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Twenty percent of intestinal transplant recipients will require a surgical alternative to conventional primary abdominal wall closure. Abdominal wall transplant is a developing technique that is increasingly performed for this purpose in isolated intestinal or multivisceral recipients; however, adequate closure of the donor is paramount while simultaneously obtaining a large enough graft. The aim of this study is to describe alternative surgical techniques for closure of the donor in cases in which abdominal wall graft extraction hinders subsequent donor abdominal closure.We describe the cases of 2 young donors in whom intestinal extraction was not carried out and in whom wall closure was not feasible, following standard techniques after abdominal wall graft extraction. We performed 2 different procedures to obtain adequate closure. 1. Hemifascia and hemiabdominal wall graft extraction: It is an option when the recipients require an extension of the abdominal aponeurosis yet have enough skin to guarantee skin closure. The perfusion of both epigastric arteries is needed. The remaining cutaneous half is used for closing the donor's abdomen.2. Hemiabdominal wall graft extraction: Full-thickness abdominal wall is harvested from the donor, selecting the most vascularized half. It is an alternative for recipients who need a skin implant in addition to an aponeurosis extension. This option should be used for recipients who do not require a large fascial graft but do require a significant cutaneous graft. The nontransplanted half of full-thickness abdominal wall is used for donor closure.Abdominal wall transplant allows for expansion of the abdominal cavity in organ recipients and reduces the risk of compartmental syndrome and subsequent ischemia. However, the donor wall defect must be considered. The choice of donation technique was based on the magnitude of the defect in the donor as well as the size of defect to be covered in the recipient while ensuring a tight and complete closure of the donor's abdomen.Abdominal wall graft extraction can be performed using nonconventional techniques that account for the extension and type of coverage needed by the recipient while guaranteeing proper closure of the donor.

An increased number of older recipients underwent liver transplantation in recent years, and consequently needing to obtain more liver grafts. In order to increase this pool, in 2006, we initiated the use of livers from uncontrolled circulatory death (uDCD). We analyzed the use of uDCD livers in sexagenarian recipients and their effect on overall survival.A retrospective and comparative study was performed among 4 groups according to recipient age (less or greater than 60 years) and donor type (donor brain death [DBD] or uDCD): Group A: DBD livers in recipients aged60 years (n = 169); Group B: uDCD livers in recipients aged60 years (n = 36); Group C: DBD livers in recipients aged60 years (n = 96); and Group D: uDCD livers in recipients aged60 years(n = 39).Intraoperative transfusion, biliary complications, primary non-function, acute rejection, chronic renal dysfunction, retransplantation, and mortality during follow-up (cardiovascular diseases in 3 patients, hepatitis C virus recurrence in 4 patients, and de novo malignancies in 3 patients) were significantly higher, and 5-year patient and graft survival was significantly lower in sexagenarian recipients. Bilirubin and packed red blood cells transfusion were risk factors for patient survival, whereas hepatocelular carcinoma, creatinine, and packed red blood cells transfusion were risk factors for patient survival. Recipient age (60 years) was confirmed as protective factor for patient and graft survival, whereas the use of uDCD was not a risk factor for patient or graft survival.Use of a uDCD liver did not demonstrate as a risk factor for patient and graft survival, and recipient age (60 years) was a protective factor for patient and graft survival.

The McCluskey index has been used as a tool to predict massive bleeding (6 red blood cells units) during orthotropic liver transplantation. The objective of this study is to verify its efficacy at our institution.Between May 1998 and December 2017, we performed 1216 orthotropic liver transplantations, of which 1016 had sufficient data registered with respect to hemoderivative transfusion. We divided these patients into groups based on the original study of McCluskey. This study was approved by the ethical committee of our Institution and was performed in accordance with the Declaration of Helsinki.The mean Model for End-Stage Liver Disease score in the 4 groups was 7.5 (range, 7-8) for low risk; 13 (range, 3-32) for medium risk, 17 (range, 8-41) for high risk, and 25 (range, 11-36) for very high risk (P.001). No significant differences were observed regarding body mass index or hospital stay. No differences have been found in the number of suboptimal donors among the groups. With respect to hemoderivative transfusions, we observed the following for red blood cells: 7 (range, 6-8) units for low risk; 5.5 (range, 0-74) for medium risk; 7 (range, 0-73) for high risk, and 12 (range, 5-30) for very high risk (P.001) and transfusion of plasma: 12 (range, 10-15) units for low risk; 11 (range, 0-89) for medium risk; 14 (range, 0-76) for high risk, and 13 (range, 3-30) for very high risk (P = .001).The McCluskey index is a good indicator of the risk of hemorrhage and hence the necessity of transfusion.

