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Body mass index (BMI) is widely used as a measure of overweight and obesity, but underestimates the prevalence of both conditions, defined as an excess of body fat.We assessed the degree of misclassification on the diagnosis of obesity using BMI as compared with direct body fat percentage (BF%) determination and compared the cardiovascular and metabolic risk of non-obese and obese BMI-classified subjects with similar BF%.We performed a cross-sectional study.A total of 6123 (924 lean, 1637 overweight and 3562 obese classified according to BMI) Caucasian subjects (69% females), aged 18-80 years.BMI, BF% determined by air displacement plethysmography and well-established blood markers of insulin sensitivity, lipid profile and cardiovascular risk were measured.We found that 29% of subjects classified as lean and 80% of individuals classified as overweight according to BMI had a BF% within the obesity range. Importantly, the levels of cardiometabolic risk factors, such as C-reactive protein, were higher in lean and overweight BMI-classified subjects with BF% within the obesity range (men 4.3 ± 9.2, women 4.9 ± 19.5 mg l(-1)) as well as in obese BMI-classified individuals (men 4.2 ± 5.5, women 5.1 ± 13.2 mg l(-1)) compared with lean volunteers with normal body fat amounts (men 0.9 ± 0.5, women 2.1 ± 2.6 mg l(-1); P0.001 for both genders).Given the elevated concentrations of cardiometabolic risk factors reported herein in non-obese individuals according to BMI but obese based on body fat, the inclusion of body composition measurements together with morbidity evaluation in the routine medical practice both for the diagnosis and the decision-making for instauration of the most appropriate treatment of obesity is desirable.

Liver transplant recipients have an increased risk of malignancy. Smoking is related to some of the most frequent causes of posttransplant malignancy. The incidence and risk factors for the development of neoplasia related to smoking (head and neck, lung, esophageal, and kidney and urinary tract carcinomas) were studied in 339 liver transplant recipients. Risk factors for the development of smoking-related neoplasia were also studied in 135 patients who had a history of smoking so that it could be determined whether smoking withdrawal was associated with a lower risk of malignancy. After a mean follow-up of 7.5 years, 26 patients were diagnosed with 29 smoking-related malignancies. The 5- and 10-year actuarial rates were 5% and 13%, respectively. In multivariate analysis, smoking and older age were independently associated with a higher risk of malignancy. In the smoker subgroup, the variables related to a higher risk of malignancy were active smoking and older age. In conclusion, smoking withdrawal after liver transplantation may have a protective effect against the development of neoplasia.

The Barcelona Clinic Liver Cancer (BCLC) staging system recommends first-line therapy for each tumor stage. We evaluated the effect of compliance with BCLC treatment allocation on the prognosis of patients with hepatocellular carcinoma (HCC). We retrospectively analyzed 359 consecutive, newly diagnosed HCC patients treated in our Liver Unit during a 14-year period. For each stage, survival was compared according to whether treatment matched the BCLC recommendation. We also compared the survival of patients in the same BCLC stage who received different treatments, and patients in different BCLC stages receiving the same treatment. BCLC-A patients treated with radical therapies (66%) survived longer (117 vs. 20 months; p

Resumen Introduccion La Fast-track surgery se ha planteado recientemente como un programa eficaz en la cirugia pancreatica. Aunque la morbimortalidad tras la duodenopancreatectomia cefalica ha mejorado en la ultima decada, la prevalencia de complicaciones postoperatorias continua siendo elevada. El objetivo de este trabajo es examinar los resultados de un programa de Fast-track en este tipo de intervenciones. Resultados Ochenta y dos pacientes fueron intervenidos de duodenopancreatectomia cefalica dentro de un protocolo de recuperacion precoz. La mediana de edad fue 63 anos. El 65% fueron varones. La mediana de estancia hospitalaria fue de 9 dias, con un 14,6% de reingresos. Se aplico la clasificacion de Clavien-DeOliveira para evaluar la severidad de las complicaciones. La morbilidad global fue del 47,6%. La complicacion mas frecuente correspondio al grupo que englobaba las generales, seguidas por la infeccion de la herida quirurgica y complicaciones cardiorrespiratorias. Teniendo en cuenta que solo el 32% de los pacientes tuvieron drenaje desde la cirugia, la frecuencia de fistula pancreatica fue del 8,5%, y esta se situaba en los grupos de mayor morbilidad (grados III, IV y V). La mortalidad postoperatoria fue del 4,9%. La cirugia asociada constituyo un factor de riesgo para la mortalidad. Conclusiones La Fast-track surgery en la duodenopacreatectomia cefalica realizada en centros de alto volumen es un programa seguro y eficaz que permite ademas mejorar los resultados de morbimortalidad.

