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Decreasing graft rejection and increasing graft and patient survival are great challenges facing liver transplantation (LT). Different T cell subsets participate in the acute cellular rejection (ACR) of the allograft. Cell‐mediated immunity markers of the recipient could help to understand the mechanisms underlying acute rejection. This study aimed to analyse different surface antigens on T cells in a cohort of adult liver patients undergoing LT to determine the influence on ACR using multi‐parametric flow cytometry functional assay. Thirty patients were monitored at baseline and during 1 year post‐transplant. Two groups were established, with (ACR) and without (NACR) acute cellular rejection. Leukocyte, total lymphocyte, percentages of CD4(+)CD154(+) and CD8(+)CD154(+) T cells, human leukocyte antigen (HLA) mismatch between recipient–donor and their relation with ACR as well as the acute rejection frequencies were analysed. T cells were stimulated with concanavalin A (Con‐A) and surface antigens were analysed by fluorescence activated cell sorter (FACS) analysis. A high percentage of CD4(+)CD154(+) T cells (P = 0·001) and a low percentage of CD8(+)CD154(+) T cells (P = 0·002) at baseline were statistically significant in ACR. A receiver operating characteristic analysis determined the cut‐off values capable to stratify patients at high risk of ACR with high sensitivity and specificity for CD4(+)CD154(+) (P = 0·001) and CD8(+)CD154(+) T cells (P = 0·002). In logistic regression analysis, CD4(+)CD154(+), CD8(+)CD154(+) and HLA mismatch were confirmed as independent risk factors to ACR. Post‐transplant percentages of both T cell subsets were significantly higher in ACR, despite variations compared to pretransplant. These findings support the selection of candidates for LT based on the pretransplant percentages of CD4(+)CD154(+) and CD8(+)CD154(+) T cells in parallel with other transplant factors.

Introduction Donation after circulatory death (DCD) has increased in the last decade, although a slight increase in surgical complications has been reported in liver transplantation (LT). Therefore, DCD is not recommended with donors aged 60 years or more because it entails an added risk. However, donation after brain death (DBD)-LT with donors aged 70 years or more shows acceptable results. Objective The objective was to analyze the characteristics and complications of DCD-LT with donors aged 70 years or more (DCD-70). Materials and Methods We included 14 DCD-70-LT and compared them with a control group of 28 DBD-LT aged 70 years or more. Statistical Analysis A descriptive analysis, Mann-Whitney U test, and Pearson chi-square or Fisher test were performed when appropriate. Results Significant differences were found in aminotransferase peak at 24 hours, with an increase in the DCD-70 group (aspartate aminotransferease [AST] 1038 vs 507, P = .013; alanine aminotransferase [ALT] 750 vs 399, P = .014). The cold ischemia time was lower in DCD-70 although without significant differences (4.8 vs 6.7 hours). Biliary complications (28.6% vs 31.7%) and vascular complications (7.1% vs 7.1%) were similar. A single transplant with DCD-70 required a retransplantation due to arterial thrombosis. Mortality was the same in both cases (14.3%). Conclusion LT results with DCD-70 are similar to those of DBD-70, so the age criteria could also be extended in this type of donation.

Acute rejection (AR) remains a significant cause of graft loss. Better approaches to predict AR are being investigated. Surface CD28 protein is essential for T-cell proliferation and survival as well as cytokine production.Pretransplant CD4Pretransplant CD4The preliminary results presented herein exhibit a fast and noninvasive method that assists clinicians to prevent AR by monitoring CD4

The aim of the present study was to describe the incidence and microbiological profiles of positive cultures obtained from preservation solution (PS) and correlate these findings with infectious complications detected in the liver transplant (LT) recipient.We conducted a single-center, retrospective study between December 2010 and August 2014 among 178 LT. In all grafts, a PS culture was carried out. All the infections in the receipt until hospital discharge were collected. In patients with1, infection was considered the most severe according to Clavien-Dindo classification.PS culture was positive for bacterial or fungal agents in 79 of 178 LT recipients (44%). The most commonly cultured organisms were coagulase-negative staphylococci (64%), Enterobacteriaceae (17%), and Staphylococcus aureus (4.7%). In the 79 patients with positive PS, 49 blood cultures were requested in the period after LT. Twenty-five postoperative infections (31.7%) were diagnosed. Only 4 of 79 patients (5%) with PS contamination had a postoperative infections related with isolated microorganism.Contamination of PS appears in a high percentage of liver grafts before LT, although there is a poor correlation with postoperative infections in LT recipient. In these patients, a standardized process including fungal and bacterial cultures could be useful.

