Abstract Background Barrett's esophagus (BE) is a premalignant pathology that can sometimes progress to adenocarcinoma (ADC) of the esophagus. Although the percentage of malignancy is low, one in every 200 patients/year, in the world literature there is great variability (0,1-1 % patients/year). This important discrepancy arises because we know that not all patients with BE have the same risk of malignancy. The objective of this work is allowing us to stratify patients according to their risk of malignancy. Methods We have 147 patients with a mean (range) follow-up is 13.3 years (2-33). During this period, 16 patients progressed to early esophageal ADC (10.8%), malignancy rate of 0.8 patients/year. Two study groups were obtained: 1. Patients with non-malignant BE: 131 (median age 43 years (10-79). 96 men (73%). 2. Patients with malignant BE: 16 (median age 51 years (21-74). 15 men (94%). Statistical method A univariate and multivariate statistical study was carried out to detect which factors have a greater risk of malignancy. We analyzed epidemiological, clinical, endoscopic, histological, functional factors (motility and pH) and therapeutic. RESULTS Age: 22 patients over 65 years, 22.7% of malignancy, and only 8.8% patients under 65 (p=0.05, OR=3.048). Sex 13.5 % men progressed and only 2.8 % women (p=0.045). Familial Barrett's esophagus was positive in 6 patients, 66.6% malignant, while only 8.5% without familial BE progressed (p=0.0001). EB length: patients with metaplastic segments greater than 4 cm have a 12 times greater risk of malignancy. Low grade dysplasia: 39 % patients had a diagnosis of LGD became malignant, and only 7 % patients with not LGD (p<0.0001, OR 8.49). Proliferation Ki67 and p53 high expression patients were malignant in 69.2% and 91.7 % (p<0.0001, OR 29.25 and 242.00). Esophageal functional studies 22.6% patients with esophageal body hypomotility became malignant and only 3.2 % with preserved esophageal body motility (p=0.001, OR 8.75). Neither the mean LES pressure nor the percentage of patients with hypotensive LES were statistically significant. 20.4% patients with severe acid reflux (pH <4 greater than 24%) became malignant versus 6.1 % patients suffered from less reflux (p=0.009, OR 3.93). Type and effectiveness of treatment Malignancy according to treatment, no differences are observed (10 % and 11.6 % en medical and surgical groups). Only 3.9 % patients with effective treatment became malignant, while in 48.1% who failed treatment (p=0.0001, OR 22.9). Multivariate analysis Only LGD reached statistical significance (p=0.007) with an OR 7.18, and the high expression of p53 (p<0.0001) with an OR 89.14. Risk groups Based on statistical analysis, we have established three risk groups (figure 1). We included 5 patients with High Risk (3.5%, F-U 8.6 years), all malignant (100%, 11.6% patients/year). Intermediate Risk 33 patients (22.5%, F-U 11.97 years, with progression in 11 patients (33.3%, 2.7% patients/year). Low Risk to 109 patients (74%), none became malignant. (p<0.0001, OR: 1.78). Conclusion In patients with high and intermediate risk, therapeutic options and endoscopic follow-up should be different than in patients with the absence of these disease characteristics, classified as low risk.

Background: The incidence of papillary thyroid microcarcinoma (PTMC) is increasing. Objective: To analyze the long-term prognosis of PTMC. Method: Study population: patients with a histopathological diagnosis of PTMC (size 1 cm) treated according to the risk of recurrence of the Latin American Thyroid Society. Inclusion criteria: minimum follow-up of 2 years, availability of histopathological samples, and treatment compliance. Exclusion criteria: previous thyroid surgery, other synchronous malignancies or ectopic location of the PTMC. Study variables: persistences, recurrences and mortality. Results: Based on the risk of recurrence, PTMC has very low risk in 65.2% (n = 105), low risk in 17.4% (n = 28) and high risk in 17.4% (n = 28). In high risk patients, total thyroidectomy was performed in all cases, cervical lymphadenectomy in 57,1% (n = 16) and metabolic therapy with I-13(1) in all cases. During a mean follow-up of 119,8 +/- 65 months, 0.6% (n = 1) of recurrences took place. Risk factors associated to recurrence were not identified. No patient died due to MCPT. Conclusions: PTMC treated based on its risk of recurrence has a good long-term prognosis, without persistences, with a low number of recurrences and absence of disease-associated mortality.