Receptor-interacting protein 140 (RIP140) is a corepressor for nuclear receptors with an important role in the inhibition of energy expenditure. Rip140-knockout mice are lean and resistant to diet-induced obesity due to an increase in mitochondrial biogenesis, fatty acid oxidation, and oxidative phosphorylation. The aim of the present work was to evaluate the effect of morbid obesity on gene and protein expression levels of RIP140 in visceral adipose tissue (VAT).VAT biopsies obtained from 17 subjects were used in the study. Patients were classified as lean (body mass index [BMI]=21.8+/-1.3 kg/m2) or obese (BMI=48.2+/-2.6 kg/m2). Reverse transcription polymerase chain reaction and Western blot analyses were performed to quantify the expression levels of RIP140 in VAT. We also analyzed glucose and lipid profile as well as some inflammatory factors.Obese patients exhibited significantly lower RIP140 mRNA expression levels compared to lean subjects (lean=1.00+/-0.17 arbitrary units, obese=0.65+/-0.18 arbitrary units; P0.05). Protein expression of RIP140 followed the same trend, being significantly higher in lean volunteers (lean=1.00+/-0.18 arbitrary units, obese=0.45+/-0.11 arbitrary units; P0.05). Furthermore, a significant negative correlation was found between RIP140 protein levels and both BMI (rho=-0.85; P0.001) and body fat percentage (rho=-0.88; P0.001).The lower gene and protein expression levels of RIP140 in obese subjects may suggest a compensatory mechanism in order to favor energy expenditure and reduce fat accumulation in obesity states.

Milan criteria are the most frequently used limits for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC), but our previous experience with expanded criteria showed encouraging results. The aim of this study was to investigate whether our expanded Clinica Universitaria de Navarra (CUN) criteria (1 nodule up to 6 cm or 2-3 nodules up to 5 cm each) could be used to select patients with HCC for LT. Eighty-five patients with HCC fulfilling CUN criteria were included as candidates for LT. Survival of transplanted HCC patients was compared with survival of patients without HCC (n = 180). After the exclusion of 2 patients with tumor seeding of the chest wall due to pre-LT tumor biopsy, survival and recurrence rates were compared according to tumor staging. Twenty-six out of 85 (30%) patients exceeded Milan criteria. Twelve patients had tumor progression on the waiting list. Patients exceeding Milan criteria had a higher dropout rate due to tumoral progression. One-, 3-, 5-, 7-, and 10-year survival rates of the 73 transplanted HCC patients were 86%, 74%, 70%, 61%, and 50%, respectively. Survival of patients with HCC was significantly lower than that of patients without HCC, but by multivariate analysis, HCC was not associated with lower survival. Tumor recurrence and survival rates were similar for patients fulfilling Milan and CUN criteria. Pathological staging showed 55 patients within Milan criteria, 7 patients exceeding them but within CUN criteria, and 9 patients exceeding CUN criteria. Tumor recurrence rates were 2/55 (4%), 0/7 (0%), and 4/9 (44%) in each of these groups, respectively. In conclusion, following CUN criteria could increase the number of HCC patients who could benefit from LT, without worsening the results. Because of the short number of patients in this series, these data need external validation.

Obesity and obesity-associated type 2 diabetes mellitus (T2DM) are frequently related to a low-grade chronic inflammatory state, which increases the risk of developing cardiovascular diseases. The aim of the present work was to evaluate the effect of obesity and T2DM on the concentrations of pro-inflammatory factors and to study the effect of weight loss after Roux-en-Y gastric bypass (RYGBP). Plasma concentrations of monocyte chemoattractant protein-1 (MCP-1), tumor necrosis factor-α (TNF-α), serum amyloid A (SAA) and sialic acid (SA) were measured in 25 female volunteers. The concentrations of these cytokines were determined in 14 female obese patients before and after weight loss following RYGBP. Additionally, visceral adipose tissue (VAT) obtained from 15 females was used to quantify expression levels of MCP-1 and CD68 by Real-Time PCR. Both obese normoglycemic (NG) and T2DM groups exhibited significantly higher MCP-1 (P

Obesity acts as a cardiovascular risk factor by mechanisms that are not fully understood. Osteopontin (OPN) is a proinflammatory mediator involved in tissue remodeling that plays a role in atherosclerosis and diabetes. OBJECTIVE: The aim of the present study was to compare the circulating concentrations of OPN and its mRNA expression in omental adipose tissue of lean, overweight, and obese individuals and to analyze the effect of weight loss. SUBJECTS AND METHODS: Plasma concentrations of OPN were measured in 77 volunteers. OPN mRNA expression in omental adipose tissue obtained from 12 women was quantified by real-time PCR. In addition, the concentrations of OPN in 12 obese men were measured before and after weight loss following a dietetic program. SETTING: The study was conducted at a University Hospital. RESULTS: Obese and overweight patients exhibited significantly increased circulating OPN concentrations as compared with lean subjects (obese 72.6 +/- 28.5, overweight 68.2 +/- 20.8, lean 42.7 +/- 27.9 ng/ml; P < 0.001). A significant positive correlation was found between OPN levels and body fat (r = 0.45; P < 0.0001). Obese individuals showed significantly increased (P < 0.05) mRNA expression of OPN in omental adipose tissue as compared with lean volunteers, which was further increased in obese diabetic patients. Diet-induced weight loss significantly decreased OPN concentrations from 64.7 +/- 22.1 to 36.6 +/- 20.1 ng/ml (P = 0.006). CONCLUSIONS: These findings represent the first observation that plasma OPN and mRNA expression of OPN in omental adipose tissue are increased in overweight/obese patients with the latter being further elevated in obesity-associated diabetes. Moreover, weight loss reduces OPN concentrations, which may contribute to the beneficial effects accompanying weight reduction. Measurement of OPN might be useful for evaluating the outcomes of various clinical interventions for obesity-related cardiovascular diseases

