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Introduction The aim of this paper is to analyze the validity and safety of a new robotic approach implantation program in the corporocaudal pancreatectomy (PCC) in a Bilio-Pancreatic Unit, evaluating morbi-mortality and hospital stay. Methods Given the controversy of which is the best therapeutic option in distal pancreatectomy in clinical process surgery tributaries, we designed this prospective, non-randomized, single-center study of pancreatic resection with Robotic approach). Ten patients (7 women and 3 men) were included, with a mean age of 57.8 years, (range 36–73 years). In all patients, the body mass index was higher than 30 and the diagnosis was made with a preoperative computed tomography. Results The robotic approach was successful in all cases, performing a corporal-caudal pancreatectomy associated with splenectomy. Blood loss was minimal during intervention, not requiring any blood transfusion. The mean operative time was 135.8 minutes. Conversion to open surgery was not necessary. Three patients had postoperative complications when a CT scan diagnosed an intra-abdominal collection in the left hypocondrium. It was resolved by percutaneous radiological drainage. Median hospital stay was 4 days (3–15). There was not perioperative mortality at 90 days. Anatomopathological study showed 5 mucinous cystic neoplasms, 2 adenocarcinomas of the pancreas and 3 well-differentiated neuroendocrine tumors. Mean size of the lesions were 4.8 cm (2.4–9). Conclusions Robotic distal pancreatectomy is an effective and safe technique. In addition, postoperative morbidity and hospital stay decreases.

Introduction The aim of this paper is to analyze the validity and safety of a new program for the implementation of a robotic approach in the treatment of choledocholithiasis (CD) in a Bilio-Pancreatic Unit, evaluating morbi-mortality and hospital stay. Methods Given the controversy of which is the best therapeutic option in CD: preoperative ERCP followed by laparoscopic cholecystectomy (LC) or laparoscopic approach to the bile duct, we designed this prospective, non-randomized and single-center study with a robotic approach to the bile duct. 25 patients were included (14 women /11 males), with a mean age of 71.4 years. Preoperative abdominal ultrasound and cholangioresonance were performed in all patients. Results The robotic approach was effective in all cases: cholecystectomy and cleaning the bile duct. In the first three cases a radiological exploration was performed through the cystic duct during intervention. In all cases an exploration of the bile duct with a flexible choledoscope after choledochotomy was performed too. The mean operative time was 128.8 +/-16.9 minutes. Choledocholithiasis was confirmed in all patients. Furthermore, a patient had a papillary tumor of the distal common bile duct associated. One patient who had advanced cholecystitis had a biliary fistula. It was resolved conservatively by placing an endoscopic plastic biliary prosthesis. If we exclude the patient with the biliary fistula, the hospital stay postoperative period was 2 days. Conclusions Robotic approach in the treatment of choledocholithiasis is an effective and safe technique. In addition, postoperative morbidity and hospital stay decreases.

Background In recent years, several studies have shown that the age of the donor may be related to an increase in the occurrence of biliary complications (BCs), which remain the main cause of morbidity after liver transplantation. This study analyzed the type and management of these BCs, the impact of BCs on graft and patient survival rates, and the influence of some characteristics of donors and recipients on BC appearance in patients transplanted with donors 75 years of age or older. Patients and Methods From 2003 to 2016, 100 liver transplantations with donors 75 years of age or older (15.6%) were performed in our hospital. The data were compared with a control group of 400 patients with younger donors (case-control 1:4 per chronology). Results The BC rate in the group of patients transplanted with organs from elderly donors was 18%, compared to 21.5% in the control group. Specifically, in the immediate post-transplantation period, 14% of the elderly donor group and 13.8% of the control group presented some BCs, with no statistically significant differences in the incidence, type, and treatment of BCs between the two groups. The occurrence of BCs was not a factor associated with graft and patient survival rates. In the global population, donor death by cerebral vascular accident and male donors have influenced the occurrence of BCs. Conclusions The advanced age of the donor has not influenced BC rates after transplantation.