Introduction Liver transplantation is the treatment of choice for various types of end-stage liver disease and the most appropriate alternative for the treatment of hepatocellular carcinoma (HCC)-associated liver cirrhosis. The aim of this study was to describe our initial experience with the use of 18-FDG positron emission tomography (PET)/computed tomography CT before and after transarterial chemoembolization (TACE) in HCC patients undergoing liver transplantation, seeking to predict the percentage of tumor necrosis achieved by TACE procedures. Patients and Methods From January 2007 through December 2009, 39 patients with HCC and liver cirrhosis were included in our liver transplantation program. We selected the 6 subjects who underwent 18-fluorodeoxyglucose PET/CT (18-FDG PET/CT) pre- and post-TACE. Results The median SUV (standarized uptake value) in the lesions studied were 4 (range, 2.79–6.95) before TACE with a median post-TACE SUV of 0 (range, 0–4). Among patients whose post-TACE SUV decreased to 80%. Conclusion Performance of an 18-FDG PET/CT before and after TACE and comparison of SUV in patients with HCC awaiting liver transplantation provided valuable information regarding the effectiveness of TACE.

A 41-year-old man, who had undergone liver retransplantation, was admitted to our institution complaining of rectorraghia. Gastroscopy and colonoscopy failed to detect the source of bleeding. Computed tomographic angiography detected a stenosis at the portal anastomosis. Capsule endoscopy showed the presence of multiple small bowel angiodysplasias. After a surgical failure, direct portography revealed severe stenosis of the extrahepatic portal vein. Subsequent to percutaneous transhepatic portography, we dilated the stenosis using a balloon catheter and placed an expandable metallic stent, stopping the bleeding without further episodes of gastrointestinal bleeding.

The 2 main indications for emergency liver transplantation are severe acute hepatic insufficiency and emergency retransplantation. In Spain, since the creation of the National Transplant Organisation (NTO), known as “the Spanish model,” there have been high rates of donation, with a mean of 33.9 donors per million inhabitants in 2003 and 34.6 donors per million inhabitants in 2004. According to data provided by the NTO, there were 169 liver emergencies in the 2-year period 2003–2004. The time on the waiting list in an emergency situation was limited; 82.8% of cases were resolved in less than 48 hours. During this 2-year period, there were 2077 liver transplantations, including 128 emergence patients, which accounted for 6.1% of transplantations.

Despite the improved overall outcomes of liver transplantation as a result of advances in surgical techniques and improved immunosuppressive control, biliary complications (BCs) continue to be the most common cause of morbidity in liver transplant recipients. The objectives of this study were to analyze the incidence, type, and management of BCs over a 20-year period. We performed a comparative study of two groups of liver transplant patients in our unit operated on by the same surgical team: group I consists of the first 300 liver transplant patients (1989-1992), and group II is composed of the last 300 liver transplants (2007-2011). We found no significant differences in the number of cases of biliary leakage whether or not a Kehr T-tube was used. However, there was a significant relationship between a greater number of anastomotic strictures and less use of a Kehr T-tube. In our series, there has been a decrease over the years in the number of surgical interventions required to resolve these complications and an increase in radiologic and endoscopic treatment.

Introduction T-tube removal in liver transplant patients can occasionally cause a massive biliary leak and may require surgical treatment for its resolution. We present our experience with a laparoscopic approach to biliary peritonitis in liver transplant patients after the removal of a T-tube. Patients and methods From January 2003 until February 2010, we performed 351 liver transplantations in 313 recipients, including 135 with a T-tube. After its removal 31 biliary leaks developed (23%); 12 were massive and required surgery, which utilized a laparoscopic approach. Results The mean length of the intervention was 72.9 ± 12.87 minutes (range = 55–95), without any complications during the procedure, and no need to convert to a laparotomy. Mean hospital stay after the intervention was 6.75 ± 3.88 days (range 4–18). There was no mortality from the procedure. Conclusion The laparoscopic approach for biliary leakage after T-tube removal is indicated when large diffuse acute peritonitis is established a few hours postremoval of the T-tube. This safe procedure treats the complication without the need for another laparotomy.

