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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) achieves the hypertrophy of the future liver remnant in seven days. We achieved the same hypertrophy placing a tourniquet in the parenchimal transection line associating a right portal vein ligation (associating liver tourniquet and right portal vein ligation for staged hepatectomy-ALTPS). In perihiliar tumors a«non touch» technique should be performed. ALPPS y ALTPS do not comply with this technical aspect because a dissection of the hilum is carried out in both procedures during the portal dissection. To avoid this problem we devised a new method called sequential ALTPS. It consists of placing a tourniquet in the umbilical fissure without ligation of the right portal vein during the first stage. Subsequently, on the 4(th) postoperative day we perform a percutaneous right portal vein embolization. We present the first case of this new technique in which we have obtained a hypertrophy of 77% of the future liver remnant seven days after portal vein embolization. In the second stage a right trisectionectomy was performed with inferior vena cava resection with a goretex graft replacement., (Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy), in 2-stage liver resections, achieves hypertrophy of the functional liver remnant (FLR) in 7 days, and the objective of this technique is the occlusion of the intrahepatic collaterals. In March 2012 we published a new surgical technique associating the insertion of a tourniquet in Cantlie' line and right portal vein ligation (ALTPS: Associating liver tourniquet and right portal vein occlusion for staged hepatectomy). In this paper we present this ALTPS technique placing the tourniquet in the umbilical fissure to obtain hypertrophy of segments II-III. It was performed in a 51 year-old patient with a recurrent right renal hypernephroma which involved all the anatomic right lobe and inferior vena cava. Preoperative FLR was 380 ml (20% of the total volume) increasing 150% at 7 days (to 953 ml, 31% of the total). In the second step, we performed a right trisectionectomy and retrohepatic inferior vena cava resection, replacing it by a 2 cm-ring goretex graft., (Copyright © 2013 AEC. Published by Elsevier Espana. All rights reserved.)

Introduction: After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc., Aim: To report our experience in laparoscopic liver resections (LLRs)., Patients and Method: Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS., Surgical Technique: 6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections., Results: There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively., Conclusion: LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery., (Copyright © 2012 AEC. Published by Elsevier Espana. All rights reserved.)

Right portal vein occlusion plus «in situ split» has recently been reported as a new method to hypertrophy the functional remnant volume (FRV) in 7 days after two-stage liver resection. It is a complex procedure associated with the occlusion of the intrahepatic collaterals between both lobes. We present an original technique for hypertrophying the FRV by occluding the right portal vein and the intrahepatic collaterals: a case is presented of a 35-year-old woman with an intestinal stromal tumour, 14 bilobar metastases and an estimated 24% FRV. Once the lesions were removed from the left lobe, we performed a right portal vein transection and applied a tourniquet on the Cantlie line, using the hanging manoeuvre. A 57% hypertrophy of the FRV was achieved by day 7, and the right hepatectomy was performed on day 8. Our technique is effective and simple to perform and if corroborated in future studies, this technique would be of choice in 2-stage liver resection., (Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved.)

Introduction: Right hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required., Patients and Method: We provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury., Results: LT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury., Conclusions: RHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion., (Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved.)

Introduction: The resection of tumours of the anatomical left lobe is normally straightforward using either left lateral sectionectomy (LLSEC) or segmentectomy II or III. Our objective is to present the results of the laparoscopic approach and to consider whether this could be the "ideal technique" in liver surgery units where the surgeons have experience of laparoscopic liver surgery (LLSURG)., Patients and Methods: We have studied patients with resected solid tumours of the anatomical left lobe using LLSURG (n=18): 10 cases with LLSEC and 8 cases with segmentectomy II or III. We carried out a comparative study with a control group of 18 patients operated on using the same surgical technique using open surgery (OS)., Results: There were no cases of mortality in either of the 2 groups (n=36). Morbidity was similar (5.5% per group). For LLSEC, the LLSURG group (n=10) had a shorter hospital stay (p=0.005) and less surgical time (141 vs. 159 min) (differences not significant.), than the OS group. For segmentary resections II or III, in the LLSURG group (n=8) there was greater use of the Pringle manoeuvre (p=0.05), greater surgical time (p=0.05) and a shorter hospital stay (4.8 vs. 5.6 days) (differences not significant), than in the OS group., Conclusions: LLSEC should be carried out by laparoscopy in centres where they have considerable experience. The patients may have a shorter hospital stay and spend less time in surgery than when OS is performed, with the same morbidity and mortality rates. Segmentectomy resections II or III carried out by laparoscopy involve a shorter hospital stay but longer surgery time and therefore the advantages are not as evident as they are for LLSEC.

Introduction: There are many studies that analyse preoperative factors with a poor prognosis in patients undergoing surgery for colorectal carcinoma liver metastases, in order to avoid unnecessary surgery. However, there are few studies that evaluate the intraand postoperative prognostic factors. The aim of this study is to analyse pre-, intra- and postoperative prognostic factors in a series of 210 patients undergoing surgery for colorectal carcinoma liver metastases, with special emphasis on the postoperative factors that can give us information on the aggressiveness of the tumour and the curative effectiveness of the surgery., Patients and Method: Between September 1996 and December 2006, 210 patients undergoing surgery for colorectal carcinoma liver metastases in whom we analysed pre-, intra- and postoperative factors of survival. Mean follow-up was 55+/-3 months (range: 12-124 months)., Results: The postoperative mortality rate was 1.4% and the morbidity rate was 22%. Actuarial and disease-free survival at 1-, 3- and 5-years was 89.9% vs 63%, 66.9% vs 32%, and 53.8% vs 23%, respectively. Among the preoperative factors analysed, the age>65 years and LM size>5 cm were independent predictors of poor overall survival, whereas the other two significant factors were obtained from those analysed postoperatively: presence of microsatellitosis and postoperative CEA levels (at 1 and 3 months)., Conclusions: In patients with colorectal carcinoma liver metastases we must take into account certain postoperative factors that can give us information on the aggressiveness of the tumour and the effectiveness of the surgery.

The differential diagnosis between macrocystic serous cystoadenoma and mucinous cystoadenoma is very difficult but is highly important due to the latter's potential for malignant transformation. We present a case of unilocular macrocystic serous cystoadenoma. Due to the impossibility of obtaining an accurate preoperative diagnosis, all macrocystic unilocular lesions, in an appropriate clinical context, must be resected.

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

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