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Background/aims: Mean survival in hepatocellular carcinoma remains low. Many efforts have been done during the last years through screening, diagnosis and treatment to improve the results. The aim of this work is to present the experience of our hospital multidisciplinary group during the first decade of this century., Methodology: The patients with hepatocellullar carcinoma presented at the multidisciplinary meeting from 1999 to 2009 were prospectively studied. According to the tumor and functional status they were treated through the current available guidelines by transplant, partial hepatectomy, local/regional procedures, systemic or symptomatic treatment., Results: One hundred and forty two patients were studied. Median tumor size was 3 cm. A single tumor was diagnosed in 64.8% of the patients. Eighteen patients had liver resection (6 transplantation and 12 with partial resection), 53 tumors were not treated due to advanced stage or liver dysfunction, and in the remaining patients radiofrequency, ethanol or embolization treatments were used, single or combined., Conclusions: a multidisciplinary approach of hepatocellular carcinoma in a second level hospital with trained professionals permits a diagnosis in early tumoral and functional stages in the majority of patients, and a variety of possible treatments with adequate survival outcomes.

Background/aims: Laparoscopic liver resection is controversial, specially for tumors. The aim of our study is to report our initial experience., Methodology: From October 2004 to October 2008, 15 patients underwent laparoscopic liver resection at our institution., Results: Fifteen laparoscopic surgeries were performed on 15 patients. Five patients with hepatocellular carcinoma (HCC), six patients presented liver metastasis and four patients were diagnosed of hydatid cyst. In the HCC group two laparoscopic left lateral segmentectomies and 3 laparoscopic atypical resections were performed. Mean operative time was 230 minutes (95%CI 171-289). In the liver metastasis group six laparoscopic resections were performed. Two patients were converted to open surgery. The laparoscopic procedures were: 2 hand-assisted right hepatectomies, 1 left lateral segmentectomy and 1 atypical resection. The mean surgical time was 257.5 minutes, (95%CI 198-317). In the hydatid cyst group 4 laparoscopic surgeries were performed: three pericystectomies and one partial cystectomy. The mean operative time was 133.75 minutes, (95%CI 68-200). No re-operations were needed and no post-operative deaths occurred. In oncological resections surgical margins were free of tumor in all cases., Conclusion: When liver laparoscopic surgery is performed in selected patients, it may offer similar results to conventional surgery with all the benefits of the minimal invasive procedures.

We report five patients who underwent laparotomy for liver metastasis from breast cancer without extrahepatic spread, with the intention to perform liver resection. All these patients had been subjected to modified radical mastectomy following systemic chemotherapy and periodical consecutive investigations to detect distant spreading. After laparotomy, patients have been regularly followed. Case 1, right trisegmentectomy in a 53-year-old woman, 36.5 months after the mastectomy. In the 17th postoperative month she continues without relapse. Case 2, hepatic artery ligature in a 41-year-old woman, 15 months after the mastectomy. In the 17th postoperative month she died. Case 3, bisegmentectomy (VI-VII) in a 51-year-old woman, 24 months after the mastectomy. In the 17th postoperative month she died. Case 4, exploratory laparotomy in a 51-year-old woman, 91 months after the mastectomy. In the 31th postoperative month she remains alive. Case 5, segmentectomy (IV) in a 59-year-old woman, 112 months after the mastectomy. In the 33th postoperative month she continues without relapse. As a conclusion, the surgical resection of liver metastasis from breast tumors after chemotherapy must be used in selected cases.

Background/aims: As there is still no effective parasiticide, treatment of hydatid cysts continues to be surgical. The possibility of treatment by PAIR. (puncture-aspiration-instillation-reaspiration) or laparoscopy has intensified the debate on the need for radical surgery. This study aims to show that radical surgical resection of the hepatic hydatid cyst is a safe and very effective technique, based on our results after 22 years of experience., Methodology: Between 1974 and 1996 in 2 large Madrid hospitals we operated on 459 patients with 630 hydatid cysts. As technical advances and experience may vary results, patients were divided into 2 groups according to the period when they had undergone surgery: group A between 1974 and 1984; and group B between 1985 and 1996. Results of radical surgical resection and changes over the course of evolution of this technique were analyzed., Results: A progressive drop was observed in morbidity and mortality. There were no deaths related to technical complications amongst total cystopericystectomy cases. Between 1990 and 1996 mortality was 0%, 2% of patients presented biliary fistula and 4% infection of the residual cavity. Mean hospital stay was 15.2 days. Only 1 patient of the 459 presented recurrence., Conclusions: As regards morbidity and mortality, technical advances and accumulated experience permit safe treatment of hepatic hydatid cysts by radical resection, with an almost nil recurrence rate. This makes it the technique of choice over others such as partial resection, PAIR or laparoscopy.