The liver is a privileged organ with a lower incidence of rejection than other organs. However, immunosuppressive regimens are still required to control the alloreactive T-lymphocyte response after transplantation. These treatments may lead to severe complications, such as infectious diseases, cancers, cardiovascular diseases, and chronic renal insufficiency. In clinical transplantation, there is increasing evidence that some liver transplant recipients who cease taking immunosuppressive drugs maintain allograft function, suggesting that tolerance is already present. This strategy is feasible in 25% to 33% of liver transplant recipients. Few of the studies performed so far have provided a detailed analysis of the impact of immunosuppression (IS) withdrawal on pre-existing complications derived from the long-term administration of immunosuppressive drugs and the side effects associated with it. In preliminary studies, IS withdrawal was safely achieved in selected liver transplant patients, and improved not only kidney function, but also other IS-associated side-effects such as hypercholesterolemia, hyperuricemia, hypertension, and diabetes control. However, longer follow-up periods are needed to confirm the benefits of IS withdrawal in liver transplant patients.

Central pontine myelinolysis (CPM) may be more prevalent after liver transplantation (OLT). Central pontine and extrapontine myelinolysis (CPEM) is rare. The occurence of CPM may be associated with hyponatremia, a rapid rise in serum sodium concentrations, postoperatively increased plasma osmolality, and the duration of the operation. Only 1 patient had abnormal sodium levels before LT. No abnormalities were detected in immunosuppressive drug blood levels. The aim of this paper was to report our experience with CPEM among LT patients.

Introduction. The use of elderly donors can increase the pool of organs available for transplant. The aim of this study was to analyze the outcomes of grafts from donors older than 75 years. Patients and methods. We selected 29 patients transplanted from January 2003 to January 2010 with livers from donors older than 75 years for comparison with a control group (58 patients), selected among patients transplanted immediately before or after each study case. Data analyzed using SPSS 15.0 were considered statistically significant at P < .05. Results. Statistically significant differences were evident in the mean age of donors (78.3 ± 2.9 vs 50.4 ± 17.8 years, P < .001), levels of aspartate aminotransferase alanine aminotransferase (30.8 ± 18.13/24.9 ± 14.4 vs 53.81 ± 68.4/39.37 ± 39.94 U/L, P < .05), and waiting list time of (122.4 ± 94.3 vs 169.2 ± 135.5 days, P = .034) of elderly donor versus control graft cohorts. The median follow-up was 32 months (range: 4―88.0) No differences were observed at 1 and 3 years after transplantation: graft survival was 78% and 61% in the older donor group and 83% and 71% in the younger donor group, respectively. Conclusion. The use of expanded donors from elderly subjects can increase the donor pool with good results.

Twenty-four-hour gastric pH measurement was used to study duodenogastric reflux. To differentiate between gastric hyposecretion and duodenogastric reflux, we also measured bile acid concentrations in the gastric juice, and regarded pH increases to above 4 as possible episodes of reflux. The procedure was used in 60 patients, divided into the following groups: (1) control group (ten patients); (2) duodenal ulcer (ten patients); (3) type 1 gastric ulcer (five patients); (4) type 3 gastric ulcer (five patients); (5) bilateral truncal vagotomy plus pyloroplasty (ten patients); (6) truncal vagotomy plus Billroth I partial gastrectomy (ten patients); and (7) truncal vagotomy plus Billroth II partial gastrectomy (ten patients). The amount of reflux (areas of pH > 4) in the type I gastric ulcer and Billroth 1 and Billroth II groups was significantly greater than that found in the control, duodenal ulcer, type 3 gastric ulcer and truncal vagotomy plus pyloroplasty groups. The mean concentration of total bile acids was also greater in the gastrectomized patients than in the rest of the groups studied. In the type 1 gastric ulcer group the mean bile acid concentration was similar to that of the control group.

Injuries of the extra hepatic biliary tree following blunt trauma to the abdomen are rare. We present a case of avulsion of the intrapancreatic common bile duct. Very often the lesion is not identifiable until the signs of jaundice and biliary ascites occur. Intraoperative cholangiography is mandatory for the diagnosis, but the noninvasive magnetic resonance cholangiopancreatography could readily depict the injury of the extrahepatic bile duct preoperatively. When the diagnosis is late the corner stone of treatment is biliary diversion and definitive repair after complete resolution of sepsis with a choledochojejunostomy.

