Publications by authors named "Martin Palavecino"

27 Publications

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Teaching strategies and outcomes in 3 different times of the COVID-19 pandemic through a dynamic assessment of medical skills and wellness of surgical trainees.

Surgery 2021 Aug 24. Epub 2021 Aug 24.

Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina.

Background: The coronavirus disease 2019 pandemic had a substantial impact on surgical training programs. This study describes the teaching strategies and outcomes in 3 different times of the coronavirus disease 2019 pandemic through a dynamic assessment of medical skills and well-being of trainees.

Methods: Three surveys were administered during 2020 to general surgery residents and fellows in a university hospital in Argentina. Perceptions on the impact of coronavirus disease 2019 were described. The stress rate and risk factors were analyzed.

Results: The study included 124 answers. In total, 59% were men, 82% of trainees reported concerns about the loss of surgical skills in early phase 1. Time spent with academic activities increased in 94.5% of the cases. Owing to the prompt implementation of changes, by the end of 2020, 73% participated in a greater number of procedures (P = .003); personal protective equipment use related problems dropped from 40% to 14% (P = .031), and the lack of adequate spaces where trainees could express reduced from 28% to zero. Half of the trainees felt stressed, and 18% required psychological assistance; reporting problems with personal protective equipment use was identified as a risk factor (P = .012).

Conclusion: Assessing trainees' perceptions at 3 different times of the coronavirus disease 2019 pandemic enabled the implementation of dynamic changes. The negative impact on surgical training was partially offset by the optimal use of virtual learning. Half of them felt stressed, identifying problems in the use of personal protective equipment as a predisposing factor.
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http://dx.doi.org/10.1016/j.surg.2021.08.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382581PMC
August 2021

Prevalence of Persistent Common Bile Duct Stones in Acute Biliary Pancreatitis Remains Stable Within the First Week of Symptoms.

J Gastrointest Surg 2021 Jun 22. Epub 2021 Jun 22.

HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina.

Background: Acute biliary pancreatitis (ABP) is often associated with persistent common bile duct (CBD) stones. The best strategy in terms of timing of surgery is still controversial. The aim of the current study is to describe the prevalence of persistent common bile duct (CBD) stones in ABP during the first week of symptoms at a high-volume referral center.

Study Design: Single-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of ABP who underwent laparoscopic cholecystectomy (LC) between January 2009 and December 2019 were extracted.

Results: Two hundred thirty-one patients were included. Cholecystectomy was performed laparoscopically in 230 (99.57%) patients. Intraoperative cholangiogram was performed in all patients. Two hundred nine (90%) patients had surgery within the first 7 days. Global prevalence of persistent CBD stones during IOC was 19.91% (95% CI 14.96-25.65). No significant association between timing to surgery and presence of CBD stones was found for the first week since the initial attack (p=0.28). Prevalence of CBD stones was significantly higher after day 7 (p=0.007 and 0.005). Positive findings in preoperative MRCP are significantly related to intraoperative CBD stones (p=0.0001). Mild postoperative complications (CD I/II) were present in 21 patients (9.09%). No difference was found in morbidity between CBD stones group and non-CBD stones group (p=0.48). We observed no severe complications nor mortality.

Conclusions: In patients with mild acute biliary pancreatitis, the prevalence of persistent CBD stones does not change within the first 7 days since the onset of symptoms. This fact may have major clinical relevance when deciding the optimal therapeutic strategy in this population.
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http://dx.doi.org/10.1007/s11605-021-05068-0DOI Listing
June 2021

Role of laparoscopy in the treatment of internal biliary fistulas in a high-volume center and a review of the literature.

Surg Endosc 2021 Mar 31. Epub 2021 Mar 31.

Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABH, Buenos Aires, Argentina.

Background: Biliary fistulas may result as a complication of gallstone disease. According to their tract, abdominal internal biliary fistulas may be classified into cholecystobiliary and bilioenteric fistulas. Surgical treatment is challenging and requires highly trained surgeons with high preoperative suspicion. Conventional surgery is still of choice by most of the authors. However, laparoscopy is emerging as a minimally invasive alternative. We investigated the surgical approach, conversion rate, and outcomes according to the type of biliary fistula.