Introduction: The first variant reported was Tourniquet-ALPPS (T-ALPPS), which occludes the intrahepatic circulation by means of a tourniquet around the liver. Methods: We present a modification of our surgical technique, T-ALPPS, named “partial Tourniquet-ALPPS” (pT-ALPPS) which avoids the pass of the tourniquet by hanging maneuver and the right extraglissionan approach. The first Stage of this variant is easier, quicker and less risky compared to ALPPS, p-ALPPS or T- ALPPS. Results: In our HBP unit 65 T-ALPPS have been performed. Since February 2017 we underwent a prospective study comparing T-ALPPS with pT-ALPPS, including 6 patients with colorectal liver metastases (CRLM) in each group. The first case of pT-ALPPS, was performed in a patient with bilobar metastases and one of them was located in segment, in front of the inferior vena cava thus the tourniquet could not be passed by hanging maneuver. After clearing the future liver remnant (FLR) of CRLM, we ligate the right portal vein. Considering that the ventral portion of the liver to the right portal pedicle is a non-vascularized area, and with the aid of intraoperative ultrasonography, an Adson clamp was passed through the liver parenchyma. This clamp emerged between the right and middle hepatic vein. A tourniquet was then passed and knotted under ultrasound control. In Stage 2, we used the tourniquet as hanging maneuver for right hepatectomy or right trisectionectomy depending on its location. Conclusion: In selected patients P-T-ALPPS is an accessible technique easier than T-ALPPS as the clamp passes through an avascular area.

PURPOSE:Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) offers better short-term results than open surgery with similar long-term results although it is technically difficult due to the risk of bleeding.METHODS:This study included patients with HCC in Child A cirrhosis who underwent TACE before LLR between 2009 and 2019. The primary endpoint was to analyze the intraoperative and early results of this technique. We also analyzed the long-term outcomes. Patients with and without clinically significant portal hypertension (CSPH) were compared.RESULTS:A total of 44 cirrhotic patients with HCC were included (24 CSPH and 20 non-CSPH). The Pringle maneuver was used in two cases (4.5%), mean blood losses was 100 ml (range 50-200), and three patients (6.8%) required a blood transfusion. The degree of necrosis achieved was greater than 90% in 27 patients (61.4%). At 1, 3, and 5 years, overall survival was 97.7%, 81.5%, and 63.4%, respectively, and disease-free survival was 85.2%, 52.5%, and 34.5%, respectively. There were no statistically significant differences between non-CSPH and CSPH groups regarding intraoperative, early, and long-term outcomes.CONCLUSION:In our experience, TACE could be beneficial to perform LLR in HCC Child-Pugh A patients with and without CSPH without serious complications and similar oncological outcomes.

Introduction: rectoscopy and 18F-FDG PET/CT as a diagnostic algorithm for the assessment of tumor response in rectal cancer after neoadjuvant chemoradiation therapy (CRT) is very useful. Material and methods: this was a prospective longitudinal study in patients with locally advanced rectal cancer treated with neoadjuvant CRT. Patients were assessed after CRT completion with a digital rectal examination, proctoscopy and 18F-FDG PET/CT. Patients were subdivided as clinical (cCR) or radiologic (rCR) responders and non-responders according to tumor response. Clinical and radiological re-assessment was compared with the surgical specimen. Pathological tumor regression (pCR) grade was determined according to Mandard’s classification. Of the 68 patients included, 15 (22 %) presented pCR in the surgical specimen and tumor persistence (non-PCR) was detected in the remaining 53 (78 %). Clinical assessment (DRE+ rectoscopy) identified 15 patients as cCR and 53 as non-cCR, two were false positives and two were false negatives. The overall accuracy was 94 %. 18F-FDG PET/CT identified 18 patients as rCR and 50 as non-rCR, one was a false positive and four were false negatives. The overall accuracy was 92 %. A combination of clinical findings and 18F-FDG PET/CT resulted in an accuracy of 96 %. The combination of clinical findings + 18F-FDG PET/CT was able to correctly identify all cases of pCR, with the exception of one case that presented a tumor regression of 80 %. In this series, 18F-PET-CT and clinical assessment had excellent accuracies in differentiating PCR from non-PCR after CRT completion. PET-CT combined with clinical assessment had a better accuracy than both modalities independently. 18F-FDG PET/CT is a valid tool that complements the clinical assessment of tumor response