Introduction Intraoperative bleeding during liver transplantation has been correlated with a higher risk of morbidity and mortality and decrease in patient and graft survival. Materials and Methods Between January 2006 and December 2016 we performed 783 orthotopic liver transplants. After applying exclusion criteria, we found liver grafts from donors after circulatory death (DCD, group A) were used in 69 patients and liver grafts from donors after brain death (group B) were used in 265 patients. Results No difference was found in terms of sex, body mass index, Model for End-Stage Liver Disease score, indication for transplantation, intensive care unit stay, and Child-Pugh score. The mean transfusion of hemoderivates was as follows: red blood cell 9 (0-28) units in group A vs 6 (0-20) units in group B (P = .004) and fresh frozen plasma 10 (0-29) units in group A vs 9.5 (0-23) in group B (P = .000). The only 2 factors related to massive blood transfusion (>6 units of red blood cell) were uncontrolled DCD condition (odds ratio = 2.38; 95% confidence interval, 1.32-4.31; P = .004), and higher Model for End-Stage Liver Disease score (odds ratio = 2.63; 95% confidence interval, 1.53-4.55; P = .001). Survival at 1, 3, and 5 years was 81.3%, 70.2%, and 68.9% in group A vs 89%, 83.7%, and 78% in group B (P = .070). Conclusion The use of liver grafts from DCDs is associated with increased necessity of transfusion of hemoderivates in comparison with the use of liver grafts from donors after brain death.

Background Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. Methods This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. Results We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p p p Discussion Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.

Resumen Introduccion La neoplasia quistica hepatica es una neoplasia poco frecuente, que representa aproximadamente el 5% de las lesiones quisticas del higado. El diagnostico preoperatorio es dificil y puede causar confusion. El objetivo del estudio es analizar una serie de casos operados en nuestro centro con diagnostico anatomopatologico de neoplasia quistica hepatica y describir la sintomatologia, diagnostico y tratamiento de acuerdo con la actual clasificacion. Metodos Se realizo un analisis retrospectivo de todas las neoplasias quisticas hepaticas operadas entre enero de 2000 y diciembre de 2019. El estudio se baso en los informes de anatomia patologica ya existentes. Los casos anteriores al 2010 fueron reclasificados segun la clasificacion de la OMS del ano 2010. Resultados La muestra total del estudio resulto en 10 pacientes: 6 fueron neoplasias mucinosas quisticas hepaticas y 4 neoplasias papilares intraductales biliares. La mayoria de los pacientes fueron mujeres (8/10) y la edad media fue de 47 anos. En cuanto al tratamiento, hubo 3 hepatectomias y 7 enucleaciones. En ningun caso se realizo una biopsia intraoperatoria de los margenes quirurgicos. En un caso se observo atipia celular variable con zonas de adenocarcinoma, por lo que el paciente recibio quimioterapia adyuvante con taxol y carboplatino. En todos los casos los margenes de reseccion fueron negativos. Conclusion Las neoplasias quisticas hepaticas son tumores poco frecuentes, que plantean un dilema en el diagnostico diferencial, por lo que, ante la sospecha radiologica, el tratamiento de eleccion deberia ser la reseccion completa del tumor para evitar su malignizacion y la recidiva.

Diagnosis of sinusoidal obstruction syndrome (SOS) after hematopoietic cell transplantation (HCT) is based on clinical criteria including weight gain, ascites, hepatomegaly, and jaundice.[1] However, clinical and histological features and prognosis of SOS after liver transplantation (LT) seem to differ from SOS after HCT.[2, 3] We aimed to determine the characteristics and outcomes of SOS after LT.

BACKGROUND: The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery.; METHODS: This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes.; RESULTS: A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P= .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ? .001). The need for vascular reconstruction was associated with higher mortality (P= .04). Two of the 4 patients transplanted died.; CONCLUSION: Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results. Copyright © 2022 Elsevier Inc. All rights reserved.

