proportional hazards models were used to calculate the hazard ratio regarding ENETS, AJCC staging, sex, tumor functionality and vascular invasion. Results: The male: female ratio was 40: 39. Twenty-one patients (26%) had functional tumors and 58 (73.4%) had nonfunctional tumors, of which 35 (44.3%) were diagnosed incidentally. Seventeen Whipple procedures, 46 distal pancreatectomies (including 26 laparoscopic and 20 open procedures), 8 laparoscopic central pancreatectomies, 1 laparoscopic resection of the uncinated process and 7 enucleations (one laparoscopic) were performed. Vascular invasion and necrosis were observed in 29 of 75 cases (38.6%) and in 16 cases (29%), respectively. The comparison between survivor functions of ENETS staging categories showed statistically significant differences (p = 0.042). Mortality rate was higher in patients with non-functioning tumors compared with hormonally functioning tumors (p = 0.052) and in those with vascular invasion (p = 0.186). Conclusions: In spite of the heterogeneity of pNETs, the ENETS TNM classification efficiently predicts long-term prognosis. The non-functioning tumors and the presence of vascular invasion are associated with poor prognosis.
Revista:
CLINICAL AND TRANSLATIONAL ONCOLOGY
ISSN:
1699-048X
Año:
2016
Vol.:
18
N°:
9
Págs.:
909-914
Combined treatment for LARC obtains a 5-year OS rounding 90 %. Follow-up based on thoracic-abdominal CT scan allows an early diagnosis of metastatic lesions. Surgical resection of metastases, regardless of their location, greatly increases the patient's survival rate.
Revista:
SURGERY TODAY
ISSN:
0941-1291
Año:
2015
Vol.:
45
N°:
3
Págs.:
374 - 377
A 75-year-old woman who had undergone pancreatoduodenectomy 19 years earlier was referred to us for investigation of progressive abdominal pain without conclusive preliminary complementary tests. Computed tomography enabled us to identify that the transanastomotic pancreatic stent had migrated distally, resulting in bowel perforation. She underwent surgery and the foreign body was removed.
Revista:
HERNIA
ISSN:
1265-4906
Año:
2015
Vol.:
19
N°:
3
Págs.:
531 - 532
Revista:
LIVER TRANSPLANTATION
ISSN:
1527-6465
Año:
2015
Vol.:
21
N°:
8
Págs.:
1107 - 1108
Revista:
LIVER TRANSPLANTATION
ISSN:
1527-6465
Año:
2015
Vol.:
21
N°:
8
Págs.:
1107 - 1108
Autores:
G. Sapisochin; C. Rodrígue de Lópe; M. Gastaca; et al.
Revista:
ANNALS OF SURGERY
ISSN:
0003-4932
Año:
2014
Vol.:
259
N°:
5
Págs.:
944-952
Patients with HCC-CC have similar survival to patients undergoing a transplant for HCC. Preoperative diagnosis of HCC-CC should not prompt the exclusion of these patients from transplant option.
Revista:
TRANSPLANTATION PROCEEDINGS
ISSN:
0041-1345
Año:
2014
Vol.:
46
N°:
9
Págs.:
3082 - 3083
Background. The role of liver biopsy in the evaluation of a candidate for living liver donation is controversial. Some authors suggest doing it routinely, but others do it only in selected cases. The aim of this work was to evaluate the usefulness of protocol liver biopsy in the evaluation of candidates for living liver donation.
Methods. Ninety potential candidates for living liver donation were evaluated. In 46 cases donation was contraindicated without the need of liver biopsy. In the remaining 44 candidates, liver biopsy was done on a protocol basis. The usefulness of protocol biopsy was compared with the use of biopsy according to the recommendations of the Vancouver Forum.
Results. Fifteen of the 44 biopsies were indicated according to the recommendations of the Vancouver Forum. Twelve of them were normal, and 3 had liver steatosis or steatohepatitis. Of the 29 biopsies done per protocol, 28 were normal and 1 showed liver steatosis. Donation was contraindicated according to liver biopsy findings in 3 of the 15 patients with liver biopsy done according to the Vancouver Forum recommendations and in none of the 29 patients with biopsy done per protocol (P=.034).
Conclusions. Protocol liver biopsy has a limited utility in the evaluation of the candidates for living liver donation.