Liver transplantation (LT) is the treatment of choice in HCC but it has been seen that more than 10% of transplanted patients have recurrences within the first year after surgery. PIVKA-II, or prothrombin induced by the absence of vitamin K, is an abnormal prothrombin molecule that increases in HCC and numerous studies have shown that it could be a useful biomarker for HCC complementary to alpha-fetoprotein (AFP). Peripheral blood was obtained from 36 patients with HCC candidates for LT. PIVKA-II was determined by LUMIPULSE G1200 system. Biochemical parameters (GOT, GPT, GGT, LDH, PCR, bilirubin) were determined by enzymatic, colorimetric and immunoturbidimetric methods in Cobas C711. AFP levels were obtained by electrochemiluminescence (ECLIA) in Cobas e 601. Median levels of PIVKA-II were 87.5 (mAU/mL) (IR: 34.5-523.75). In the correlation analysis between biochemical parameters and PIVKA-II only LDH showed a statistically significant positive correlation with PIVKA-II levels (Rho= 0.367; p=0.046). Likewise, statistically significant differences in PIVKA-II levels were observed between patients with pathological and non-pathological LDH levels (U=50; p=0.044), so that patients with LDH levels ≤225 U/L had median PIVKA-II levels of 67 mAU/mL (RI: 30-154) while patients with LDH levels >225 U/L had 571 mAU/mL (RI: 138-6232). Therefore, the levels of pre-LT PIVKA-II could be a good predicting marker of the liver function after LT and it would reflect the status of liver inflammation and therefore an increase of these levels would mean a worse prognosis and would be very useful when selecting candidates for LT.

Introduction: Hepatocellular carcinoma (HCC) is one of the most common and malignant tumors. Preoperative portal vein embolization (PVE) is currently the most accepted treatment before major hepatic resection for HCC in patients with liver fibrosis or cirrhosis and associated insufficient future liver remnant (FLR). In the last decade, ALPPS technique has been described to obtain an increase of volume regarding PVE and a decrease of drop out. Methods: We provide a review about HCC in cirrhotic patients treated ALPPS or PVE utilizing EMBASE, Medline/PubMed, Cochrane and Scopus databases. Results: In PVE postoperative hepatic liver failure was inferior than ALPPS (0-9% vs 0-50%, respectively). Mayor complications (11.7-62.5% vs 0-30%) and mortality (12.5-50% vs 0-7.1%) was higher in ALPPS. Volume of the FLR was higher in ALLPS (38.1-71.1% vs 31.1-41%). Drop out ranged 0-20% in ALPPS versus 8-14.2%. While all de PVE groups present drop out in ALPPS in 4 of the 7 studies all the patients achieved the second stage. Conclusion: The initial excessive morbidity and mortality of this technique have decreased drastically due to a better selection of patients, the learning curve and the use of less aggressive variations of the original technique in the first stage. For both techniques a complete preoperative assessment of the FLR is the most important issue and only patients with and adequate FLR should be resected. ALPPS could be a feasible technique in very selected patients with HCC and cirrhosis.