Impaired fasting glucose (IFG) is a pre-diabetic state defined as a fasting plasma glucose (FPG) between 100 and 125 mg/dl. However, individuals in this group do not exhibit the same atherogenic risk.The atherogenic profile of subjects with IFG110 mg/dl (IFG110, n = 96) or110 mg/dl (IFG100, n=131) were compared and the potential differential impact of the waist circumference analyzed. In addition, the same clinical variables were measured in 18 morbidly obese patients (8 males, 10 females; BMI 45.3 +/- 1.9 kg/m2) before and after weight loss following Roux-en-Y gastric bypass (RYGBP), in order to analyze the influence of the reduction in waist circumference on the improvement of the metabolic risk factors.Individuals in the IFG110 group showed decreased HDL-cholesterol levels together with an increased total cholesterol to HDL ratio (TC/HDL), accompanied by elevated homocysteine concentrations and white blood cell (WBC) count, and higher waist circumference (P0.05 for all). Significant correlations between waist circumference and HDL-cholesterol (r=-0.200, P0.05), TC/HDL (r=0.190, P0.05), WBC count (r=0.299, P0.05), and QUICKI (r=-0.375, P0.0001) were observed. An almost 3-fold increase in the prevalence of T2DM in subjects in the IFG110 group as compared to IFG100 was observed. In the group of patients who underwent RYGBP, the reduction in waist circumference was significantly associated with the improvement in insulin sensitivity as evidenced by the QUICKI index (r=-0.582, P0.05) and the reduction in TC/HDL (r=0.595, P0.05).Waist circumference is related to metabolic risk factors associated with increased levels of IFG. Our data support that individuals with IFG110 mg/dl and a high waist circumference should undergo an OGTT to exclude the presence of diabetes.

The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Pathological findings remain the most significant prognostic factor. The presence of mucin pools and their prognostic significance is a controversial issue. The aim of this study was to analyze the incidence of cellular and acellular mucin pools and their clinical significance. Four-hundred and forty-six consecutive prospectively collected specimens from patients with LARC treated with long-course preoperative CRT and surgery were analyzed. Kaplan–Meier analysis was performed. Mucin pools were present in 182 specimens (40.8 %); 66 (14.7 %) were acellular, and viable tumor cells were identified in 116 (26 %). The complete pathological response rate was 13.5 % (60 of 446). With a median follow-up of 79.0 months, the 5- and 10-year disease-free survivals for patients with acellular and cellular mucin pools were 81.5, 78.1, 63.7 and 61.2 %, respectively (p ≤ 0.026). The presence of cells in the colloid response to treatment was associated with a 17.8 and 16.9 % decrease in 5- and 10-year disease survival vs. acellular colloid response. Our results suggest that cellular mucin pools are an indicator of an aggressive phenotype and harbingers of a worse prognosis.

Resumen Introduccion En el pasado, la experiencia de la cirugia laparoscopica del pancreas se mantenia limitada a experiencias individuales con un reducido nucleo de pacientes. El reciente estudio multicentrico europeo ha permitido conocer los limites y los resultados de la tecnica. En este trabajo se presenta el analisis de los resultados del Registro Nacional Espanol de la Cirugia Laparoscopica del Pancreas (RNEP). Material y metodos Se ha incluido a 132 pacientes con lesiones localizadas en el pancreas izquierdo: 42 tumores neuroendocrinos, 40 neoplasias quisticas, 24 quistes y seudoquistes, 8 tumores inflamatorios, 8 carcinomas ductales, 7 neoplasias papilares mucinosa, 1 carcinoma acinar, 2 tumores solidos seudopapilares. Resultados El indice de conversion fue del 9,7%. La tecnica de enucleacion se realizo tan solo en pacientes portadores de un insulinoma. La pancreatectomia distal con preservacion esplenica fue la utilizada con mas frecuencia. La mortalidad fue nula y, como morbilidad, la fistula pancreatica aparecio en el 16% de los casos. Conclusiones A pesar de que el numero de hospitales espanoles es limitado, los resultados obtenidos hacen esperar una mayor experiencia en un futuro proximo.