Methods: We retrospectively reviewed 11,130 laparoscopic cholecystectomies, 31 open cholecystectomies, and 31 surgeries for gallstone ileus at our institution from May 2007 to May 2020. We diagnosed internal biliary fistula in 73 patients and divided them into two groups according to their fistulous tract: cholecystobiliary fistula and bilioenteric fistula. We described demographic characteristics, preoperative imaging modalities, surgical approach, conversion rates, surgical procedures, and outcomes. We additionally revised the literature and compared our results with 13 studies from the past 10 years.

Results: There were 22 and 51 patients in the cholecystobiliary and bilioenteric groups, respectively. Our preoperative suspicion of a fistula was 80%. We started 88% of procedures by laparoscopic approach. The effectiveness of laparoscopy in the resolution of internal biliary fistula was 40% for cholecystobiliary fistula and 55% for bilioenteric fistulas. The most frequent cause for conversion to laparotomy was the difficulty to identify anatomical features, in addition to the need to perform a Roux en-Y hepaticojejunostomy. Choledocholithiasis was not associated with an increase in conversion rates.

Conclusions: Laparoscopic resolution of a biliary fistula is still a matter of controversy. Despite the high conversion rates, we believe that a great number of patients benefit from this minimally invasive technique. A high preoperative suspicion and trained surgeons are vital in the treatment of internal biliary fistulas.
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http://dx.doi.org/10.1007/s00464-021-08459-1DOI Listing
March 2021

[Endovascular treatment of incidental and emergency splenic aneurysm].

Medicina (B Aires) 2021 ;81(1):96-98

Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.

True splenic aneurysms are saccular dilations of all the layers of the splenic artery, more common in women, pregnancy and portal hypertension. They are usually asymptomatic and diagnosed incidentally during the study of other abdominal diseases. Up to 10% may present with rupture, which implies a high morbidity and mortality. Treatment of splenic aneurysms is still a subject of controversy and there is a great variety of therapeutic modalities. We present two cases of patients with splenic aneurysms: one who presented with rupture and the other one incidentally diagnosed. Both were treated with endovascular embolization achieving optimal results. Although the utility of this therapy has not been assessed for giant or ruptured aneurysms, it allowed us to solve these scenarios in a secure and effective way, with minimum morbidity and mortality.
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February 2021

Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass.

Surg Endosc 2021 Jan 4. Epub 2021 Jan 4.

HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina.

Background: Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB.

Methods: This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE.

Results: Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1 min, adding, on average, 35 min to LC (113.1 min vs 77.9 min, p = 0.004).

Conclusions: LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.
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http://dx.doi.org/10.1007/s00464-020-08201-3DOI Listing
January 2021

Long-term follow-up of Branch-Duct Intraductal Papillary Mucinous Neoplasms with negative Sendai Criteria: the therapeutic challenge of patients who convert to positive Sendai Criteria.

HPB (Oxford) 2021 Feb 21;23(2):290-300. Epub 2020 Jul 21.

HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina. Electronic address:

Background: The management of Branch-Duct Intraductal Papillary Mucinous Neoplasm (BD-IPMN) is still controversial. Our objective was to assess the long-term follow-up (FU) of patients with "low-risk" BD-IPMN according to the Sendai-International Consensus Guidelines (ICG-I).

Methods: We retrospectively analyzed a cohort of patients with BD-IPMN and Negative Sendai-Criteria (NSC) from January 2004 to October 2019. A univariate analysis was performed to determine factors associated with conversion to Positive Sendai-Criteria (PSC) and malignancy. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of the IGC-I were assessed for the development of malignancy.

Results: A total of 219 patients were selected and underwent a median 58-month FU. Thirty-seven (17%) patients developed PSC during FU including 12 (5.5%) with malignant lesions. Conversely, 182 patients (83%) did not develop malignancy. The NPV and PPV of ICG-I for malignancy were 100% and 32.4%, respectively. Among patients who developed PSC, those with cancer were >65years (OR = 3.57;p = 0.015) and had significantly higher serum CA-19-9 levels (OR = 5.27;p = 0.007).

Conclusion: The ICG-I is a safe strategy for FU of patients with BD-IPMN. The absence of PSC exclude malignancy. Among patients who develops PSC, the risk of cancer remains low and surgery should be decided according to their surgical risk and life expectancy.
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http://dx.doi.org/10.1016/j.hpb.2020.06.011DOI Listing
February 2021

Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting.