Revista:
HPB
ISSN:
1365-182X
Año:
2014
Vol.:
16
N°:
4
Págs.:
320 - 326
ObjectivesThe laparoscopic approach is widely used in abdominal surgery. However, the benefits of laparoscopy in liver surgery have hitherto been insufficiently established. This study sought to investigate these benefits and, in particular, to establish whether or not the laparoscopic approach is beneficial in patients with lesions involving the posterosuperior segments of the liver. MethodsOutcomes in a cohort of patients undergoing mostly minor hepatectomy (50 laparoscopic and 52 open surgery procedures) between January 2000 and December 2010 at the University Clinic of Navarra were analysed. The two groups displayed similar clinical characteristics. ResultsPatients submitted to laparoscopic liver resection (LLR) had a lower risk for complications [odds ratio (OR) = 0.24, 95% confidence interval (CI) 0.07-0.74; P = 0.013] and shorter hospital stay (OR = 0.08, 95% CI 0.02-0.27; P < 0.001) independently of the presence of classical risk factors for complications. In the cohort of patients with lesions involving posterosuperior liver segments (20 laparoscopic, 21 open procedures), LLR was associated with significantly fewer complications (OR = 0.16, 95% CI 0.04-0.71) and a lower risk for a long hospital stay (OR = 0.1, 95% CI 0.02-0.43). ConclusionsThis study confirms that the laparoscopic approach to hepatic resection decreases the risk for post-surgical complications and lengthy hospitalization in patients undergoing minor liver resections. This beneficial effect is observed even in patients with lesions located in segments that require technically difficult resections.
Revista:
ANNALS OF SURGICAL ONCOLOGY
ISSN:
1068-9265
Año:
2014
Vol.:
21
N°:
1
Págs.:
165 - 166
Background. Laparoscopic right hepatectomy (LRH) is a complex but feasible procedure. Preoperative portal vein embolization (PVE) can add difficulties that warrant particular technical modifications. A LRH extended to middle hepatic vein after PVE is presented, with special attention paid to specific operative findings and to useful technical modifications.
Methods. A 62-year-old female patient with a body mass index of 30.5 kg/m(2) was diagnosed with a 3-cm unresectable centrally located intrahepatic cholangiocarcinoma with infiltration of the retrohepatic vena cava, segment VII portal branch, and adjacent to the middle hepatic vein and portal bifurcation. After four cycles of GEMOX, partial response was observed, disappearing vascular infiltration. PVE was required to perform an extended LRH. Consequently, during pedicle dissection, significant inflammation was found in the vicinity of the right portal vein. Thus, the section of the portal and biliary elements was delayed until the transection of the parenchyma reached the hilum. The opening of the parenchyma improved exposure, allowing the safe management of these structures individually.
Results. The total operative time was 438 min. Three periods of 15-min pedicle occlusion resulted in <100 ml bleeding. Hospital stay was 4 days. Pathological examination revealed residual cholangiocarcinoma with intense posttreatment changes (pT1) and tumor-free margins. After an 18-month follow-up, the patient was alive and free of disease.
Conclusions. LRH is feasible and safe, even after PVE. Nevertheless, periportal inflammation can hinder hilar dissection. In this setting, delaying section of portal and biliary elements until parenchymal transection reaches the hilar region may result in a useful and safe strategy.
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2013
Vol.:
105
N°:
4
Págs.:
229 - 231
Adult hepatoblastoma (AHB) is a very rare tumor, having been described 45 cases up to June 2012. In contrast to HB in infancy (IHB), it has poor prognosis. We present the case of a 37-year-old asymptomatic woman who consulted for a large -12 cm diameter- mass involving segments 5 and 6 of the liver, and alfa-fetoprotein of 1,556,30 UI/mL. A bisegmentectomy was carried out. The microscopic study confirmed the AHB diagnosis, revealing the presence of epithelial cells forming clusters, trabecular patterns and tubules. The patient died on the 10th postoperative month due to progression disease.The Wnt/Beta-Catenin signaling pathway mutation has been reported and associated with a poor prognosis in IHB. Due to the AHB poor prognosis, seems reasonable to introduce the therapeutic regimens described in children who have a better outcome.
Revista:
CIRUGIA ESPAÑOLA
ISSN:
0009-739X
Año:
2013
Vol.:
91
N°:
10
Págs.:
659 - 663
Introduction: There is currently no effective medical therapy for polycystic liver (PCL). Cyst puncture and sclerotherapy, cyst fenestration, or partial hepatic resections have been used as palliative treatments. Orthotopic liver transplantation (OLT) has become the treatment of choice for terminal PCL, being indicated in patients with limiting symptoms not susceptible to any other medical treatment. It is also difficult to determine the priority on the waiting list using the Model for End-Stage Liver Disease (MELD).
Methods: A retrospective analysis of OLT for PCL was conducted in our centre. Inclusion criteria were patients with limiting symptoms, bilateral cysts liver, and insufficient remaining liver. In all cases a deceased donor liver transplantation with piggy-back technique without veno-venous bypass was performed.