Background: Obesity is considered a state of low-grade chronic inflammation, which may favor the development of cardiovascular diseases. Serum amyloid A (SAA) is an acute phase protein synthesized in response to infection, inflammation, injury, and stress. The aim of the present study was to compare the circulating concentrations of SAA and the mRNA expression in omental adipose tissue between lean and obese individuals and to analyze the effect of weight loss after gastric bypass. Methods: 16 lean volunteers (BMI 20.5 ± 0.6 kg/m2) and 24 obese patients (BMI 47.0 ± 1.2 kg/m2) were included in the study. Serum concentrations of SAA were measured by ELISA. In addition, the concentrations of SAA in 18 morbidly obese patients (7 male/11 female; BMI 44.6 ± 1.9 kg/m2) were measured before and after weight loss following Roux-en-Y gastric bypass (RYGBP). SAA expression in omental adipose tissue was quantified by RT-PCR in biopsies from obese patients undergoing RYGBP and from age-matched lean individuals subjected to Nissen fundoplication. Results: Obese patients exhibited significantly increased circulating SAA concentrations (6.6 ± 0.5 vs 39.3 ± 9.1 μg/ml; P

Resumen Introduccion La experiencia en cirugia hepatica por laparoscopia es limitada; para realizar una valoracion critica son necesarias series amplias y multicentricas. Objetivo Analizar los resultados del registro nacional de cirugia hepatica por via laparoscopica. Valorar las indicaciones, los aspectos tecnicos, el indice de conversion y la morbimortalidad. Pacientes y metodo Se incluye a 74 pacientes de 10 centros de febrero de 2000 a abril de 2005. Cincuenta y ocho mujeres y 16 varones, con una edad media de 55 anos. Dieciseis pacientes presentaban mas de una lesion, por lo que se trato a 74 pacientes con 156 lesiones. Resultados Cuarenta y seis pacientes presentaban lesiones quisticas (26 quistes simples, 13 enfermedad poliquistica, 5 quistes hidatidicos y 2 cistoadenomas). Se practicaron 37 fenestraciones, 5 quistoperiquistectomias, 2 resecciones limitadas, 1 segmentectomia y 1 bisegmentectomia II-III. En 28 pacientes las lesiones eran solidas (4 adenomas, 6 hiperplasias nodulares focales, 3 hemangiomas, 4 hepatocarcinomas, 5 metastasis colorrectales, 2 metastasis de pulmon, 1 metastasis de mama, 1 metastasis de melanoma maligno, 1 metastasis de vipoma pancreatico y 1 linfoma). Se realizaron 10 bisegmentectomias II-III, 17 resecciones limitadas y 1 segmentectomia del segmento III. En 23 casos se asocio otra cirugia. El tiempo quirurgico medio fue de 160,5 min y el indice de conversion, del 8%. La estancia media fue de 5,6 dias, y el 78% de los pacientes estuvo menos de 5 dias. En el 55% la analgesia se administro menos de 48 h. La morbilidad fue de 8 casos (11%). Tres casos fueron reintervenidos. No existio mortalidad en la serie. Conclusiones La reseccion hepatica laparoscopica es factible y segura en casos seleccionados. Se hace necesario disponer de series amplias y controladas para conocer los resultados a largo plazo. El registro nacional es una buena alternativa para valorar la cirugia hepatica realizada por via laparoscopica en Espana.

En pacientes con tumores hepaticos, el tratamiento mas eficaz es la cirugia. Sin embargo, no todos pueden ser tratados de esta manera. Uno de los motivos que contraindican el tratamiento quirurgico es que el parenquima hepatico que queda tras la reseccion de la zona tumoral sea insuficiente para asegurar la funcion hepatica del paciente. Es conocido que el hepatocito, tras determinados estimulos, tiene la posibilidad de desdiferenciarse y clonarse. La embolizacion portal prequirurgica (EPP) del volumen hepatico que se va a resecar puede generar, tras este estimulo y respuesta (que sera diferente en higados fibroticos y no fibroticos), un crecimiento hepatico que alcanzara niveles adecuados en 3-4 semanas. Por tanto, la EPP puede incrementar el numero de candidatos a recibir tratamiento quirurgico y, del mismo modo, puede disminuir la aparicion de posibles complicaciones postoperatorias. En este articulo se presentan lo criterios de inclusion y exclusion que, de forma comunmente aceptada, se utilizan para realizar una EPP. No hay acuerdo, sin embargo, sobre la tecnica mas adecuada para acceder al sistema portal, por ejemplo, la via contralateral (con puncion de los segmentos portales que no van a ser resecados) tiene considerables ventajas tecnicas, pero pone en riesgo de trombosis a las ramas portales del tejido hepatico sano. Son muchos los materiales embolizantes que se han usado en EPP, algunos autores recomiendan el empleo de «pegamentos», pues son relativamente sencillos de utilizar, de bajo coste y altamente eficaces pero, por otra parte, generan una importante inflamacion periportal que puede dificultar la reseccion quirurgica. Si se emplean particulas, estas deben ser de un tamano que oscile entre las 100 y las 300 micras. En conclusion, aunque todavia hay muchos aspectos de la EPP que requieren ser investigados, la tecnica deberia de estar disponible en todos los centros en los que se realice cirugia hepatica, pues los beneficios clinicos derivados de esta son muy satisfactorios.