Introduction: Papillary thyroid microcarcinoma (PTMC) usually has an indolent course, but some have worse prognostic factors, such as the presence of central (6.9%-51.5%) and lateral (3%-49.6%) lymph node metastases. The aim of this study is to analyze the factors associated with PTMC with metastatic lymph nodes and its long-term prognosis. Methods: Retrospective study whose study population consists of patients with PTMC (size <= 1 cm). Patients with previous thyroid surgery, other synchronous malignancies and ectopic location of the PTMC were excluded. Two groups were compared: PTMC without metastatic lymph nodes (group 1) and PTMC with metastatic lymph nodes (group 2). A multivariate analysis using a logistic regression model and a Kaplan-Meier survival analysis with log-rank test were performed. Results: Out of the 161 selected patients, 9.3% (n = 15) had metastatic lymph nodes. Multifocality (OR 5.284, 95%CI 1.056-26.443; P =.043) and extrathyroidal extension (OR 7.687, 95%CI 1.405-42.050; P =.019) were associated with the presence of metastatic lymph nodes. In PTMC with metastatic lymph nodes, more aggressive treatments were performed: lymphadenectomy (4.8% vs. 100%; P <.001) and radioactive iodine (24.7% vs. 100%; P <.001). During a mean follow-up of 119.8 +/- 65 months, one recurrence was detected in group 2 (0% vs. 6.7%; P =.093). No patients died due to the disease. Conclusions: Multifocality and extrathyroidal extension of PTMC were associated with the presence of metastatic lymph nodes. Metastatic PTMC, with more aggressive treatments, presents an excellent long-term prognosis. (C) 2019 AEC. Published by Elsevier Espana, S.L.U. All rights reserved.

La incidencia del microcarcinoma papilar de tiroides (MCPT) está aumentando en los últimos años, especialmente en pacientes intervenidos por enfermedad tiroidea presumiblemente benigna. El objetivo de este estudio es analizar las diferencias entre el MCPT de diagnóstico incidental y de diagnóstico clínico preoperatorio, así como su pronóstico a largo plazo. La población a estudio la constituyen los pacientes con diagnóstico histológico de MCPT. Se excluyeron los pacientes con cirugía tiroidea previa, con otras enfermedades tiroideas o extratiroideas malignas sincrónicas y localización ectópica del MCPT. Se compararon 2 grupos: pacientes con diagnóstico incidental (grupo 1) y con diagnóstico clínico (grupo 2). Se realizó un análisis multivariante de los factores diferenciadores. El MCPT de diagnóstico clínico presentó mayor frecuencia de hipotiroidismo (4,6% vs. 18,9%; p = 0,004), invasión extracapsular (5,7% vs. 17,6%; p = 0,018), adenopatías metastásicas (1,1% vs. 18,9%; p < 0,001) y tiroiditis linfocitaria (5,7% vs. 27%; p < 0,001). En el análisis multivariante la presencia de adenopatías metastásicas (OR: 22,011; IC 95%: 2,621-184,829; p = 0,004) y la tiroiditis linfocitaria (OR: 4,949; IC 95%: 1,602-15,288; p = 0,005) se asociaron con el diagnóstico clínico del MCPT. Durante un seguimiento medio de 119,8 ± 65,1 meses se detectó una recidiva en el grupo 2 (0 vs. 1,4%; p = 0,460). Ningún paciente falleció debido a la enfermedad. El MCPT de diagnóstico clínico, aunque presenta características histopatológicas más agresivas (invasión extracapsular y de adenopatías metastásicas), su pronóstico a largo plazo es similar al MCPT incidental. La presencia de adenopatías metastásicas y tiroiditis linfocitaria fueron factores independientes asociados al MCPT de diagnóstico clínico. The incidence of papillary thyroid microcarcinoma (PTMC) has increased in recent years, especially in patients operated on for presumably benign thyroid disease. The aim of this study was to analyze the differences between PTMC incidentally diagnosed and PTMC clinically diagnosed, as well as its long-term prognosis. The study population consisted of patients with a histological diagnosis of PTMC. Patients with previous thyroid surgery, other synchronous thyroid or extrathyroid malignancies and an ectopic location of PTMC were excluded. Two groups were compared: patients with PTMC incidentally diagnosed (group 1) and patients with PTMC clinically diagnosed (group 2). A multivariate analysis of differentiating factors was performed. PTMC clinically diagnosed had a high frequency of hypothyroidism (4.6% vs. 18.9%; P = .004), extrathyroidal extension (5.7% vs. 17.6%; P = .018), metastatic lymph nodes (1.1% vs. 18.9%; P < .001) and lymphocytic thyroiditis (5.7% vs. 27%; P < .001). In the multivariate analysis, metastatic lymph nodes (OR: 22.011, IC 95%: 2.621-184.829; P = .004) and lymphocytic thyroiditis (OR: 4.949; IC 95%: 1.602-15.288; P = .005) were associated with the clinical diagnosis of PTMC. During a mean follow-up of 119.8 ± 65.1 months, one recurrence was detected in group 2 (0% vs. 1,4%; P = .460). No patient died due to the disease. PTMC clinically diagnosed, although it has more aggressive histopathological characteristics (extrathyroidal extension and metastatic lymph nodes), presents a long-term prognosis similar to the PTMC incidentally diagnosed. The presence of metastatic lymph nodes and lymphocytic thyroiditis were independent factors associated with PTMC clinically diagnosed.