J Gastrointest Surg 2019 09 12;23(9):1848-1855. Epub 2018 Nov 12.

Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina.

Background: Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency.

Methods: This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups.

Results: Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109).

Conclusion: Emergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.
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http://dx.doi.org/10.1007/s11605-018-4029-xDOI Listing
September 2019

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients.

World J Surg 2018 10;42(10):3134-3142

Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina.

Introduction: In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE.

Methods: A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression.

Results: After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p < 0.004) and jaundice (p = 0.019) before surgery and longer operative times (OT, p < 0.001); they were less likely to have incidental intraoperative diagnosis (p = 0.031) or to have biliary colic as the reason for surgery (p = 0.031). In the final multivariate model, leukocytosis (p = 0.013) and OT (p < 0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p < 0.001).

Conclusion: The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.
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http://dx.doi.org/10.1007/s00268-018-4611-0DOI Listing
October 2018

Protocol for extended antibiotic therapy after laparoscopic cholecystectomy for acute calculous cholecystitis (Cholecystectomy Antibiotic Randomised Trial, CHART).

BMJ Open 2015 Nov 18;5(11):e009502. Epub 2015 Nov 18.

Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.

Introduction: Acute calculous cholecystitis represents one of the most common complications of cholelithiasis. While laparoscopic cholecystectomy is the standard treatment in mild and moderate forms, the need for antibiotic therapy after surgery remains undefined. The aim of the randomised controlled Cholecystectomy Antibiotic Randomised Trial (CHART) is therefore to assess if there are benefits in the use of postoperative antibiotics in patients with mild or moderate acute cholecystitis in whom a laparoscopic cholecystectomy is performed.

Methods And Analysis: A single-centre, double-blind, randomised trial. After screening for eligibility and informed consent, 300 patients admitted for acute calculus cholecystitis will be randomised into two groups of treatment, either receiving amoxicillin/clavulanic acid or placebo for 5 consecutive days. Postoperative evaluation will take place during the first 30 days. Postoperative infectious complications are the primary end point. Secondary end points are length of hospital stay, readmissions, need of reintervention (percutaneous or surgical reinterventions) and overall mortality. The results of this trial will provide strong evidence to either support or abandon the use of antibiotics after surgery, impacting directly in the incidence of adverse events associated with the use of antibiotics, the emergence of bacterial resistance and treatment costs.

Ethics And Dissemination: This study and informed consent sheets have been approved by the Research Projects Evaluating Committee (CEPI) of Hospital Italiano de Buenos Aires (protocol N° 2111).

Results: The results of the trial will be reported in a peer-reviewed publication.

Trial Registration Number: NCT02057679.
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http://dx.doi.org/10.1136/bmjopen-2015-009502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654351PMC
November 2015

Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center.

J Am Coll Surg 2013 May 18;216(5):894-901. Epub 2013 Mar 18.

Hepato-Pancreato-Biliary and Liver Transplant Sections, General Surgery Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.

Background: Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). The best strategy in terms of timing of repair is still controversial. The purpose of the current study is to review the experience in the intraoperative repair of bile duct injuries sustained during LC at a high-volume referral center.

Study Design: Single-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of BDI sustained during LC between October 1991 and November 2010 were extracted.

Results: Among 10,123 LC performed during the study period, 19 patients had a BDI sustained during the procedure. Intraoperative cholangiography was routinely used. Bile duct injury was diagnosed intraoperatively in 17 patients (89.4%). Mean age was 56.4 years (range 18 to 81 years) and 15 patients were women (88%). According to the Strasberg classification of BDI, there were 3 type C lesions, 12 type D lesions, and 2 type E2 lesions. There were no associated vascular injuries. Twelve cases (71%) were converted to open surgery. The repairs included 10 primary biliary closures, 4 Roux-en-Y hepaticojejunostomies, 2 end to end anastomosis, and 1 laparoscopic transpapillary drainage. Postoperative complications occurred in 5 patients (29.4%). During the follow-up period, early biliary strictures developed in 2 patients (11.7%) and were treated by percutaneous dilation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.

Conclusions: The current series represents one of the largest single-center experiences in terms of intraoperative repair of BDI sustained during LC. The results suggest that a high level of intraoperative diagnosis is possible, where intraoperative cholangiography is a useful tool. The intraoperative repair of BDI sustained during LC by experienced hepatobiliary surgeons either by open or laparoscopic approach appears of paramount importance to assure optimal results.
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http://dx.doi.org/10.1016/j.jamcollsurg.2013.01.051DOI Listing
May 2013

Modified Makuuchi incision for foregut procedures.