Herpes zoster is the consequence of the reactivation of latent varicella-zoster infection. Immunosuppression may be a predisposing factor for herpes zoster. We have retrospectively assessed the risk of herpes zoster, the risk factors for its occurrence, and its evolution in a population of 209 consecutive liver transplant recipients. Herpes zoster developed in 25 (12%) of patients. One-, 3-, 5-, and 10-year actuarial rates of herpes zoster were 3%, 10%, 14%, and 18%, respectively. In a case-control study, patients developing herpes zoster were younger, received a higher number of immunosuppressive drugs, and were more frequently receiving mycophenolate mofetil or azathioprine. In multivariate analysis, the only factor related to herpes zoster occurrence was treatment with mycophenolate mofetil or azathioprine. Eight patients (31%) developed postherpetic neuralgia. In conclusion, herpes zoster is a relatively common complication after liver transplantation. It is related to immunosuppressive therapy. Postherpetic neuralgia develops in one third of patients with posttransplant herpes zoster.

Introduction Complete portal vein thrombosis (PVT) may complicate orthotopic liver transplantation (OLT), increasing its technical difficulty and the transfusion requirements and as well as affecting survival in some cases. Transjugular intrahepatic portosystemic shunt (TIPS) prevents total portal vein occlusion in patients with partial PVT. Objective We aimed to assess the efficacy and safety of TIPS to prevent total portal vein occlusion among patients listed for OLT. Patients and methods We analyzed the clinical records of 15 consecutive patients with partial PVT who underwent TIPS before OLT. The control group consisted of 8 transplanted patients without TIPS but partial PVT diagnosed before OLT. Portal vein patency at surgery, ischemia time, and transfusion requirements during OLT, and survival thereafter were compared between both groups. The main complications were also compared: mortality after TIPS (from TIPS placement to OLT), intraoperative technical complications, and technical complications during the 6 months after OLT. Results Clinical characteristics at the time of OLT were similar between the groups. No relevant complications were observed after TIPS; all patients underwent transplantation. One- and 5-year actuarial survival rates were similar in both groups (92% and 85% in TIPS-group versus 100 and 75% in the control group, respectively). No differences in transfusion requirement, duration of ischemia, and frequency of technical complications during and after OLT were observed between the groups. The portal vein was patent at surgery in all TIPS patients and 4 of 8 (50%) in the control group ( P = .008). Conclusion TIPS may prevent PVT in liver transplantation candidates with partial PVT.

Background Liver transplant recipients have a high risk of developing nonmelanoma skin cancer (NMSC). Some develop multiple NMSC. Methods Patients with a follow-up of >1 year have been prospectively followed to detect NMSC. We studied the risk of developing >1 NMSC. Results After a follow-up of 2658 patient-years (mean, 8.5 years per patient), 59/312 (19%) patients were diagnosed with NMSC. Twenty-five had >1 NMSC. The 5-year risk of developing 1 NMSC, >1 NMSC, and a subsequent NMSC (a new NMSC after a first one) were 15%, 5.5%, and 46.5%, respectively. Age >60 years and transplantation for hepatocellular carcinoma were independently associated with a higher risk of developing >1 NMSC. Conclusion NMSC are frequent complications after liver transplantation and they may show a high rate of recurrence. Older age and hepatocellular carcinoma were related to the development of multiple NMSC.

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.

695 Background: The prognostic significance of perineural and/or lymphovascular invasion (PLVI) and its relationship with tumor regression grade (TRG) in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (CRT) and surgery. Methods: A total of 324 patients with LARC treated with CRT were operated on between January 1992 and June 2007. Tumors were graded using a quantitative 5-grade TRG classification, and the presence of PLVI was studied histologically. Results: At a median follow-up of 79.0 months (range 3–250 months), a total of 80 patients (24.7%) relapsed. The observed 5- and 10-year overall survival (OS) was 83.2% and 74.9% respectively. The 5- and 10-year disease-free survival (DFS) was 75.1% and 71.4%, respectively. A significant correlation was found between the TRG and survival (log rank, p

The surgical treatment of benign tumors of the neck of the pancreas usually consists of enucleation or formal pancreatectomy. Central pancreatectomy has been put forward because it has fewer major complications and can preserve endocrine and exocrine function. Between January 1999 and march 2003, three patients with benign tumors of the neck of the pancreas underwent central pancreatectomy. all patients underwent computed tomography scans, intraoperative ultrasound and frozen-section analysis. pathologic examination showed two mucinous cystadenomas and one serous cystadenoma. after a mean follow-up of 34 months, none of the patients has shown major complications or local recurrence, or has developed diabetes. In conclusion, central pancreatectomy is a useful technique for selected benign or low-grade malignant pancreatic tumors of the neck of the pancreas.

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.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.The total operative time was 438 min. Three periods of 15-min pedicle occlusion resulted in100 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.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.

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.

In recent years different minimal access strategies have been designed in order to perform living donor liver surgery for adult recipients with less morbidity. Techniques involve shortening the length of the incision with or without previous laparoscopic mobilization of the liver. Herein we present two cases of totally laparoscopic living donor left hepatectomy, with and without removal of the middle hepatic vein, respectively. We describe in detail the anatomical and technical aspects of the procedure focusing on relevant points to enhance safety.