To study a cohort of patients with intra-abdominal postsurgical infection treated with tigecycline to analyze its effectiveness and mortality related factors.Prospective study of patients with intra-abdominal postsurgical infection with microbiological isolation and treated with tigecycline.Out of 103 patients only 61 full fit inclusion criteria. Mean age was 67 year-old and 72% were male. Charlson score was ≥ 3 in 65.5%, being diabetes and colon cancer the most prevalent diseases. Cancer surgery was the most frequent procedure (n=44, 72%) and previous antibiotic administration was present in 43 cases (69%). Pitt score was ≥ 3 in 69% and most prevalent bacteria were Escherichia coli (38 %), Enterococcus spp. (34%; mainly Enterococcus faecium) and Klebsiella pneumoniae together with Enterobacter cloacae (28%). Tigecycline was prescribed alone (17; 28%) or in combination with other antibiotics (44; 72%), mainly meropenem (25; 57%) or amikacin (19, 43%). 11 patients died (18%), all of which suffered extended cancer surgery and isolation of extended-spectrum betalactamase producing Enterobacteriaceae. Factors statistically associated to death in univariate analysis were Charlson score3, pH7.3 and leucocyte count20.000 cells/mm3.As being a cohort of patients treated with tigecycline, E. faecium isolation was very frequent. Non-fatal evolution was achieved in 82% cases, being tigecycline a potentially good option in the empiric treatment of very severe infections.

Introduction The aim of this study was to analyze the correlation between 18-FDG positron emission tomography (PET)/computed tomography (CT), histological necrosis, and prognosis after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) patients undergoing orthotopic liver transplantation (OLT). Patients From January 2007 through December 2013, 81 patients with HCC and liver cirrhosis were included in our liver transplantation program. For this study we selected patients who underwent 18-FDG PET/CT pre-TACE and post-TACE. All patients underwent liver transplantation within 8 weeks after PET/CT. Results Twenty patients with a median age of 58 years (range, 46–69 years) underwent an 18-FDG PET/CT before and after TACE. The median Standardized Uptake Value (SUV) before TACE was 3.8 (range, 2.6–8.7), with a median post-TACE SUV of 0% (range, 0–4). Among patients whose post-TACE SUV decreased to 70% necrosis was observed upon study of a hepatectomy sample, with a survival rate of 100% and 80% at 1 and 3 years, respectively. Conclusion In conclusion, performance of an 18-FDG PET/CT before and after TACE with comparison of SUV values among patients with HCC awaiting OLT provided valuable information regarding the effectiveness of TACE.

The mortality associated with acute pancreatitis (AP) is largely attributable to abnormalities that occur in distant organs and supportive care remains the only treatment for patients with these complications. Recently, prophylactic pharmacological blockade of poly(ADP-ribose) polymerase (PARP) enzymes has been shown to attenuate the severity of the disease. However, the clinical relevance of PARP inhibitors administered after the onset of AP remains uncertain. The aim of the present study was to investigate the therapeutic effects of PARP inhibitors in established AP.Mice were fed a choline/methionine-deficient/ethionine-supplemented (CMDE) diet to induce AP. PARP inhibitors were given at 36 h after the onset of CMDE diet. Severity of pancreatitis was assessed by measurements of serum amylase, lipase, IL-1beta and IL-6, and histological grading. Serum hepatic enzymes, myeloperoxidase (MPO) activity and morphological changes were measured as indicators of hepatic insult. Lung injury was evaluated by MPO activity and morphological changes. Survival rates of mice were monitored for 7 days.CMDE diet administration resulted in a significant increase in serum amylase, lipase, IL-1beta, IL-6, alanine aminotransferase and aspartate aminotranferase levels, indicating AP and associated liver injury. Analysis of the histopathological changes in pancreas, liver and lung revealed extensive tissue damage. Treatment of mice with PARP-inhibitors after the onset of AP was associated with a reduction in the severity of AP and, accordingly, with a reduced mortality rate.Our results support the therapeutic application of PARP inhibitors in the treatment of established AP.