Arch Surg 2010 Mar;145(3):281-4

Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA.

The Makuuchi or J incision completely exposes the liver and right-sided retroperitoneal organs. The modified Makuuchi incision also achieves a superb en face view of critical structures, including the hepatocaval junction and the esophageal hiatus, but does not divide the intercostal muscles, thus reducing muscle atrophy and postoperative pain. This incision also offers significant advantages over other incisions commonly used in foregut surgery. We describe herein the use of the modified Makuuchi incision for foregut procedures, with particular emphasis on strategic retractor placement.
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http://dx.doi.org/10.1001/archsurg.2010.7DOI Listing
March 2010

Endoscopic management of biliary complications after adult living-donor versus deceased-donor liver transplantation.

Transplantation 2009 Dec;88(11):1280-5

Gastrointestinal Endoscopy Unit, Gastroenterology Service, Italian Hospital, Buenos Aires, Argentina.

Background: Although data about the incidence and management of biliary complications after deceased-donor liver transplantation (DDLT) are well defined, those pertaining to adult living-donor liver transplantation (LDLT) are conflicting.

Methods: We retrospectively compared endoscopic retrograde cholangio-pancreatography (ERCP) findings in 30 LDLT vs. 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction. LDLT and DDLT recipients were followed up for median durations of 30.5 and 36.0 months after the last ERCP, respectively.

Results: Postoperative biliary complications were more frequently identified at ERCP after LDLT versus DDLT (10/30 [33.3%] vs. 34/357 [9.5%]; P<0.001). Complications mainly consisted of anastomotic biliary strictures (10/30 [33.3%] vs. 27/357 [7.6%]; LDLT vs. DDLT recipients, respectively; P<0.001) and biliary leaks (4/30 [13.3%] vs. 6/357 [1.7%]; LDLT vs. DDLT recipients, respectively; P=0.005; some patients had both complications). Stricture dilation was successful in 4/10 (40%) LDLT vs. 27/27 (100%) DDLT recipients (P<0.001), and bile ducts remained patent up to the end of follow-up without further intervention in 2/10 (20.0%) vs. 21/27 (77.8%) patients, respectively (P=0.002). Endoscopic treatment of bile leaks was successful in 3/4 (75.0%) vs. 5/6 (83.3%) LDLT versus DDLT recipients, respectively (NS).

Conclusions: Biliary complications were more frequent after LDLT compared with DDLT. Endoscopic treatment of anastomotic biliary strictures was successful in a minority of patients after LDLT, in contrast with DDLT. Most biliary leaks were successfully treated at endoscopy after LDLT or DDLT.
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http://dx.doi.org/10.1097/TP.0b013e3181bb48c2DOI Listing
December 2009

Association of computed tomography morphologic criteria with pathologic response and survival in patients treated with bevacizumab for colorectal liver metastases.

JAMA 2009 Dec;302(21):2338-44

Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 444, Houston, TX 77030, USA.

Context: The standard criteria used to evaluate tumor response, the Response Evaluation Criteria in Solid Tumors (RECIST), were developed to assess tumor shrinkage after cytotoxic chemotherapy and may be limited in assessing response to biologic agents, which have a cytostatic mechanism of action.

Objective: To validate novel tumor response criteria based on morphologic changes observed on computed tomography (CT) in patients with colorectal liver metastases treated with bevacizumab-containing chemotherapy regimens.

Design, Setting, And Patients: A total of 234 colorectal liver metastases were analyzed from 50 patients who underwent hepatic resection after preoperative chemotherapy that included bevacizumab at a comprehensive US cancer center from 2004 to 2007; date of last follow-up was March 2008. All patients underwent routine contrast-enhanced CT at the start and end of preoperative therapy. Three blinded, independent radiologists evaluated images for morphologic response, based on metastases changing from heterogeneous masses with ill-defined margins into homogeneous hypoattenuating lesions with sharp borders. These criteria were validated with a separate cohort of 82 patients with unresectable colorectal liver metastases treated with bevacizumab-containing chemotherapy.