Radical resection remains the only potential curative therapy for hilar cholangiocarcinoma (HCCA). The aim of staging laparoscopic (SL) is to identify patients with previously undetected advanced disease who will not benefit from surgical palliation and therefore avoid unnecessary laparotomies. The accuracy of non-invasive imaging techniques has significantly improved during the last years. As a consequence, the diagnostic yield of SL of biliary tract malignancy should have decreased proportionally. At the same time, some authors have recently questioned the value of laparoscopic ultrasound (LUS) as a complement of SL. In this setting, the precise role of SL and LUS in the preoperative workup of HCCA remains unclear. As it seems undoubtedly clear that its efficacy has decreased in the last decades, there is a general consensus that the universal use of SL shouldn't be recommended anymore; SL should be performed only in selected patients with higher risk of holding unresectable disease (T2/T3 or Bismuth type 3/4 and patients with suspicion of metastases). It would also be recommended in patients with potentially resectable disease who would need preoperative invasive procedures. Finally, SL should be performed preceding laparotomy in one session. Further studies on the benefit of SL and LUS in this subset of HCCA patients are warranted.

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 being a combined liver–kidney transplantation. The mean intraoperative packed red blood cell transfusion was 3.25 L and fresh frozen plasma was 1200 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 the 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.

The use of the laparoscopic approach in managing early liver transplant complications has been shown to be safe and feasible in various settings with the advantages of shorter recovery period, decreased postoperative pain, and rapid functional recovery. The laparoscopic approach has been used to resolve postoperative complications in kidney and pancreas recipients and less often in orthotopic liver transplantation (OLT) recipients, most of them in the late period (> 1 month posttransplantation). We herein describe our experience with the laparoscopic management of early complications after liver transplantation. From May 2009 to May 2011, we successfully treated three patients with early abdominal complications after OLT using a laparoscopic approach. Three patients—two with intraabdominal bleedings and one with a small bowell obstruction were treated successfully, thereby avoiding risks of a relaparotomy. In addition to these benefits, the laparoscopic approach causes less tissue injury and consequently evokes a minor innate inmune response.

Proinflammatory and proapoptotic cytokines such as TNF-α are upregulated in human obesity. We evaluated the association between ghrelin isoforms (acylated and desacyl ghrelin) and TNF-α in obesity and obesity-associated type 2 diabetes, as well as the potential role of ghrelin in the control of apoptosis and autophagy in human adipocytes.Plasma concentrations of the ghrelin isoforms and TNF-α were measured in 194 participants. Ghrelin and ghrelin O-acyltransferase (GOAT) levels were analysed by western-blot, immunohistochemistry and real-time PCR in 53 biopsies of human omental adipose tissue. We also determined the effect of acylated and desacyl ghrelin (10 to 1,000 pmol/l) on TNF-α-induced apoptosis and autophagy-related molecules in omental adipocytes.Circulating concentrations of acylated ghrelin and TNF-α were increased, whereas desacyl ghrelin levels were decreased in obesity-associated type 2 diabetes. Ghrelin and GOAT were produced in omental and subcutaneous adipose tissue. Visceral adipose tissue from obese patients with type 2 diabetes showed higher levels of GOAT, increased adipocyte apoptosis and increased expression of the autophagy-related genes ATG5, BECN1 and ATG7. In differentiating human omental adipocytes, incubation with acylated and desacyl ghrelin reduced TNF-α-induced activation of caspase-8 and caspase-3, and cell death. In addition, acylated ghrelin reduced the basal expression of the autophagy-related genes ATG5 and ATG7, while desacyl ghrelin inhibited the TNF-α-induced increase of ATG5, BECN1 and ATG7 expression.Apoptosis and autophagy are upregulated in human visceral adipose tissue of patients with type 2 diabetes. Acylated and desacyl ghrelin reduce TNF-α-induced apoptosis and autophagy in human visceral adipocytes.

Mujer de 65 anos con carcinoma de celulas grandes de pulmon T2N0M1 hace 4 anos tratado con quimioterapia y cirugia. Hace un ano presento metastasis u nica suprarrenal derecha con infiltracion de vena cava inferior, arteria polar superior derecha, vena renal derecha –trombosaday pilar diafragmatico (fig. 1). Se trato con quimio-radioterapia, obteniendo buena respuesta inicial con posterior crecimiento tumoral. Ante la imposibilidad de continuar la irradiacion, se decide tratamiento quiru rgico. Se realiza adrenalectomia y nefrectomia derechas con sustitucion de cava infrahepatica por injerto criopreservado (fig. 2), conservando la vena renal izquierda (flecha). Diagnostico Anatomopatologico: Metastasis de carcinoma de celulas grandes. c i r e s p . 2 0 1 3 ; 9 1 ( 1 ) : e 5

