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Laparoscopic resection of the pancreas (LRP) has been implemented to a varying degree because it is technically demanding and requires a long learning curve. In the present study we analyze the risk factors for complications and hospital readmissions in a single center study of 105 consecutive LRPs.We conducted a retrospective study using a prospective database. Data were collected on age, gender, BMI, ASA score, type of surgery, histologic type, operative time, hospital stay, postoperative complications, degree of severity and hospital readmission.The cohort included 105 patients, 63 females and 42 males with a median age and BMI of 58 (53-70) and 25.5 (22,2-27.9) respectively. Eighteen (17%) central pancreatectomies, 5 (4.8%) enucleations, 81 (77.6%) distal pancreatectomies and one total pancreatectomy were performed. Fifty-six patients (53.3%) experienced some type of complication, of which 13 (12.3%) were severe (Clavien-DindoIIIb) and 11 (10.5%) patients were readmitted in the first 30 days after surgery. In the univariate analysis, age, male gender, ASA score, central pancreatectomy and operative time were significantly associated with the development of complications (P0.05). In the multivariate analysis, male gender (OR 7.97; 95% CI 1.08-58.88)), severe complications (OR 59.40; 95% CI, 7.69-458.99), and the development of intrabdominal collections (OR 8.97; 95% CI, 1.28-63.02)) were associated with hospital readmission.Age, male gender, ASA score, operative time and central pancreatectomy are associated with a higher incidence of complications. Male gender, severe complications and intraabdominal collections are associated with more hospital readmissions.

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p

Despite many developments, postoperative bile leakage (POBL) remains a relatively common postoperative complication after laparoscopic liver resection (LLR) and open liver resection (OLR). Previous studies regarding the incidence and clinical impact of POBL have mainly focused on patients undergoing OLR. The aim of this study is to compare the incidence and clinical impact of POBL between patients undergoing LLR and OLR in a large international multicenter cohort using a propensity score matched analysis.

Radical re-resection has been demonstrated beneficial in incidental gallbladder cancer (iGBC) stages ≥ pT1b [1]. Anatomical resection (AR) of segments IVb-V is recommended, particularly for iGBC and liver-sided tumors [2]. Laparoscopically, this is a challenging procedure, as well as the regional lymphadenectomy, since inflammation from previous surgery can hinder identification of extrahepatic bile ducts. This difficult minimally invasive procedure, facilitated with indocyanine green (ICG) fluorescence enhancement [3] is herein didactically demonstrated.A 73 y. o. female patient underwent laparoscopic cholecystectomy for cholelithiasis. An iGBC -pT2b with positive cystic node-was found. Completion radical surgery was decided. Before surgery, 1.5mg of ICG was intravenously administered. A regional lymphadenectomy (stations 5-8-9-12-13) was safely performed: ICG allowed for bile duct visualization despite scarring from previous procedure. AR (IVb-V) was performed based on a glissonian-pedicle approach. After completing the procedure, a new dose of ICG was administered to discard ischemic areas in the remnant.Total operative time was 359 min. Intermittent Pringle maneuver resulted in50 ml bleeding. Hospital stay was 3 days. Pathological examination revealed no residual tumor in the liver bed. Ten lymph nodes were resected; 3 of them (2 retroportal and 1 common hepatic artery) showing tumoral invasion. After surgery, 6 cycles of adjuvant chemotherapy (Gemcitabine-Oxaliplatin) was administered.Laparoscopic radical surgery (AR of segments IVb-V plus regional lymphadenectomy) for iGBC is feasible and safe [4]. ICG fluorescence can be of help to identify hilar structures and rule out areas of ischemia.

Objectives To evaluate the safety and patency of self-expanding stents to treat hepatic venous outflow obstruction after orthotopic liver transplantation. To evaluate differences in the response between patients with early obstruction and patients with late obstruction. Material and methods This is a retrospective analysis of 16 patients with hepatic venous outflow obstruction after liver transplantation treated with stents (1996–2011). Follow-up included venography/manometry, ultrasonography, CT, and laboratory tests. We did a descriptive statistical analysis of the survival of patients and stents, technical and clinical success of the procedure, recurrence of obstruction, and complications of the procedure. We also did an inferential statistical analysis of the differences between patients with early and late obstruction. Results The mean follow-up period was 3.34 years (21–5331 days). The technical success rate was 93.7%, and the clinical success rate was 81.2%. The rate of complications was 25%. The survival rates were 87.5% for patients and 92.5% for stents. The rate of recurrence was 12.5%. The rate of primary patency was 0.96 (95% CI 0.91–1) at 3 months, 0.96 (95% CI 0.91–1) at 6 months, 0.87 (95% CI 0.73–1) at 12 months, and 0.87 (95% CI 0.73–1) at 60 months. There were no significant differences between patients with early and late obstruction, although there was a trend toward higher rates of primary patency in patients with early obstruction ( P = 0.091). Conclusions Treating hepatic venous outflow obstruction after orthotopic transplantation with self-expanding stents is effective, durable, and effective. There are no significant differences between patients with early obstruction and those with late obstruction.