Main Outcome Measures: Response determined using morphologic criteria and RECIST was correlated with pathologic response in resected liver specimens and with patient survival.

Results: Interobserver agreement for scoring morphologic changes was good among 3 radiologists (kappa, 0.68-0.78; 95% confidence interval [CI], 0.51-0.93). In resected tumor specimens, the median (interquartile range [IQR]) percentages of residual tumor cells for optimal morphologic response was 20% (10%-30%); for incomplete response, 50% (30%-60%); and no response, 70% (60%-70%; P < .001). With RECIST, the median (IQR) percentages of residual tumor cells were for partial response 30% (10%-60%); for stable disease, 50% (20%-70%); and for progressive disease, 70% (65%-70%; P = .04). Among patients who underwent hepatic resection, median overall survival was not yet reached with optimal morphologic response and 25 months (95% CI, 20.2-29.8 months) with incomplete or no morphologic response (P = .03). In the validation cohort, patients with optimal morphologic response had median overall survival of 31 months (95% CI, 26.8-35.2 months) compared with 19 months (95% CI, 14.6-23.4 months) with incomplete or no morphologic response (P = .009). RECIST did not correlate with survival in either the surgical or validation cohort.

Conclusion: Among patients with colorectal liver metastases treated with bevacizumab-containing chemotherapy, CT-based morphologic criteria had a statistically significant association with pathologic response and overall survival.
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http://dx.doi.org/10.1001/jama.2009.1755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139149PMC
December 2009

Laparoscopic resection for liver tumors: initial experience in a single center.

Surg Laparosc Endosc Percutan Tech 2009 Oct;19(5):388-91

Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Hospital Italiano de Buenos Aires, Argentina.

Background: Laparoscopic liver resections are 1 of the most complex procedures in hepatobiliary surgery. During the last 20 years, laparoscopic liver surgery has had an important development in specialized centers.

Objective: To describe the initial experience in laparoscopic liver resection for benign and malignant tumors, to assess its indications and outcomes, and to describe technical aspects of these resections.

Methods: Review of the records of 28 patients who underwent laparoscopic liver resection between November 2000 and November 2007. Analysis of the data regarding preoperative management and postoperative outcomes.

Results: Twenty-six liver resections were performed laparoscopically (20 purely laparoscopic, 3 hand assisted, and 3 hybrid technique) and 2 were converted to open surgery. The laparoscopic approach was attempted in 6% (28 out of 459) of the liver resections carried out in the analyzed period. Indications for resection were: benign tumors in 22 patients (78%) and malignant tumors in 6 patients (22%). Resections were minor in 27 patients (96%) and major in 1 patient (4%). Pringle maneuver was performed in 14 patients (50%). Margins were negative in all the cases. Mean operative time was 170 minutes (range 70 to 350), and the mean length of stay was 3 days (range 1 to 6). Mortality rate was 0%. Only 2 patients (7%) had postoperative minor complications (self-limited bile leaks).

Conclusions: In selected patients with benign and malignant liver tumors, laparoscopic liver resections can be safely performed. This procedure must be carried out by the surgeons trained in both the hepatobiliary and laparoscopic surgery.
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http://dx.doi.org/10.1097/SLE.0b013e3181bb9333DOI Listing
October 2009

Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy: analysis of 1,557 consecutive liver resections.

Surgery 2010 Jan 6;147(1):40-8. Epub 2009 Sep 6.

Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.

Background: Blood transfusions are an independent risk factor for adverse outcomes after hepatectomy. In-hospital transfusions are still reported in one third of patients in major series. Data on factors affecting blood transfusions in large series of liver resection are limited. The aim of this study was to evaluate factors predictive of blood transfusion in hepatectomies performed at a tertiary referral center.

Methods: Records of 1,477 patients who underwent 1,557 liver resections between 1998 and 2007 were reviewed. Multivariate analysis of risk factors for red cell transfusion was performed.

Results: Median intra-operative blood loss was 250 cc, and 30-day peri-operative red cell transfusion rate was 27%. On multivariate analysis, factors that significantly predicted increased red cell transfusion rates were female sex, pre-operative hematocrit<30%, platelet count<100,000/mm3, simultaneous resection of other organs, major hepatic resection, use of the Pringle maneuver, and tumors>10 cm. Parenchymal transection technique was an independent risk factor for perioperative red cell transfusion; the usage of the 2-surgeon technique (combined saline-linked cautery and ultrasonic dissection) was associated with a lower transfusion rate than other techniques, including ultrasonic dissection alone, finger fracture, and stapling (P<.001).