Long-term humoral immunity and its protective role in liver transplantation (LT) patients have not been elucidated. We performed a prospective multicenter study to assess the persistence of immunoglobulin G (IgG) antibodies in LT recipients 12 months after coronavirus disease 2019 (COVID-19). A total of 65 LT recipients were matched with 65 nontransplanted patients by a propensity score including variables with recognized impact on COVID-19. LT recipients showed a lower prevalence of anti-nucleocapsid (27.7% versus 49.2%; P = 0.02) and anti-spike IgG antibodies (88.2% versus 100.0%; P = 0.02) at 12 months. Lower index values of anti-nucleocapsid IgG antibodies were also observed in transplantation patients 1 year after COVID-19 (median, 0.49 [interquartile range, 0.15-1.40] versus 1.36 [interquartile range, 0.53-2.91]; P

Abdominal wall transplantation has been consolidated as an alternative to primary abdominal wall closure in intestinal and multiple organ transplant recipients. Given that it is feasible to obtain the visceral graft and the abdominal wall graft from the same donor, abdominal wall transplantation could offer satisfactory outcomes and be easily coordinated. Non-vascularized fascia is one of the alternatives for abdominal wall closure in transplantation. We report two cases of non-vascularized fascia transplantation in intestinal and multivisceral transplants, respectively. Both donors were young (23 and 18 years old). Both recipients had endured multiple previous surgeries, and no surgical alternatives for primary wall repair could be offered. In both cases, a complete abdominal wall flap was retrieved from the donor, however, due to the characteristics of the recipient's abdominal wall defect, only non-vascularized fascia was used after removing skin and subcutaneous cellular tissue from the graft. Abdominal wall transplantation is an option to consider for abdominal wall closure in patients with multiple previous surgeries and no alternatives for primary wall repair.

Resumen El cierre de la pared abdominal despues del trasplante de organos abdominales, especialmente en los casos de trasplante intestinal y multivisceral, sigue siendo un reto en muchos pacientes debido al importante numero de intervenciones previas al trasplante, asi como al edema de asas que dichos injertos presentan. Ante la imposibilidad de cierre primario y debido a las complicaciones en el uso de mallas, surge la opcion del trasplante de la pared abdominal. Existen diversas opciones para dicho procedimiento, desde el empleo unicamente de la fascia no vascularizada hasta el trasplante de espesor completo de la pared abdominal. Revisamos la literatura en cuanto al uso de los injertos referidos y presentamos 2 casos de trasplante de fascia no vascularizada realizados en nuestra unidad de trasplante.

AIM To increase the number of available grafts. METHODS This is a single-center comparative analysis performed between April 1986 and May 2016. Two hundred and twelve liver transplantation (LT) were performed with donors ≥ 70 years old (study group). Then, we selected the first cases that were performed with donors < 70 years old immediately after the ones that were performed with donors ≥ 70 years old (control group). RESULTS Graft and patient survivals were similar between both groups without increasing the risk of complications, especially primary non-function, vascular complications and biliary complications. We identified 5 risk factors as independent predictors of graft survival: recipient hepatitis C virus (HCV)-positivity [hazard ratio (HR) = 2.35; 95% confidence interval (CI): 1.55-3.56; P = 0.00]; recipient age (HR = 1.04; 95%CI: 1.02-1.06; P = 0.00); donor age X model for end-stage liver disease (D-MELD) (HR = 1.00; 95%CI: 1.00-1.00; P = 0.00); donor value of serum glutamic-pyruvic transaminase (HR = 1.00; 95%CI: 1.00-1.00; P = 0.00); and donor value of serum sodium (HR = 0.96; 95%CI: 0.94-0.99; P = 0.00). After combining D-MELD and recipient age we obtained a new scoring system that we called DR-MELD (donor age X recipient age X MELD). Graft survival significantly decreased in patients with a DR-MELD score ≥ 75000, especially in HCV patients (77% vs 63% at 5 years in HCV-negative patients, P = 0.00; and 61% vs 25% at 5 years in HCV-positive patients; P = 0.00). CONCLUSION A DR-MELD ≥ 75000 must be avoided in order to obtain the best results in LT with donors ≥ 70 years old.