Background/aims: We performed a retrospective evaluation of 11 patients in the final stages of hepatic disease with chronic kidney failure, in whom simultaneous double liver-kidney transplantation was performed., Methodology: In the immediate pre-, intra- and postoperative periods, we assessed metabolic, hemodynamic and coagulation parameters; bicarbonate, calcium and inotropic drug requirements; the incidences during reperfusion of the graft; the surgical technique employed; the need for hemodialysis and/or ultrafiltration; and the survival rate of the patients., Results: Of the 11 cases studied, four patients needed hemodialysis, while only one patient needed ultrafiltration; three patients required both techniques, and no dialysis or ultrafiltration was performed in three patients. The following surgical techniques were employed: Total clamping of the inferior vena cava using an external venovenous bypass in two cases; total clamping of the inferior vena cava without an external venovenous bypass in three cases; and partial clamping of the inferior vena cava with preservation of the retrohepatic cava in six cases. The results showed one death in the first postoperative month and two deaths in the course of subsequent follow-up. The survival rate was 72.7%., Conclusions: The use of conventional intraoperative hemodialysis and/or ultrafiltration is feasible, useful and achieves good results in patients undergoing double liver-kidney transplantation. Partial clamping of the inferior vena cava at the anhepatic stage appears to reduce the need for ultrafiltration. There is no increase in perioperative mortality in patients who underwent liver transplantation while conserving their renal function.

Living related liver transplantation is one of the strategies currently used to increase the donor pool. A preoperative and non-invasive estimate of the donor's liver volume is needed to ensure sufficient functional liver reserve for survival after resection, and to obtain a graft of adequate volume to suit the recipient's features. A method based on a preoperative abdominal computerised axial tomography of the donor, that enables the volume and mass of the whole liver, and the graft, to be calculated is herein described. The compatibility of the estimate with real graft mass after its removal has been proved, and the accuracy of the calculi has been compared with other published methods. Moreover, progressive growth of the recipient liver remnant has been demonstrated in subsequent explorations.

Background/aims: Clinical aspects and preneoplastic potential of Zenker's diverticulum justify its surgery. The clinical signs of the patients and the size of the diverticulum determine the surgical technique., Methodology: Between January 1974 and December 1995, 32 patients underwent surgery in our department. In order to compare the surgical technique, we divided the patients into 3 groups: group A (cricopharyngeus myotomy: 15 patients (46.9%)), group B (myotomy with diverticulectomy: 15 patients (46.9%)) and group C (myotomy with diverticulopexy: 2 patients (6.7%)). The chi-square test was used for statistical analysis, p < 0.05., Results: Local or regional anaesthesia was used in 7 patients from group A (46.6%); 5 patients from group B (33.3%) and all the patients from group C (100%). General anaesthesia was used in 8 patients from group A (53.4%), 10 patients from group B (66.7%) and 0 patients from group C (0%). The overall mortality was 0%. The mean postoperative stay in group A was 6 +/- 2 days (3-10 days); in group B was 11.6 +/- 6.4 days (5-25 days) and in group C was 3.5 +/- 0.7 days (3-4 days). The mean postoperative stay in patients with local or regional anaesthesia was 5.3 +/- 1.6 days (3-9 days) and in patients with general anaesthesia, 10.9 +/- 6.1 days (4-25 days). No statistically significant difference was found between the anaesthetic technique and the surgical technique (p = 0.193), between the surgical technique and the mean postoperative stay (p = 0.596) and between the anaesthetic technique and the mean postoperative stay (p = 0.166)., Conclusions: Cricopharyngeus myotomy is the main surgical technique, however, in diverticula longer than 3 cm of diameter it is mandatory to associate diverticulectomy. Diverticulopexy is indicated in patients of advanced age with a high surgical risk. Local or regional anaesthesia facilitates the identification of the diverticulum intraoperatively and reduce the mean postoperative stay, however, there is no statistical significant difference.

Six out of 1,612 patients operated on for biliary diseases between January 1974 and January 1985, had Caroli's disease. A summary of the clinical records is included. The treatment performed was: external drainage in a patient with sepsis, who did not improve and died; left hepatic lobectomy and biliary-jejunal diversion in two patients; right extended lobectomy in one patient; distal spleno-renal shunt in a patient with severe biliary cirrhosis and recurrent hemorrhage from esophageal varices. The last patient suffered from a combination of a choledochal cyst and dilatation of the left intrahepatic branches, and underwent complete resection of the choledochal cyst, and biliary jejunal anastomosis on a porta-hepatis using a Roux-en-Y jejunal loop. Currently, five patients are recovering and are free of symptoms. The authors discuss the indications for liver resection and resection of a choledochal cyst.