Conclusion: Although most factors that affect the red cell transfusion rate for liver resection are patient- or tumor-related, the parenchymal transection technique is under the surgeon's control. The decrease in transfusion rate associated with the use of the 2-surgeon technique emphasizes the important role of the hepatobiliary surgeon in determining outcomes after liver resection.
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http://dx.doi.org/10.1016/j.surg.2009.06.027DOI Listing
January 2010

Portal vein embolization in hilar cholangiocarcinoma.

Surg Oncol Clin N Am 2009 Apr;18(2):257-67, viii

Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, TX 77030, USA.

In patients with hilar cholangiocarcinoma, extended hepatectomy and caudate lobe resection are often performed to achieve an R0 resection. In patients whose standardized future liver remnant is less than or equal to 20% of total liver volume, portal vein embolization (PVE) should be performed. In patients with biliary dilatation of the future liver remnant, a biliary drainage catheter should be placed before PVE. If the planned surgery is an extended right hepatectomy, segment 4 branch embolization improves the hypertrophy of segments 2 and 3. In high-volume centers, PVE can be safely performed; it increases the resectability rate and results in the same survival rates as those in patients who undergo resection without PVE.
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http://dx.doi.org/10.1016/j.soc.2008.12.007DOI Listing
April 2009

Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: Perioperative outcome and survival.

Surgery 2009 Apr;145(4):399-405

Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA.

Background: Preoperative portal vein embolization (PVE) is performed to minimize perioperative risks of major hepatic resection for hepatocellular carcinoma (HCC), but its effects on tumor growth are ill defined. Perioperative outcome and survival after major hepatic resection for HCC, with and without PVE, were investigated.

Methods: Patients that underwent major hepatic resection (> or =3 segments) for HCC between January 1998 and May 2007 were analyzed retrospectively. Preoperative PVE was performed when the remnant liver volume was predicted to be insufficient.

Results: A total of 54 patients underwent major hepatic resection for HCC: 21 patients with PVE before resection (PVE group) and 33 patients without PVE (non-PVE group). PVE and non-PVE groups had similar rates of fibrosis or cirrhosis, hepatitis C virus, hepatitis B virus, American Joint Committee on Cancer stage, preoperative transarterial chemoembolization, overall postoperative complications, and positive margin (P = nonsignificant for all rates). There were no perioperative deaths in the PVE group and 6 (18%) deaths in the non-PVE group (P = .038). Median follow-up was 21 months. Excluding perioperative deaths, overall survival rates at 1, 3, and 5 years were 94%, 82%, and 72%, respectively, in the PVE group and 93%, 63%, and 54%, respectively, in the non-PVE group (P = .35). Similarly, disease-free survival (DFS) rates were not significantly different between the groups, with 1-, 3-, and 5-year DFS rates of 84%, 56%, and 56%, respectively, in the PVE group and 66%, 49%, and 49%, respectively, in the non-PVE group (P = .38).

Conclusion: PVE before major hepatic resection for HCC is associated with improved perioperative outcome. Excluding perioperative mortality, overall survival and DFS rates were similar between patients with and without preoperative PVE.
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http://dx.doi.org/10.1016/j.surg.2008.10.009DOI Listing
April 2009

Hepatic resection for gastrointestinal stromal tumor liver metastases.

Hematol Oncol Clin North Am 2009 Feb;23(1):115-27, ix

Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, TX 77030, USA.

Liver resection is the preferred treatment for gastrointestinal stromal tumor liver metastases (GIST LMs) when complete resection can be achieved. Major and extended hepatic resections can be safely performed, and using modern techniques, an increasing proportion of patients with GIST LMs are candidates for potentially curative therapy. The combination of tyrosine kinase inhibitor therapy (eg, imatinib) with surgery seems to improve outcome, and although prospective data are lacking, a short neoadjuvant course (6 months) of imatinib therapy followed by resection may improve patient selection for surgery and outcome from treatment. Postoperative therapy with imatinib is generally advised, although the duration of such therapy is not yet clearly defined. These questions may formulate the basis for future prospective studies of imatinib with complete resection of GIST LMs.
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http://dx.doi.org/10.1016/j.hoc.2008.11.001DOI Listing
February 2009

Blood neutrophil-to-lymphocyte ratio predicts survival in patients with colorectal liver metastases treated with systemic chemotherapy.