Results: Six patients underwent liver transplantation for PCL between April 1992 and April 2010, one of them a combined liver-kidney transplantation. The mean intraoperative packed red blood cell transfusion was 3.25 L and fresh frozen plasma was 1.200 cc. Mean operation time was 299 min, and 498 min in the liver-kidney transplantation. There was no peri-operative mortality. The mean hospital stay was 6.5 days. All patients are healthy after a mean follow-up of 71 months.
Conclusion: OLT offers an excellent overall survival. Results are better when OLT is performed early; thus these patients should receive additional points to be able to use the MELD score as a valid prioritisation system for waiting lists.
Keywords: Enfermedad poliquística hepática; Liver transplantation; MELD en la poliquistosis hepática; MELD score for polycystic liver disease; Polycystic liver disease; Trasplante hepático.
Revista:
AMERICAN JOURNAL OF TRANSPLANTATION
ISSN:
1600-6135
Año:
2013
Vol.:
13
N°:
12
Págs.:
3269-3273
The overriding concern in living donor liver transplantation is donor safety. A totally laparoscopic right hepatectomy without middle hepatic vein for adult living donor liver transplantation is presented. The surgical procedure is described in detail, focusing on relevant technical aspects to enhance donor safety, specifically the hanging maneuver and dynamic fluoroscopy-controlled bile duct division.
Revista:
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
ISSN:
0930-2794
Año:
2012
Vol.:
26
N°:
9
Págs.:
2617-22
We describe a novel extra-glissonian approach (EGA) for totally laparoscopic left hepatectomy. Published techniques for totally laparoscopic left hepatectomy generally involve the selective ligation of the vascular and biliary elements of the left pedicle. The laparoscopic dissection of these structures can be tedious, difficult, and dangerous. The EGA has proven useful in open surgery for major hepatectomies. We feel that this approach could be even more useful in the laparoscopic context. We describe an extra-glissonian laparoscopic technique in which the left pedicle is isolated extraparenchymally, detaching the left hilar plate, with particular attention to preserving the branch for segment I. The left portal triad is encircled with a cotton tape and transected with an endostapler. This is performed totally extraparenchymally without damaging the surrounding parenchyma. This EGA technique for laparoscopic left hepatectomy follows by laparoscopy the same steps and recommendations that make the EGA safe and effective in open surgery. The EGA for LLH can be performed as described in open surgery, therefore offering the same advantages.
Revista:
Transplantation Proceedings
ISSN:
0041-1345
Año:
2012
Vol.:
44
N°:
6
Págs.:
1560 - 1561
Revista:
Transplantation Proceedings
ISSN:
0041-1345
Año:
2012
Vol.:
44
N°:
9
Págs.:
2603 - 26058
Revista:
LANGENBECKS ARCHIVES OF SURGERY
ISSN:
1435-2443
Año:
2012
Vol.:
397
N°:
3
Págs.:
481-485
This paper aims to describe an extracorporeal tourniquet (ET) method for laparoscopic Pringle maneuver (PM). From January 2007 to June 2011, we have performed 44 laparoscopic hepatic resections: one hand-assisted and 43 totally laparoscopic procedures. In 39 of these patients, an ET was prepared. In 20 cases (lesions posteriorly located), the patient was placed in the left lateral position, and in 19 cases (lesions anteriorly located), in the supine position. The ET is prepared according to the following steps: from the right flank and through the foramen of Winslow, a grasper is passed behind the hepatoduodenal ligament to place a 75-cm cotton tape around it. The tape is externalized through a 5-mm incision and then passed through a 22CH Tiemann catheter whose ends are cut. The internal end of the catheter is left close to the pedicle, while the other part, with the ends of the tape, is kept outside. The PM is performed from outside the abdomen. In every patient, the ET was uneventfully prepared. No unsuccessful attempts were made. Intermittent clamping was applied. Median (interquartile range) occlusion time was 47.5 min (26.7-64.2). No lesions of any structures related to the placement and use of the tourniquet were observed. This ET for laparoscopic liver resection is easy to prepare and its use simple, fast, and safe.
Revista:
European Journal of surgical Oncology
ISSN:
0748-7983
Año:
2012
Vol.:
38
N°:
7
Págs.:
594 - 601
Revista:
CIRUGIA ESPAÑOLA
ISSN:
0009-739X
Año:
2012
Vol.:
90
N°:
9
Págs.:
569 - 575
Objective: To assess the results of a single-centre series of solid hepatic lesion resections using a totally laparoscopic approach.