Introduction For patients with fulminant hepatic failure who show a poor evolution despite medical treatment, liver transplantation is an option, with survival rates of greater than 50%. The ideal time to perform the transplant is controversial, as it must not be done too soon (when the liver disease is still reversible) or too late (when the patient is in an irreversible clinical situation). Patients and methods Retrospective review of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure included 26 who underwent transplantation. The most frequent cause was viral ( n = 10, 38%); with no etiology established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of AB0/DR compatibility, 13 cases were identical (40%), 17 compatible (51%), and the other three incompatible (9%). Results Thirty-three transplants were performed in 26 patients: four were retransplants due to chronic rejection, two for primary graft failure, and one for hyperacute rejection. The overall mortality rate was 46% (12 patients). The most frequent cause of death was infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years, and 59% at 5 years. The factors associated with a poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the last being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the last being the only prognostic factor identified in the multivariate analysis. Conclusion Good results of transplantation for the management of fulminant hepatic failure depends on optimal selection of transplant candidates, which means identifying them early, reducing the waiting time, and excluding factors associated with a poor prognosis.

Introduction Due to the technical experience acquired in the field of liver transplantation portal vein thrombosis is no longer considered a contraindication for transplantation. Nevertheless, the results obtained in patients with portal vein thrombosis are at times suboptimal, and there is no consensus on the appropriate surgical technique. Patients and methods Among the 455 liver transplants performed between May 1988 and December 2001, 32 (7%) presented with portal vein thrombosis. Twenty (62%) were type Ib, seven (22%) type II/III, and five (16%) type IV. Twenty-two were men (69%), with a mean age of 50 years (range: 30–70 years); the thrombosis in all cases developed in a cirrhotic liver. The surgical method in all cases consisted of an eversion thromboendovenectomy under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. Results Among the 32 cases undergoing thrombectomy, 31 (96%) were successful with a failure in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis rethrombosed. The 5-year survival rate of the patients in the series was 69%. Only two patients died from causes related to the thrombosis, both showing type IV thrombosis. Conclusion The ideal treatment for portal thrombosis during liver transplantation depends on its extension and on the experience of the surgeon. In our experience, eversion thromboendovenectomy resolves most thromboses (types I, II, and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal hemitransposition.

Medical treatment for fulminat hepatic failure seeks spontaneous recovery of the liver function, but the results are very discouraging (50-80% mortality). Liver transplantation is an option in patients with a poor evolution despite medical treatment, with survival rates of50%. The ideal moment for performing the transplant is controversial, as it should not be done too soon, when the liver disease is still reversible, or tool late, when the patient is in an irreversible clinical situation.A retrospective review was made of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure, of whom 26 underwent transplantation. The most frequent cause was viral, with 10 cases (38%); no aetiology at all could be established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of ABO/DR compatibility, 13 cases were identical (40%), 17 compatible (51%) and the other 3 incompatible (9%).Thirty-three transplants were performed in 26 patients: 4 were retransplants due to chronic rejection, 2 for primary graft failure and 1 for hyperacute rejection. The overall mortality rate was 46% (12 patients), the most frequent cause of death being infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years and 59% at 5 years. The factors of poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the latter being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the latter being the only prognostic factor identified in the multivariate analysis.The achievement of good results with the use of transplantation in the management of fulminant hepatic failure depends on an optimum selection of transplant candidates, which means identifying them early, i.e. early indication for transplant, reduction in mean waiting time and exclusion of factors of poor prognosis.