Ann Surg Oncol 2009 Mar 8;16(3):614-22. Epub 2009 Jan 8.

Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030-4009, USA.

Background: Whether neutrophil-to-lymphocyte ratio (NLR) predicts survival of patients with colorectal liver metastases (CLM) treated with systemic chemotherapy remains unclear.

Methods: Clinicopathologic data were reviewed for patients with CLM treated with chemotherapy and resection (n=200) or chemotherapy only (n=90). Univariate and multivariate analyses for prognostic factors were performed. In the resection group, whether chemotherapy normalizes high NLR and the effect of NLR normalization on survival were evaluated.

Results: In the resection group, patients with preoperative NLR>5 had a worse 5-year survival rate than patients with NLR 5 was the only independent preoperative predictor of worse survival (P=0.016; hazard ratio [HR]=2.22; 95% confidence interval [95% CI], 1.16-4.25). In the nonresection group, patients with prechemotherapy NLR>5 had a worse 3-year survival rate than patients with NLR 5 was the only independent predictor of worse survival (P=0.001; HR = 2.91; 95% CI, 1.54-5.50). In the resection group, chemotherapy normalized high NLR in 17 of 25 patients, and these 17 patients had better survival than the 8 patients with high NLR both before chemotherapy and before surgery (P=0.021).

Conclusion: NLR independently predicts survival in patients with CLM treated with chemotherapy followed by resection or chemotherapy only. When chemotherapy normalizes high NLR, improved survival is expected.
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http://dx.doi.org/10.1245/s10434-008-0267-6DOI Listing
March 2009

Is embolization of segment 4 portal veins before extended right hepatectomy justified?

Surgery 2008 Nov 10;144(5):744-51. Epub 2008 Aug 10.

Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030-4009, USA.

Background: Preoperative portal vein embolization (PVE) is increasingly used as a preparation for major hepatectomy in patients with inadequate liver remnant volume or function. However, whether segment 4 (S4) portal veins should be embolized is controversial. The effect of S4 PVE on the volume gain of segments 2 and 3 (S2+3) was examined.

Methods: Among 73 patients with uninjured liver who underwent right portal vein embolization (RPVE, n = 15) or RPVE extended to S4 portal veins (RPVE+4, n = 58), volume changes in S2+3 and S4 after embolization were compared. Clinical outcomes and PVE complications were assessed.

Results: After a median of 27 days, the S2+3 volume increased significantly after both RPVE and RPVE+4, but the absolute increase was significantly higher for RPVE+4 (median, 106 mL vs 141 mL; P = .044), as was the hypertrophy rate (median, 26% vs 54%; P = .021). There was no significant difference between RPVE and RPVE+4 in the absolute S4 volume increase (52 mL for RPVE vs 55 mL for RPVE+4; P = .61) or the hypertrophy rate of S4 (30% for RPVE vs 26% for RPVE+4; P = .45). Complications of PVE occurred in 1 patient (7%) after RPVE and 6 (10%) after RPVE+4 (P > .99). No PVE complication precluded subsequent resection. Curative hepatectomy was performed in 13 patients (87%) after RPVE and 40 (69%) after RPVE+4 (P = .21).

Conclusions: RPVE+4 significantly improves S2+3 hypertrophy compared with RPVE alone. Extending RPVE to S4 does not increase PVE-associated complications.
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http://dx.doi.org/10.1016/j.surg.2008.05.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901738PMC
November 2008

Liver transplantation: the last measure in the treatment of bile duct injuries.

World J Surg 2008 Aug;32(8):1714-21

General Surgery and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Esmeralda 1319 4 piso 4 cuerpo, Buenos Aires, 1007 Argentina.

Background: Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI.

Methods: Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan-Meier test.

Results: Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24-152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively.

Conclusion: Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.
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http://dx.doi.org/10.1007/s00268-008-9650-5DOI Listing
August 2008

Liver metastasis resection: a simple technique that makes it easier.

J Gastrointest Surg 2007 Sep 11;11(9):1183-7. Epub 2007 Jul 11.

Department of Surgery and Liver Transplant, Hospital Italiano de Buenos Aires, Gascon 450, Buenos Aires, Argentina.