During a 10-year period 2610 patients were operated on for biliary lithiasis; in 225 (8·6 per cent) cases the operation concluded with a choledochoduodenostomy. The commonest preoperative diagnosis (62·2 per cent) in these 225 patients was choledocholithiasis; 30 patients had previously had a cholecystectomy. After choledochoduodenostomy, 4·0 per cent of patients had an intra-abdominal complication; six patients developed an intra-abdominal abscess and three developed an external biliary fistula. Four patients (1·8 per cent) died, three from pulmonary complications and one from a biliary fistula. After a mean follow-up period of 4·6 years, 71·5 per cent of patients were asymptomatic. The remainder suffered from dyspepsia (15·1 per cent), colicky pain (8·7 per cent) or episodes of cholangitis (4·7 per cent). Endoscopy in the symptomatic patients allowed the following conclusions: (a) no patient with dyspepsia had a problem at the anastomosis; (b) 27 per cent of those with colic had anastomotic stenosis or the sump syndrome; and (c) all patients with cholangitis had anastomotic stenosis and residual calculi.

We conducted a daily analysis of bile cellularity in 25 patients undergoing 29 orthotopic liver transplants (OLT) and correlated the cytological parameters with the clinical outcome of each patient. The 16 patients without complications only showed slides with cells during the first 4-5 postoperative days. The four patients with primary non-function (PNF) of the graft had a high cell density up to the time of the retransplant, with a preponderance of polymorphonuclear (PMN) leucocytes (59.2%) and epithelial cells (29.2%). During the episodes of sepsis (n = 3) and rejection (n = 7) we noted the sudden appearance of high cellularity, almost exclusively PMN leucocytes (96.5%), and a preponderance of PMN leucocytes (84.2%) with appreciable percentages of mononuclear cells and macrophages as well as the early appearance of lymphoblasts in the rejection episodes. Our results show that bile cytology can be a useful method for diagnosing graft complications in liver transplantation.

Laparoscopic cholecystectomy (LC) has displaced open cholecystectomy (OC) in the management of cholelithiasis. However, there are few studies on the role of this technique in patients who run a high risk of surgical complications. We performed a prospective study in 264 patients aged65 years undergoing surgery for symptomatic cholelithiasis. They were divided into two groups according to the surgical technique performed: OC (131 patients) and LC (133 patients). Conversion from LC to OC was necessary in 11 patients (8.3%). Mean surgery time was 70.9 min for the OC group and 75 min for the LC group. The LC group had a lower rate of postoperative complications (13.53%) than the OC group (23.6%). The incidence of mild complications was similar in both groups; however, the rate of moderate complications was significantly higher in the OC group. Hospital stay was significantly longer in the OC group (9.9 days) than in the LC group (3.71 days). These results suggest that LC should be indicated in elderly patients, as they are better than those obtained with with OC and involve a lower morbidity rate and shorter hospital stay.

We conducted a daily analysis of bile cellularity in 16 orthotopic liver transplant patients fitted with a T-tube, and correlated the cytological parameters (number of cells per slide, and percentage of difference cell types) with the duration of cold ischemia time (CIT). Two groups were established: one comprised patients whose CIT was less than 7 hr (CIT averaged 345 min) and the other comprised patients with a CIT of more than 7 hr (CIT averaged 505 min). The control group consisted of 15 patients who had received cholecystectomy for biliary lithiasis and were fitted with a T-tube. All 3 groups showed the highest cell density on the 1st postoperative day (control: 53.3 +/- 15.5 cells/slide; short ischemia: 70 +/0 21.4 cells/slide; long ischemia: 158.8 +/- 53.2 cells/slide), which steadily ischemia group showed a higher cell density than did the control group for the first 2 days, although this was not significant. The long ischemia group showed the highest cell density, although only significantly for the first 2 days when compared with the controls, and basically at the expense of a increase in ductal epithelial cells. Our results show that prolonged cold ischemia causes an increase in bile cell density at the expense of ductal epithelial cells: the longer the preservation time, the greater the increase.