Enteropathy associated T cell lymphoma is the most serious complication of celiac sprue. The incidence of malignancy, in general, is approximately twofold greater in celiac disease than in the general population, but the risk of specific gastrointestinal malignancies is markedly increased. Lymphoma of the small intestine, comprises approximately 50% of the malignancies, and the most are of T-cell origin. We report a case of celiac disease associated T-cell Lymphoma of the jejunum in a woman. At the age of 33 the diagnosis of Celiac sprue was made, after institution of a gluten free diet the patient improved, but, fifteen year later, the patient begin with fever and abdominal pain. Laparotomy showed a perforation of the intestine by a tumour.

The therapeutic use of new drugs for inhibiting gastric secretion together with Helicobacter pylori antimicrobe therapy has given rise to controversy over the current incidence of perforated peptic ulcer (gastroduodenal peptic ulcer, GDPU). The aim of this study is to analyze the incidence of ulcer perforation over the last 12 years in our health area and the influence of new medical treatments.Our series includes 246 patients operated on for perforated peptic ulcer during a 12-year period (January 1987 to December 1998) in our health area. The mean patient age was 55.2 +/- 18.1 (16-93) years, and there was a predominance of males (199/246; 80.9%). The ulcer was located fundamentally in the pylorus (48.3%) and duodenal bulb (39.1%), and the most frequent surgical technique was bilateral truncal vagotomy associated with pyloroplasty (85.3%).During the 1987-1992 period, 152 patients underwent surgery, whereas 94 patients were operated on between 1993 and 1998, which reveals a statistically significant difference (p0.001). Furthermore, if we divide the study into four 3-year periods (1987-1989, 1990-1992, 1993-1995 and 1996-1998), we see that there were 74 and 78 GDPUs in the first two periods, with no statistical differences between each other, and 48 and 46 cases in the last two periods, also with no statistical differences between each other, but statistically significant when compared to the first two periods.The incidence of perforated GDPU has dropped by half over the last 6 years due fundamentally to the use of proton pump inhibitors.

Enteropathy associated T cell lymphoma is the most serious complication of celiac sprue. The incidence of malignancy, in general, is approximately twofold greater in celiac disease than in the general population, but the risk of specific gastrointestinal malignancies is markedly increased. Lymphoma of the small intestine, comprises approximately 50% of the malignancies, and the most are of T-cell origin. We report a case of celiac disease associated T-cell Lymphoma of the jejunum in a woman. At the age of 33 the diagnosis of Celiac sprue was made, after institucion of a gluten free diet the patient improved, but, fifteen year later, the patient begin with fever and abdominal pain. Laparotomy showed a perforation of the intestine by a tumour.

Carcinoma of the gallbladder is the most frequent biliary tract lesion but the 5-year survival is less than 5%. The aim of this study was to analyze the influence of several clinico-pathological variables on survival in a series of 226 carcinomas of the gallbladder.The results were retrospectively analyzed and prognostic factors were identified by univariate statistical analysis and Cox regression model. All patients underwent surgery and in 67 of these (29.6%), surgery was potentially curative. In 63 patients (27.9%) diagnosis was made when the resected gallbladder was studied for benign disease. Tumor node metastasis (TNM) stage was 0 in 7 patients (3.1%), stage I in 19 patients (8.4%), stage II in 21 patients (9.3%), stage III in 61 patients (27%) and stage IV in 118 patients (52%).Overall 5-year survival was 17.3%. In the univariate analysis, significant variables were the presence of jaundice, weight loss, palpation of abdominal tumors at diagnosis, surgical technique, TNM stage and the three variables of this system (T: size, N: adenopathies; M: distant metastasis). In the multivariate analysis, the three variables of the TNM system and surgical technique were significantly associated with survival.The most important prognostic factor was TNM stage. Currently, radical cholecystectomy in stages II and III has become another important prognostic factor.