Resumen Objetivos Evaluar la seguridad y permeabilidad del tratamiento de la obstruccion del drenaje venoso hepatico tras trasplante ortotopico con endoprotesis autoexpandibles. Valorar las diferencias en la respuesta en pacientes con obstruccion precoz y tardia. Material y metodos Analisis retrospectivo de 16 pacientes trasplantados con obstruccion del drenaje venoso hepatico tratados con endoprotesis (1996-2011). El seguimiento se realizo mediante venografia/manometria, ecografia, TC y pruebas de laboratorio. Se realizo analisis estadistico descriptivo de supervivencia de pacientes e injertos, exito tecnico y clinico, recurrencia y complicaciones del total de la muestra, asi como inferencial para comparar las diferencias entre pacientes con obstruccion precoz y tardia. Resultados La media de seguimiento fue de 3,34 anos (21-5.331 dias). La tasa de exito tecnico fue del 93,7%, y la de exito clinico, del 81,2%. La tasa de complicaciones fue del 25%. La tasa de supervivencia para pacientes fue de 87,5%, y para injertos, de 92,5%. La tasa de recurrencia fue del 12,5%. La tasa de permeabilidad primaria a los 3, 6, 12 y 60 meses fue de 0,96 (IC 95% 0,91-1), 0,96 (IC 95% 0,91-1), 0,87 (IC 95% 0,73-1) y 0,87 (IC 95% 0,73-1), respectivamente. No hubo diferencias significativas entre los pacientes con obstruccion precoz o tardia, aunque las tasas de permeabilidad primaria mostraron tendencia a ser significativamente superiores en el grupo precoz (p = 0,091). Conclusiones El tratamiento con endoprotesis autoexpandibles en obstrucciones del drenaje venoso hepatico tras trasplante ortotopico es efectivo, duradero y seguro. No hay diferencias significativas entre pacientes con obstruccion precoz y tardia.

BackgroundPost-treatment contralateral hemiliver hypertrophy has created an interest in lobar liver radioembolization (RE) as a pre-surgery tool.MethodsLiver and spleen volumes and function were studied in 83 patients submitted to partial liver volume RE at 4–8 weeks (T1), 10–26 weeks (T2), and >26 weeks (T3) after RE.ResultsMore than half of the patients had cirrhosis with hepatocellular carcinoma. The main finding was a progressive increase in the volume of the spared hemiliver (mean absolute increase at T3: 230ml). The percentage of patients in whom the baseline ratio of spared volume to total liver volume was

Resumen Introduccion A dia de hoy no existe una terapia medica eficaz para la poliquistosis hepatica (PQH), considerandose tratamientos paliativos la puncion quistica con escleroterapia, la fenestracion o la hepatectomia parcial. El trasplante ortotopico de higado (TOH) es el tratamiento de eleccion para la PQH terminal, estando indicado en pacientes con sintomas limitantes no susceptibles de recibir tratamiento medico. Con la aplicacion del sistema Model for End-Stage Liver Disease (MELD) es dificil determinar la prioridad en la lista de espera. Metodos Analisis retrospectivo de los TOH por PQH realizados consecutivamente en nuestro centro. Los criterios de inclusion para TOH en pacientes con sintomas limitantes fueron la presencia de poliquistosis bilateral (Gigot tipo iii ) y la hepatomegalia masiva con un higado remanente insuficiente que imposibilitara una hepatectomia. Se realizo de donante cadaver con tecnica piggy-back sin by-pass veno-venoso. Resultados Entre abril de 1992 y abril de 2010 se realizaron 6 TOH, uno de ellos combinando trasplante hepatorrenal. La media de transfusion fue 3,25 concentrados de hematies y 1.200 cc de plasma fresco congelado. El tiempo quirurgico medio fue 299 min y 498 min en el hepatorrenal. No hubo mortalidad perioperatoria. La media de hospitalizacion fue 6,5 dias, permaneciendo sanos todos los pacientes tras una media de seguimiento de 71 meses. Conclusion El TOH ofrece una excelente supervivencia global. Los resultados son mejores cuando el trasplante se realiza de una manera precoz, por lo que estos pacientes deberian recibir una puntuacion adicional para poder emplear el MELD como una escala valida.