Laparoscopic cholecystectomy has several advantages over traditional cholecystectomy, which make it the treatment of choice for patients with uncomplicated biliary lithiasis. However, in patients with acute cholecystitis, the role of this technique remains controversial and some clinicians regard this condition as a contraindication to laparoscopic cholecystectomy.Between June, 1991 and July, 1993, a total of 259 patients with cholelithiasis underwent laparoscopic cholecystectomy at the "Virgen de la Arrixaca" University Hospital. Of these patients, 60 underwent laparoscopic cholecystectomy for acute cholecystitis.Conversion to laparotomy was necessary in eight patients (13 percent). Mean operating time was 83 minutes (range, 45 to 180 minutes). Overall mean hospital stay (laparoscopy and conversions) was 3.1 days (range, one to nine days). There was no mortality or injury to the common bile duct in our series.We believe that laparoscopic cholecystectomy in patients with acute cholecystitis is a safe and effective procedure, in which the patient can benefit from the advantages of laparoscopic surgery without an increase in mortality and morbidity rates.

The objective of this study was to evaluate the effect of the surgical technique on postoperative renal function during the first week after liver transplantation (OLT). We performed a retrospective study of 184 consecutive OLT. Criteria for acute renal failure were: serum creatinine1.5 mg/dL, an increase by 50% in the baseline serum creatinine, or oliguria requiring renal replacement therapy. The distribution of patients according to the surgical technique was: standard (n=84), venovenous bypass (n=20), and piggyback (n=80). Other variables analyzed were: intraoperative requirement for blood products, treatment with adrenergic agonists, intraoperative complications, and postreperfusion syndrome. Univariate analysis showed the following parameters to be significantly related to postoperative renal failure: intraoperative fresh frozen plasma and cryoprecipitate requirements, intraoperative complications, postreperfusion syndrome, need for noradrenaline or dobutamine, standard surgical technique versus piggyback (39% vs 18%, P.01) and venovenous vs piggyback (50% vs 18%, P.01). Logistic regression analysis identified the following variables as having independent prognostic value: (1) Standard surgical technique vs piggyback (OR=3.3, P=.01); (2) venovenous vs piggyback (OR=4.7, P=.02); and (3)20 U cryoprecipitate requirement (OR=1.04, P=.01). In conclusion, compared with the piggyback technique, the standard surgical technique appears to be an independent risk factor for postoperative acute renal failure. When venovenous bypass is used in patients who do not tolerate trial clamping of inferior vena cava, it does not reduce the incidence of postoperative renal failure. Finally, the piggyback technique significantly reduces the probability of acute renal failure after liver transplantation.

We reviewed 69 patients who underwent surgery for primary malignant tumors of the small bowel over a 15-year period. Patients with periampullary lesions were excluded, as were those with known adenocarcinomas in other sites. There were 46 males (67%) and 23 females (33%) with an average age at presentation of 52.6 years (range 4-92). Of the 69 patients, four (6%) were asymptomatic. The mean duration of symptoms before diagnosis, in the remaining 65 symptomatic patients, was 3.6 months (range 1 day 1.2 years). The most frequent symptom was abdominal pain (83%), followed by nausea and/or vomiting (54%), and weight loss (43%). Abdominal mass was the most common finding on physical examination (29%), followed by abdominal distension (24%) and abdominal guarding and rigidity (14%). Laboratory examinations were normal in 26 patients (40%). Radiographic study of the duodenum and small bowel was abnormal in 87%. The diagnosis was suspected preoperatively in 51%. Lymphoma was the most common tumor (42%), followed by adenocarcinoma (38%), carcinoid (10%) and leyomiosarcomas (10%). In 41% the neoplasm was located in the jejunum, in 33% in the ileum, in 22% in the duodenum and in 4% multiple sites were found. Lymph node metastases were found in 45% and vascular invasion was found in 19%. Of the 65 symptomatic patients 43% presented as surgical emergencies, the rest had elective surgery. 61% had a curative resection, the rest were palliative or a bypass. The operative mortality rate was 10% and the morbidity rate was 24%. Ten patients underwent emergency surgery, developed a complication, giving a morbidity rate of 32% in this group. The 5-year overall survival was 43.25%. The 5-year survival for carcinoid tumors was 60% while the 5-year survival for small bowel malignant lymphoma and adenocarcinoma was 40 and 34.28% respectively.