Introduction. Ecuadorians are the largest immigrant group in Spain. In countries with preclinical programs of xenotransplantation (XenoTx), it is important to know the population attitude toward them; however, in the Ecuadorian population it is not known. Objective. To analyze the attitude toward XenoTx of organs among the Ecuadorian population residing in Spain. Methods. Population under study. Ecuadorians residing in Spain. Inclusion criteria: Sample of population over 15 years stratified by age and sex. Instrument valuation. Validated questionnaire of attitude towards xenotransplantation PCID-XenoTx-Rios. Setting for the study. Random selection of people to survey based on stratification. Results. Of the 461 respondents, 36% are in favor of XenoTx if the results were similar to those obtained with humans, 15% against, and 49% undecided. If the results were worse than with human organs, 11% would be in favor, 26% against, and 63% undecided. The variables associated with this attitude are age (P = .018), marital status (P = .026), studies (P < .001), comment with family (P = .001), couple attitude (P = .039), attitude toward cadaveric donation (P < .001), previous experience with donation (P = .001), consider the possibility of needing a transplant in the future (P < .001), and attitude toward related living donation (P < .001). In the multivariate analysis, these data persist: university studies (odds ratio [OR] = 3.875; P = .007); in favor of cadaveric organ donation (OR = 2.840; P < .001); previous relationship with donation and organ transplantation (OR = 1.901; P = .026); and consider the possibility of needing a transplant in the future (OR = 4.329; P = .002). Conclusions. The attitude toward XenoTx among Ecuadorian residents in Spain is unfavorable and is conditioned by different psychosocial variables.

•African immigrants residing in Spain who are Catholic have a more favorable attitude toward organ donation and transplantation than do Muslims.•Regarding Africans living in Spain, understanding the favorable attitude of religions toward donation can improve the attitude toward the donation of organs of the parishioners.•A majority of the African population residing in Spain are Muslim and have a worse attitude toward organ donation and transplantation.

Introduction: Obesity represents a risk factor in case of major hepatectomy, because the future liver remnant (FLR) must be proportional with body weight. To avoid post-hepatectomy liver failure, and further increase the ratio between FLR and body weight, we performed a bariatric procedure in the first stage of the ALPPS technique. Patient concerns: Fifty-four-year-old woman, with morbid obesity (BMI 58.5) and type II diabetes mellitus, was scheduled for a major hepatectomy due to multiple colorectal liver metastases Diagnosis: Six months before, the patient was diagnosed with colorectal cancer and synchronous liver metastases. She was initially treated with sigmoidectomy and chemotherapy. After partial response of the liver metastases, we considered a liver resection but the FLR was very low, especially in relation to her BMI. Intervention: We planned a novel approach and, for the first time, we performed a sleeve gastrectomy during the first stage of Tourniquet ALPPS (T-ALPPS). After achieving an adequate FLR, we successfully completed the major hepatectomy during the second stage of T-ALPPS. Outcome: The association between sleeve gastrectomy and T-ALPPS produced an increase of FLR/body weight ratio up to 0.8 that allowed completing a right trisectionectomy in the second stage of ALPPS. The major hepatectomy was performed without severe complications, and several months after surgery the patient is still alive without any recurrence Conclusion: Despite obesity represents a risk factor involved in the carcinogenesis, the role of the bariatric surgery in the oncological setting is not well established. In this clinical case, we benefited from the weight loss produced by bariatric surgery combined with an effective hypertrophy technique and chemotherapy. These findings suggest that bariatric surgery could be useful for obese patients with liver malignancy and need for extended hepatectomy.