The overriding concern in living donor liver transplantation is donor safety. A totally laparoscopic right hepatectomy without middle hepatic vein for adult living donor liver transplantation is presented. The surgical procedure is described in detail, focusing on relevant technical aspects to enhance donor safety, specifically the hanging maneuver and dynamic fluoroscopy-controlled bile duct division.

Resumen Objetivo Valoracion de los resultados de una serie institucional de resecciones de lesiones solidas hepaticas realizadas mediante abordaje totalmente laparoscopico. Pacientes y metodo Desde noviembre de 2002 hasta febrero de 2012 hemos realizado 71 resecciones de lesiones solidas hepaticas con abordaje totalmente laparoscopico: 65 por enfermedad maligna y 6 por enfermedad benigna. Se extirparon 21 hepatocarcinomas, 16 sobre higado cirrotico. Se realizaron 52 (73,2%) resecciones limitadas, 14 seccionectomias (3 posteriores derechas y 11 laterales izquierdas). Finalmente, 5 resecciones hepaticas mayores: 3 hepatectomias izquierdas y 2 derechas. En 14 casos (19,7%) se asocio algun otro procedimiento quirurgico (colecistectomia no incluida).Del total, 41 (57,7%) lesiones se localizaron en segmentos anteriores (SA) y 30 (42,3%) en segmentos posterosuperiores (SPS). Resultados Hubo 2 conversiones a cirugia abierta (2,8%).Cinco pacientes requirieron transfusion intraoperatoria (7%). La mediana de estancia fue de 4 dias (3-5). Hubo un fallecimiento (1,4%) y una reintervencion por fistula de anastomosis esofago-yeyunal. Los margenes de reseccion estuvieron libres de tumor en el 100% de los casos. La cirugia asociada supuso un aumento significativo en la tasa de morbilidad (35,7 frente a 7%, p = 0,012). Las resecciones en SPS no mostraron diferencias en cuanto a indice de complicaciones (p = 0,28), transfusion (p = 0,69) o estancia hospitalaria (p = 0,44) frente a resecciones de SA. Conclusion El abordaje totalmente laparoscopico es factible y seguro en la reseccion de lesiones hepaticas solidas. La cirugia asociada puede suponer un aumento significativo en la tasa de morbilidad. Las resecciones de lesiones localizadas en SPS pueden realizarse con igual seguridad que en SA.

Background Liver surgery after selective internal radiation therapy (SIRT) has been scarcely reported. The combination of laparoscopic approach in post-SIRT major liver surgery is a complex scenario to our knowledge not reported so far. Method From July' 2007–July' 2016, 40 patients underwent post-SIRT R0 resections in our center: 30 resections and 10 liver transplants. From March'2011, 5 (out of those 30) were full-laparoscopic resections: Three patients underwent laparoscopic right hepatectomy (LRH) after previous right hemiliver radiation lobectomy: two cirrhotic patients with HCC and one with colorectal cancer liver metastasis; one segment-VI resection in a cirrhotic patient, due to HCC and finally, a patient with a Budd-Chiari Syndrome and an infiltrating HCC in segment-III underwent left lateral seccionectomy. In all cases, the procedure was uneventfully completed full-laparoscopic and none required transfusion. Hospital stay was 3, 2, 5, 3 and 3 days respectively. We herein present a LRH in a 71 year-old patient after right hemiliver radiation lobectomy (due to a 7 cm unresectable HCC in a HCV cirrhotic liver). Case presentation, surgical findings and technique are detailed in this video, which also demonstrates the comparative hypoperfusion of the treated hemiliver revealed with ICG fluorescence, a hitherto undescribed finding. Results Hospital stay was 3 days. No early or late morbidity occurred. At this writing, 18 months after the resection and 43 months after the initial diagnosis the patient is alive and free of disease. Conclusion This experience suggests that laparoscopic liver resection after SIRT is feasible and safe, even in major hepatectomies.

The constant updating in the field of liver transplant led to the holding of the III Consensus Meeting of the Spanish Liver Transplant Association. Three current topics of great clinical interest were debated during this meeting; transplant in patients with liver cirrhosis due to hepatitis C, live donor liver transplant and the evaluation of the quality of liver grafts. A subject of great interest to Liver Transplant Units was also discussed: the assessment of their quality.

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

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

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

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

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

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

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