We analyzed the influence of packed red blood cell (PRBC) transfusions on the prognosis of 163 patients with gastric adenocarcinoma undergoing subtotal gastrectomy with a curative intention. Over a period of 15 years, our department admitted 505 patients with gastric adenocarcinoma, with curative subtotal gastrectomy being performed in 167 cases. Mean age was 62.2 years (range: 30-87); there was a predominance of males (104 cases; 63.8%). Excluding the four patients who died in the immediate postoperative period (first 30 days), the remaining 163 were reviewed twice yearly in our department until either they died or the study ended. Follow-up averaged 49.5 months, with a median of 36 months. Sixty-nine (42.3%) of the 163 patients received transfusions of PRBC. On correlating the variables with the transfusion, we found a statistical significance only between the rate of transfusion and patient age over 63 years (P0.01), with an evolution time of less than three months (P0.05) and in tumors of4 cm (P0.05). The five-year survival rate of the nontransfusion patients was 56.9% and of the transfusion patients 40%, with statistically significant differences (P = 0.0132). On studying patients according to tumor stage, we found that blood transfusion had a statistically significant influence on prognosis only in patients with tumor stage III (P = 0.0051). In the univariate analysis of the remaining variables collected, the existence of abdominal tumor (P = 0.0307), tumor size (P = 0.00001), degree of involvement of the gastric wall (P = 0.00001), lymph node involvement (P = 0.00001) and tumor stage (P = 0.00001) revealed a statistically significant influence on prognosis. If we apply Cox's regression model to the variables that in the univariate analysis had a statistically significant influence on prognosis, we found that only tumor size and stage were independent predictors of survival. In our experience, PRBC transfusion does not influence the long-term survival of patients with resected gastric adenocarcinoma.

Introduction In the majority of patients transplanted for unresectable liver metastases, long-term results are disappointing because of early tumor recurrence. Due to its biologically less aggressive nature, neuroendocrine metastases (NM) may represent a good indication for liver transplantation (LT). Patients and methods Between January 1996 and May 2000, five patients with NM were transplanted. The primary tumors were located in the pancreas (n = 4) and the small bowel (n = 1). In three cases there were symptoms related to hormone production: two carcinoids, and one gastrinoma. The management of primary tumors was sequential in three patients with the tumor being resected before LT (one Whipple procedure and two left pancreatectomies). In two patients the resections of the primary tumors and the LT were simultaneous namely one bowel resection and one left pancreatectomy All patients were treated with chemotherapy. Results Two patients developed recurrent disease succumbing at 15 months (nonfunctioning NE pancreatic head tumor) and 17 months (carcinoid of the pancreatic tail) post-LT. Another patient died at 3 months post-LT due to technical complications. The other two patients are alive and free of recurrence. Conclusion Despite the promising results obtained with LT for NM, our experience indi- cates that patients must be carefully selected. Perhaps the use of more aggressive chemotherapeutic protocols combined with an individualized approach will improve the results.

We reviewed 50 patients with benign tumors of small intestine treated over a period of 15 years. Mean age was 58 years, and 54% of the patients were female. The most frequent location of the tumors was the jejunum (54%). The commonest histological variety was leiomyoma (56%), followed by fibroma (14%). Average size of tumor was 4.8 cm. With regard to clinical data, 20% of the patients were asymptomatic; in the remaining 80% of the patients, abdominal pain, gastrointestinal hemorrhage and abdominal distension were the most frequent symptoms. The mean symptom-diagnosis interval was 2 months. Barium studies, duodenal endoscopy and selective angiography were the most useful diagnostic tools. However, only in 30% of cases the correct diagnosis was reached preoperatively. All patients underwent surgical treatment. The more frequent surgical technique was segmental resection of small bowel (84%). Operative mortality was 4% and morbidity was 10%. Actuarial 5-year survival for all patients was 96%.

A patient with Budd-Chiari's syndrome of idiopathic etiology, received an emergency liver transplant because of terminal liver insufficiency, including encephalopathy, functional renal failure and progressive deterioration of coagulation. The diagnosis was confirmed by biopsy. The transplanted liver was from a patient with the same blood group and the preserving solution was Euro Collins. No veno-venous by-pass was necessary during operation. Anticoagulation was started from the immediate post-operative stage, as well as triple immunosuppressive therapy with azathioprine, cyclosporine and corticoids. The patient is asymptomatic twenty months after transplantation.