•The Latin American population that emigrates to Spain is younger, more educated, and less religious than the population that emigrates to the United States.•The psycho-social profile toward organ donation is similar among the Latin American population migrating to Spain and the United States.•The better attitude toward organ donation among Latin Americans living in Spain than that of US residents cannot be justified by their socio-personal characteristics.•The immigrant population in Spain is mainly South American, compared with that of the United States, which is Mexican and Central American.

INTRODUCTION:In liver transplantation, living donation shows better and better results. However, rates of living liver donation (LLD) are low.OBJECTIVE:To analyze the attitude towards LLD among patients on the waiting list for liver transplantation.METHOD:Study population: Patients included in the waiting list for liver transplantation who are not in code 0 and do not present with encephalopathy above grade I.PROTOCOL:After being included in the waiting list, they are informed of the study and they are cited in the Psychology Consultation.INSTRUMENTS:attitude questionnaire towards LLD, carried out in the Psychological Care consultation.RESULTS:Of the 147 patients included in the waiting list, 112 fulfilled the inclusion criteria in the study. After being cited in the consultation, 100% of respondents are in favor of living liver donation. However, when considering the related LLD, 80% of the respondents indicated that they would not accept a living donation from a family member and therefore did not want to complete the questionnaire. Of the remaining 20% who completed the study, 11% would accept it from any family member, 8% only from some family members (mainly excluding children and grandchildren), and the remaining 1% would accept it but excluded all their family members.CONCLUSION:Currently, there is a disconnect between patients' intentions in favor of living liver donation and the real attitude when they are on the waiting list and related living donation is raised.

Introduction. The favorable knowledge of the concept of brain death (BD) is a determinant for organ donation. Objective. To analyze the level of knowledge of the concept of BD in the population of Cienfuegos (Cuba) and determine the factors that condition it. Methods. Sample of Cubans residing in Cienfuegos (n = 636) stratified by age and sex. The assessment instrument is the validated questionnaire of attitude toward donation and transplant, "PCID-DTO-Rios," self-administered and anonymously filled out. Statistics. chi(2), Student t test, and a logistic regression analysis. Results. A total of 636 individuals completed the questionnaire. Fifty percent of participants understood the concept of BD and accept it as a person's death (n = 318). Of the rest, 13.4% (n = 85) did not understand it, and 36.6% (n = 233) had a misconception. The marital status (be married and / or with a partner) of the respondent is associated with the knowledge BD (P < .001) as are the following variables: level of education; offspring; having discussed the issue of donation and transplantation with the family; opinion of the couple toward donation and transplantation; religion; and favorable attitude toward the organ donation and transplant. In the multivariate analysis, the following are independent variables: 1. studies (odds ratio [OR] = 4.664; P = .002); 2. has no offspring (OR = 3.129; P < .001); 3. has commented on it in the family nucleus (OR = 2.759; P < .001); 4. despite having an opinion against (OR = 16.999; P < .001); 5. religion (OR = 1.878; P = .042); and 6. favorable attitude toward the donation of cadaver organs (OR = 2.026; P = .011). Conclusions. Half of the population of Cienfuegos knows and accepts the concept of BD as the death of an individual, associating said acceptance with a favorable attitude toward organ donation.