Patients and method: A total of 71 solid hepatic lesion resections using a totally laparoscopic approach were performed from November 2002 to February 2012. Of these, 65 were due to malignant disease, and 6 due to benign diseases. A total of 21 hepatocellular carcinomas were removed, 16 on a cirrhotic liver. Limited resections were performed in 52 (73.2%) cases, as well as 14 sectionectomies (3 right posterior and 11 left laterals). Finally, there were 5 major liver resections: 3 left and 2 right hepatectomies. In 14 cases (19.7%) it was combined with some other surgical procedure (cholecystectomy not included). The lesions were located in the anterior segments (SA) in 41 cases (57.7%) and in postero-superior segments (PSS) in 30 cases.
Results: There were 2 (2.8%) conversions to open surgery. Five (7%) patients required transfusions during surgery. The median hospital stay was 4 (3-5) days. There was one (1.4%) death, and one patient required further surgery due to esophagojejunal anastomotic leak. The resection margins were tumour-free in 100% of the cases. Combined surgery showed a significant increase in the morbidity rate (35.7 compared to 7%, p=.012). There were no differences in regards to complication rate (p=.28), transfusions (p=.69) or hospital stay (p=.44) with PSS resections when compared to AS resections.
Conclusion: The totally laparoscopic approach is feasible and safe in the resection of solid liver lesions. Combined surgery can significantly increase the morbidity rate. Resections of lesions situated in PSS can be performed with similar safety to those in SA.
Revista:
Transplantation Proceedings
ISSN:
0041-1345
Año:
2011
Vol.:
43
N°:
3
Págs.:
690 - 691
Fewer than 25% of potential liver donors became effective donors leading us to conclude that adult living donor liver transplantation has a low applicability
Revista:
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
ISSN:
0930-2794
Año:
2011
Vol.:
25
N°:
10
Págs.:
3426 - 3427
Revista:
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
ISSN:
1130-0108
Año:
2010
Vol.:
102
N°:
5
Págs.:
314 - 320
Background: intraductal papillary mucinous neoplasm (IPMN) shows a series of lesions which evolve from benign lesions -adenoma- to invasive carcinoma.
Aim: To analyze the clinical and pathological results of 15 patients diagnosed of IPMN, and surgically treated according to the guidelines of International Consensus Conference.
Material and methods: A retrospective analysis of 15 patients surgically treated between March 1993 and September 2009, according to the International Consensus recommendation. Demographic, diagnostic tools, surgical report, pathologic database and actuarial survival were analyzed with a follow-up from one and a half month through nine years.
Results: 6 Patients underwent pancreaticoduodenectomies, 4 total pancreatectomies, 2 body or central pancreatectomies, 2 partial pancreatectomies (enucleation) and 1 distal pancreatectomy. A morbidity of 46 and 0% hospital mortality were assessed, with a median length hospital stay of 10 days. In five cases, the IPMN was combined type (both main and branch pancreatic ducts involved) in four main duct-type and branch duct-type in the another six as well. Several atypia (IPMN carcinoma in situ) was observed in 2 patients and invasive carcinoma with negative lymph nodes was identified in 3 patients. A patient without invasive carcinoma died at 66 months of follow-up for pancreas adenocarcinoma. The actuarial survival up to recurrence or death was 105,133 months with a range of follow-up from 1 month and a half until 9 years.
Conclusions: IPMN main duct or mixed type warrants complete resection due to its incidence of invasive carcinoma or precursor lesions of malignancy as well. Due to its multifocal pattern, patients should be followed in long-term surveillance. The management of asymptomatic IPMN type branch less than 3 cm is controversial.
Revista:
TRANSPLANTATION PROCEEDINGS
ISSN:
0041-1345
Año:
2010
Vol.:
42
N°:
8
Págs.:
3079 - 3080
Diffuse thrombosis of the entire portal system (PVT) and cavernomatous transformation of the portal vein (CTPV) represents a demanding challenge in liver transplantation. We present the case of a patient with nodular regenerative hyperplasia and recurrent episodes of type B hepatic encephalopathy concomitant with PVT as well as CTPV, successfully treated with orthotopic liver transplantation. The portal inflow to the graft was carried out through the confluence of 2 thin paracholedochal varicose veins, obtaining good early graft function and recovery of the encephalopatic episodes. This alternative should be kept in mind as an option to assure hepatopetal splanchnic flow in those cases of diffuse thrombosis and cavernomatous transformation of portal vein.
Revista:
Revista española de enfermedades digestivas
ISSN:
1130-0108
Año:
2010
Vol.:
102
N°:
5
Págs.:
338 -339