The diagnosis of Mallory-Weiss syndrome was made in 142 patients with upper gastrointestinal haemorrhage by early endoscopy. These patients represent 5.16% of all patients with haemorrhage treated in our unit over a period of ten years. Emergency surgery was needed in 13 due to persistent haemorrhage. In the remaining 129, conservative management sufficed to stop the bleeding. All patients receiving medical therapy survived while one of the surgically treated patients died of pulmonary thromboembolism in the early postoperative period.

We report the case of a 65 year old male patient in whom an early diagnosis of embolism of the superior mesenteric artery was made and successfully treated by an intraarterial infusion of urokinase.

The results of 313 gastric adenocarcinomas, treated by the same surgical team during 10 years have been evaluated retrospectively. The pathological characteristics, operability (88.8%) and resectability (69.8%) rates, surgical technique and morbility and mortality rates are analyzed. The causes of late mortality, total five-year survival, depending on the stage of the tumors, and survival in relation to treatment are reported.

A series of 29 patients with early gastric cancer operated on in our department over a period of 10 years is presented; this figure represents 9.10% of total number of gastric cancers. The most common symptom was epigastric pain, present in 51.72% of cases. Diagnosis was established by endoscopy and biopsy in 96.5% patients. Treatment was subtotal gastrectomy in 28 cases; most lesions (24) were located in the distal third of the stomach. Lesion was intramucosal in 44.8% of cases; in 55.17% there was infiltration of the submucosal layer and only 13.8% of tumors presented lymph node metastases. Macroscopically the most common pattern of the lesions was the ulcerated type. All patients have been followed up at least 4 years; of them died: one of carcinoma of the bladder and three of chronic respiratory failure. There were no recurrences of the gastric lesion and the 5 years actuarial survival was 84.32%.

The enteric-coated mycophenolate sodium (EC-MPS) is a new formulation of mycophenolic acid with a gastro-resistant enteric coating, which releases the drug in the intestine, reducing the incidence of the gastrointestinal (GI) adverse effects. The present work provided a summary of 20 patients with liver transplantation and more than a 1 year of treatment with mycophenolate mofetil (MMF) who, after presentation of GI complications, were converted to EC-MPS. The patients were followed over a 3-month period after beginning EC-MPS treatment. The mean age of the cohort was 53 +/- 10 years and included 75% men. The reasons for transplantation were ethanol cirrhosis (70%), hepatitis C cirrhosis (30%), hepatocarcinoma (5%), and Wilson's disease (5%). At baseline, all patients were being treated with cyclosporine (CsA). CsA doses and levels were reduced during follow-up: baseline dose 179 mg/day versus 143 mg/day at 3 months; levels: 90.4 ng/mL versus 85.8 ng/mL, respectively (P = .017). The administered dose of EC-MPS was 720 mg/day in all cases. The GI complications at baseline were: diarrhea 60% (92% moderate-severe), abdominal discomfort 60% (58% moderate), abdominal pain 45% (44% moderate-severe), gas 40% (38% moderate-severe), nausea 20% (25% moderate), and dyspepsia 20% (mild). After 3 months of EC-MPS treatment, only two patients (10%) displayed moderate diarrhea. The renal evolution was favorable, serum creatinine was reduced, and 24-hour creatinine clearance significantly increased (creatinine: 1.78 +/- 1.6 mg/dL at baseline versus 1.30 +/- 0.3 mg/dL at 3 months, P = .002; creatinine clearance: 72.8 +/- 18 mL/min versus 79.6 +/- 13 mL/min, P = .001). Conversion of MMF to EC-MPS in liver transplant recipients solved the GI tolerability problems and improved renal function during the first 3 months, probably due to the concomitant reduction of anticalcineurinic dose.