Background. Living donation is a potential source of organs that could help to reduce the organ transplant deficit. Given that we have a worldwide aging population, it is important to assess the opinion of older people toward this type of donation. Objectives. To analyze the attitude of people aged > 65 years toward living kidney donation (LKD) and living liver donation (LLD) and to investigate the variables affecting their attitudes. Methods. A multicentric study was carried out using a representative sample of people > 65 years stratified by sex and geographic location in southeastern Spain (n = 420). The measurement instrument was a validated questionnaire about LKD and LLD. Statistics were analyzed using SPSS version 21.0 (IBM Corp, Armonk, NY, United States) software. Descriptive analysis was carried out using Student t test, chi(2) test, and a multivariate analysis. Results. The questionnaire completion rate was 84% (n = 351) with 88% (n = 310) in favor of LKD, and 89% (n = 311) in favor of LLD. Favorable attitude decreased to 3% when the donation under consideration was unrelated. Attitudes toward LKD and LLD were associated with having received information from the television (P = .016 and P = .045) and from friends (P = .017 and P = .03); accepting an autopsy after death (P = .001 and P = .002); and not being worried about scars (P = .015 and P = .044). In the multivariate analysis, the following variables continued to be significant: having received information from the television (odds ratio [OR], 2) and from friends (OR, 10.3); and the acceptance of an autopsy (OR, 2). Conclusions. Older people are in favor of both LKD and LLD, assuming it is a related donation. In addition, the information the elderly population receives regarding organ donation and transplantation affects their attitudes.

Background: Pancreatic ductal adenocarcinoma (PDA) has a poorly surveillance. To improve the prognosis it is essential to diagnose and treat the disease in the initial stages. It is demonstrated that invasive PDA develops from well-defined precursor lesions (like pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasia (IPMN) and mucinous cystic neoplasm (MCN)). The aim of this study is to determine if total pancreatectomy improves survillance in pancreatic head adenocarcinoma patients with histological finding of precursor lesions in pancreatic body or tail. Material and Methods: It is a non-randomized prospective study of patients undergoing total pancreatectomy due to pancreatic head neoplasia. Results: Total of 110 patients (58.2% male, 41.8% female), the most frequent TNM stage was T3N1M0 (59.1%). PanIN1, PanIN2 and PanIN3 lesions were found in head (26.3%, 43.7%, 40.8%), body (34,1%, 34.1%, 24.6%) and tail (38.1%, 47.3%, 18.8%) respectively. It shows us that the precursor lesions are also frequent in the remaining pancreas after standard Whipple (43.4% of PanIN3). IPMN lesion was found in the body and tail in one surgical specimen. This case also presented PanIN2 lesions. Discussion: In body and tail of the pancreas we found at least one of the precursor lesions of ductal adenocarcinoma and in many of them there are more than one of this lesions. The standard Whipple surgical procedure due to pancreatic head neoplasia may be insufficient to improve the prognosis of patients with PDA. Conclusions: Precursor lesions of adenocarcinoma in pancreatic body and tail are frequent and could have a roll in overall survival. Total pancreatectomy could be useful in this patients.

Blackground: Bouveret's syndrome and biliary ileus, an extremely rare cause of gastric obstruction (about 300 cases published about Bouveret's syndrome), is due to the impaction of a duodenal calculus secondary to a cholecystoduodenal or cholecystogastric fistula. It is associated with women, with more than 70 years old and large gallstones. The surgical treatment depends of the patient, the side of the calculus and its location. Surgical treatment is enterolithotomy with or without cholecystectomy. The fistula can close spontaneously so its repair may be unnecessary. The aim is to present two cases of biliary ileus and we do a bibliographic review to know its management. Material & Methods: The first patient was an 81 years old male who consulted in the emergency room for oral intolerance and vomiting. A CT study was performed, finding a cholecystoduodenal fistula and lithiasis that causes intestinal obstruction in the duodenum (figure 1). The other patient, was an 91 years old female who consulted in the emergency room for vomiting. In CT we could see a cholecystoduodenal fistula and a lithiasis in ileon that caused intestinal obstruction. Results: First patient underwent surgery with enterolithotomy. Six days after surgery, the patient was discharged home without symptoms. In the second case, the patient needed surgery with enterolithtomy, cholecystectomy and closure of the duodenum. In Conclusion: in these patients, intestinal obstruction must be treated first with an enterolithotomy and a biliary procedure, including cholecystectomy and biliary-enteric fistula closure, in low-risk patients.