Liver resection is the only therapeutic option that achieves long-term survival for patients with hepatic metastases. We propose a technique that causes traction and countertraction on the resection area, thus easily exposing the structures to be ligated. Because the parenchyma protrudes like a cork from a bottle, we named this procedure the "corkscrew technique". The objective of this work was to describe an original surgical technique to resect liver metastases. We delimit the resection area at 2 cm from the tumor. We place separated stitches, in a radiate way. The needle diameter must allow passing far from the deepest margin of the tumor. The stitches must be tractioned all together to separate the tumor from the normal parenchyma. Between the years 1983 and 2006, we perform 1,270 liver resections. We used the corkscrew technique-like procedure in only 612 patients, whereas in 129 patients, we associated it to an anatomic resection. Mortality was 1%. Morbidity was 16% with a reoperation rate of 3%. The corkscrew technique is simple and safe, spares surgical time, avoids blood loss, ensures free tumor margins, and is easy to perform.
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http://dx.doi.org/10.1007/s11605-007-0227-7DOI Listing
September 2007

[Percutaneous management of benign pathology of the main biliary tract: experience in a section of pancreatic and hepatobiliary surgery].

Acta Gastroenterol Latinoam 2004 ;34(2):61-8

Sección de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Gascón 450, Buenos Aires, Argentina.

Background: Biliary percutaneous procedures (BPP) are useful on management of benign biliary pathology.

Objective: Communicate our experience with percutaneous biliary procedures made by surgeons in a specific Hepato-Pancreato-Biliary Section.

Population: Retrospective evaluation in 84 patients with benign biliary diseases, treated with BPP from January 1989 through January 2002.

Results: Diagnosis common bile duct stones 21 patients, strictures after common bile duct injury (SCBDI) 29 patients, and other benign bile duct strictures (OBBDS) 34 patients.

Indications: Acute cholangitis 45, pruritus 11, high surgical risk 10, contraindicated or failed endoscopic access 9, before liver transplantation 12 and other causes 3. Procedures (n=141): percutaneous drainage 96, stricture dilatation 27, percutaneous stone treatment 12, stents 5 and biopsy 1.

Effectiveness: Cholangitis 94.8%, stones 100%, anastomotic stricture dilatation (by SCBDI 45.5% and by OBBDS 90%).

Complications: Total 32 (38.1%).

Mortality: 3 (3.6%).

Conclusions: 1-Percutaneous drainage was an effective method for bile duct decompression in acute cholangitis, allowing an elective and definitive treatment of the pathology. 2-BPP solved strictures in patients with a high surgical risk and in those with complex diseases. 3-The results of biliary percutaneous dilatation were related to their etiology.
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December 2004

[Complications of hepatic resection surgery: a 12-month experience in a high case-load specialized center].

Acta Gastroenterol Latinoam 2004 ;34(1):9-15

Sección de Cirugía Hepato Bilio Pancreática y Trasplante Hepático, Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.

Background: Surgical treatment indications in benign and malignant hepatic tumors changed in last 20 years. Total number of hepatic resections increased in reference centers.

Objective: To evaluate complications after hepatic resections in a specific center, during a 12 months period.

Methods: Between January 2001 and January 2002, 80 patients with hepatic resection were analyzed. Mean age 55 years (r:14-79). Female: 55%. We analyze: tumor specifications, hepatic resection performed, transfusions, vascular clamping, operative time, associated procedures, length of hospital stage, postoperative complications and mortality.

Results: 61 patients (76.2%) were treated because of malignant pathology and 19 for benign. In 30 patients (37.5%) was made major resections and minor in 50 (62.5%). 16 patients (20%) required blood transfusions. Vascular intermittent clamping was used in 66 patients (82.5%). Associated procedures were made in 46 patients (58%). Mean operative time was 200'. Mean hospital stage: 6 days (r:3-12). Morbidity: 15 patients (18.7%). Complications were significantly higher in patients with: major hepatic resections (p: 0.002); primary hepatic tumors (p: 0.01); mean operative time more than 200' (p: 0.00007). Mortality associated with the procedure: 0%.

Conclusions: 1-Hepatic resections performed in high volume centers have a low complication risk and almost with no mortality. 2-Major hepatic resection, primary malignant tumors and mean operative time more than 200', were risk factors associated with postoperative complications.
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September 2004
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