OBJECTIVE To assess the predictive capacity of a recently described equation that we have termed CUN-BAE (Clínica Universidad de Navarra-Body Adiposity Estimator) based on BMI, sex, and age for estimating body fat percentage (BF%) and to study its clinical usefulness. RESEARCH DESIGN AND METHODS We conducted a comparison study of the developed equation with many other anthropometric indices regarding its correlation with actual BF% in a large cohort of 6,510 white subjects from both sexes (67% female) representing a wide range of ages (18–80 years) and adiposity. Additionally, a validation study in a separate cohort (n = 1,149) and a further analysis of the clinical usefulness of this prediction equation regarding its association with cardiometabolic risk factors (n = 634) was carried out. RESULTS The mean BF% in the cohort of 6,510 subjects determined by air displacement plethysmography was 39.9 ± 10.1%, and the mean BF% estimated by the CUN-BAE was 39.3 ± 8.9% (SE of the estimate, 4.66%). In this group, BF% calculated with the CUN-BAE showed the highest correlation with actual BF% (r = 0.89, P < 0.000001) compared with other anthropometric measures or BF% estimators. Similar agreement was found in the validation sample. Moreover, BF% estimated by the CUN-BAE exhibits, in general, better correlations with cardiometabolic risk factors than BMI as well as waist circumference in the subset of 634 subjects. CONCLUSIONS CUN-BAE is an easy-to-apply predictive equation that may be used as a first screening tool in clinical practice. Furthermore, our equation may be a good tool for identifying patients at cardiovascular and type 2 diabetes risk.

Background Occasionally, patients with hepatocellular carcinoma (HCC) who receive radioembolization with palliative intent are downstaged for radical treatments. The aim of this study was to describe and analyze the overall survival (OS) in these patients compared with patients of the same baseline stage (UNOS T3), who were not eligible for radical treatment after radioembolization. Methods Between September 2003 and August 2010, 118 patients with HCC received radioembolization with yttrium-90 ( 90 Y) resin microspheres. Of these, 21 patients with UNOS T3 stage were retrospectively identified and included in this analysis. Results In total, 6 of 21 patients were downstaged and treated radically between 2 and 35 months post-radioembolization. Three patients were resected, 2 received liver transplantation and 1 was ablated and then resected. Patients treated radically were significantly younger (62 vs . 73 years, p = 0.006) and had higher tumor volume (583 mL vs. 137 mL, p = 0.001) than patients who did not achieve radical treatment. There were no differences between the groups in number of lesions, BCLC stage, previous cirrhosis, activity administered per tumor volume, or median levels of alpha-fetoprotein or total bilirubin. Across the whole series, the median OS was 27.0 months (95% CI 5.0–48.9), varying significantly between those treated radically (OS not reached after a median follow-up of 41.5 months since radical therapy) and those who received palliative treatment only (22.0 months; 95% CI 15.0–30.9). Conclusions Radical therapy following tumor downstaging with radioembolization provides the possibility of long-term survival in a select subgroup (UNOS T3 stage) with otherwise limited options.

Background Type 2 diabetes mellitus (T2DM) is a well-known factor risk for non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) in obese patients. Aims To better understand the association between T2DM and NAFLD, global changes in protein expression in diabetic and non-diabetic obese subjects were assessed by a proteomic approach. Methods Liver samples were obtained from diabetic and non-diabetic morbid obese subjects (BMI>40 kg/m2). Histological analysis was used to evaluate hepatic steatosis and the degree of anatomopathological alteration. Changes in protein expression were analysed by two-dimentional electrophoresis combined with MALDI-TOF mass spectrometry. Levels of glutathione, carbonyl and 4-HNE protein adducts were used to assess oxidative stress status. Results Of 850 proteins analysed, 33 were differentially expressed in T2DM obese subjects. Of these, 27 were unequivocally identified by mass spectrometry. Analysis of protein sets revealed patterns of decreased abundance in mitochondrial enzymes, proteins involved in methione metabolism, and oxidative stress response. Accordingly, T2DM subjects showed decreased levels of glutathione, the antioxidant byproduct of methionine metabolism via the transsulfuration pathway, and higher levels of protein and lipid oxidative damage. Changes in detoxyfing enzymes, carbohydrate metabolism, proteasome subunits and retinoic acid synthesis were also found. Conclusions The results suggest alterations in mitochondrial function and methionine metabolism as potential contributing factors to increased oxidative stress in liver of obese diabetic patients which may be influencing the development of NAFLD and NASH.

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.

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.

Introduction The aim of this study was to investigate the applicability of living donor liver transplantation in a program of adult liver transplantation. Patients and methods We studied the outcomes of the evaluation of 71 potential donor candidates for 53 adult candidates to liver transplantation. Results Ten of the potential donor candidates did not complete their evaluation. Among the remaining 61 potential donors, 29 (47.5%) were considered to be suitable donors. Only 17 (24% of the 71 initial candidates) underwent donation. The main causes for unsuitability for liver donation were a small remnant liver and vascular anatomic variants. Conclusion Fewer than 25% of potential liver donors became effective donors leading us to conclude that adult living donor liver transplantation has a low applicability.

Obesity is the major risk factor for the development of prediabetes and type 2 diabetes. BMI is widely used as a surrogate measure of obesity, but underestimates the prevalence of obesity, defined as an excess of body fat. We assessed the presence of impaired glucose tolerance or impaired fasting glucose (both considered together as prediabetes) or type 2 diabetes in relation to the criteria used for the diagnosis of obesity using BMI as compared to body fat percentage (BF%). We performed a cross-sectional study including 4,828 (587 lean, 1,320 overweight, and 2,921 obese classified according to BMI) white subjects (66% females), aged 18-80 years. BMI, BF% determined by air-displacement plethysmography (ADP) and conventional blood markers of glucose metabolism and lipid profile were measured. We found a higher than expected number of subjects with prediabetes or type 2 diabetes in the obese category according to BF% when the sample was globally analyzed (P < 0.0001) and in the lean BMI-classified subjects (P < 0.0001), but not in the overweight or obese-classified individuals. Importantly, BF% was significantly higher in lean (by BMI) women with prediabetes or type 2 diabetes as compared to those with normoglycemia (NG) (35.5 ± 7.0 vs. 30.3 ± 7.7%, P < 0.0001), whereas no differences were observed for BMI. Similarly, increased BF% was found in lean BMI-classified men with prediabetes or type 2 diabetes (25.2 ± 9.0 vs. 19.9 ± 8.0%, P = 0.008), exhibiting no differences in BMI or waist circumference. In conclusion, assessing BF% may help to diagnose disturbed glucose tolerance beyond information provided by BMI and waist circumference in particular in male subjects with BMI

Glycerol constitutes an important metabolite for the control of lipid accumulation and glucose homeostasis. The impact of obesity and obesity-associated type 2 diabetes as well as the potential regulatory role of insulin and leptin on aquaglyceroporins (AQP) 3, 7, and 9 were analyzed.The tissue distribution and expression of AQP in biopsies of omental and sc adipose tissue as well as liver were analyzed in lean and obese Caucasian volunteers (n = 63). The effect of insulin (1, 10, and 100 nmol/liter) and leptin (0.1, 1, and 10 nmol/liter) on the expression of the glycerol channels was determined in vitro in human omental adipocytes and HepG2 hepatocytes. The translocation of AQP in response to insulin and isoproterenol was analyzed by immunocytochemistry.In addition to the well-known expression of AQP7 in adipose tissue, AQP3 and AQP9 were also expressed in both omental and sc adipose tissue. Obese type 2 diabetes patients showed higher expression of AQP in visceral adipose tissue and lower expression of AQP7 in sc adipose tissue and hepatic AQP9. The staining of AQP9 in the plasma membrane of adipocytes was reinforced by insulin, whereas isoproterenol induced the translocation of AQP3 and AQP7 from the lipid droplets to the plasma membrane. Insulin up-regulated all AQP, whereas leptin up-regulated AQP3 and down-regulated AQP7 and AQP9 in adipocytes and hepatocytes. These effects were abrogated by both the phosphatidylinositol 3-kinase inhibitor wortmannin and the mammalian target of rapamycin inhibitor rapamycin.Our findings show, for the first time, that insulin and leptin regulate the AQP through the phosphatidylinositol 3-kinase/Akt/mammalian target of rapamycin pathway in human visceral adipocytes and hepatocytes. AQP3 and AQP7 may facilitate glycerol efflux from adipose tissue while reducing the glycerol influx into hepatocytes via AQP9 to prevent the excessive lipid accumulation and the subsequent aggravation of hyperglycemia in human obesity.

Laparoscopic pancreatic procedures have increased in recent years. However, only a single case of laparoscopic uncinatectomy has been reported to date, performed through an anterior approach. This video presents a hitherto undescribed laparoscopic inframesocolic approach and also an undescribed maneuver to expose the uncinate process.A 39-year-old women had a 16-mm insulinoma in the uncinate pancreas. The patient was placed in the supine position with legs apart. A 30º, 5-mm optic was used, and only a 12-mm trocar was needed. The first maneuver moved the major omentum and transverse colon upward to expose the mesenteric root. The duodenum was identified through the peritoneal sheath and mobilized. The superior mesenteric vein was identified and carefully exposed in the vicinity of the uncinate pancreas. To improve the exposure for the uncinatectomy, a hanging maneuver of the mesenteric root was performed with cotton tape. Intraoperative ultrasound identified the tumor and defined the limits of the resection. An inferior pancreaticoduodenal vein was sectioned between clips, and the uncinate process was dissected from the retropancreatic fascia. The transection was performed with a reinforced endostapler. The specimen was dragged into a bag and removed through the 12-mm orifice, which did not have to be enlarged. No drain was left.The patient was discharged on postoperative day 3. No early or late surgical complications were observed. At this writing 1 year after the procedure, the patient has lost 35 kg and shows a normal body mass index. She remains asymptomatic with normal blood sugar levels.Laparoscopic resection of the uncinate process of the pancreas is feasible and safe. The inframesocolic approach is easy to perform and achieves an optimal exposure that is improved with a hanging maneuver of the mesenteric root.