Resumen Introduccion La quimioembolizacion transarterial (QETA) es considerada una opcion terapeutica utilizada en el tratamiento del carcinoma hepatocelular y de las metastasis hepaticas secundarias del carcinoma colorrectal, tumores neuroendocrinos y melanoma ocular. Aunque es un procedimiento seguro, no esta exento de complicaciones, siendo la mas frecuente la colecistitis aguda. Otras complicaciones descritas son el tromboembolismo pulmonar, el absceso hepatico, lesiones de la mucosa gastrointestinal, lesiones de la via biliar, etc. El objetivo principal del estudio es revisar y describir las complicaciones derivadas de la QETA en el tratamiento de los tumores hepaticos. Metodos Se ha realizado un analisis retrospectivo de todas las QETA practicadas en nuestro centro entre enero de 2013 y diciembre de 2016. En dicho periodo se realizaron 322 QETA en 196 pacientes. Resultados Del total de procedimientos, 258 (80%) fueron realizados en hombres y 64 (20%) en mujeres. Ademas, la edad media de los pacientes fue de 66,5 anos. Las complicaciones mayores derivadas de la QETA fueron descompensacion edemo-ascitica (6 casos), colecistitis aguda (4), pancreatitis aguda (3), rotura hepatica (1), absceso hepatico (1) y deterioro de la funcion renal (1). Ademas, el sindrome postembolizacion se objetivo en 71 (22%) casos. En el analisis multivariante se observo que el antecedente cardiovascular (OR: 4,5; IC 95%: 1,2-17; p = 0,025) es un factor de riesgo para el desarrollo de complicaciones post-QETA. Conclusiones Las complicaciones derivadas de la QETA son poco frecuentes y con una baja incidencia de mortalidad.

We present the case of a 41-year-old male with type A blood group and a diagnosis of fulminant liver failure of an unknown cause, who was admitted to the Intensive Care Unit (ICU) with severe coagulopathy (INR 6), hyperammonemia (250 umol/l) and grade IV encephalopathy (four King's criteria and both Clichy's criteria). He also had GCS 8/15, despite TDE-MARS, dialysis and ventilator support via endotracheal tube due to encephalopathy. He was registered as status 0 for liver transplant. In the absence of a compatible donor, the patient received an ABO incompatible liver transplant (LT), group O, using the piggyback technique, without any complications. He required transfusion of five units of plasma but did not require a blood transfusion.

A survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. Methods: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. Results: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (< 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. Conclusions: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country. Introducción: realizamos una encuesta sobre soporte nutricional perioperatorio en cirugía pancreática y biliar en hospitales españoles en 2007, que mostró que pocos grupos quirúrgicos seguían las guías de ESPEN 2006. Diez años después enviamos un cuestionario para comprobar la situación actual. Métodos: treinta y ocho centros recibieron un cuestionario con 21 preguntas sobre tiempo de ayunas antes y después de la cirugía, cribado nutricional, duración y tipo de soporte nutricional perioperatorio, y número de procedimientos. Resultados: respondieron 34 grupos. La mediana de pancreatectomías (cabeza/total) fue de 29,5 (IC 95 %: 23,0-35; rango, 5-68) (total, 1002), la de cirugías biliares malignas de 9,8 (IC 95 %: 7,3-12,4; rango, 2-30) y la de resecciones biliares por patología benigna de 10,4 (IC 95 %: 7,6-13,3; rango, 2-33). Solo el 41,2 % de los grupos utilizaban soporte nutricional antes de la cirugía (< 50 % habian efectuado un cribado nutricional). El tiempo medio de ayuno preoperatorio para sólidos fue de 9,3 h (rango, 6-24 h), y de 6,6 h para líquidos (rango, 2-12). Tras la pancreatectomía, el 29,4 % habían intentado administrar una dieta oral precoz, pero el 88,2 % de los grupos usaron algún tipo de soporte nutricional y el 26,5 % usaron NP en el 100 % de los casos. Los demás grupos usaron diferentes porcentajes de NP y NE en sus casos. En la cirugía biliar maligna, el 22,6 % utilizaron NP siempre y NE en el 19,3 % de los casos. Conclusiones: la NP es el soporte nutricional más utilizado tras la cirugía de cabeza pancreática. Solo el 29,4 % de las unidades usan nutrición oral precoz y el 32,3 % emplean la NE tras este tipo de cirugía. El 22,6 % de las instituciones usan NP habitualmente tras la cirugía de tumores biliares malignos. Las guías ESPEN 2006 no se siguen de forma habitual en nuestro país tras más de 10 años desde su publicación.

Resumen Introduccion La fuga anastomotica (FA) es una complicacion seria en cirugia colorrectal, dado que conlleva un aumento de la morbimortalidad. El objetivo de este estudio prospectivo no aleatorizado es determinar si la proteina C reactiva (PCR) es util como predictor de FA en pacientes intervenidos por via laparoscopica versus cirugia abierta. Metodos Se incluyeron 168 pacientes intervenidos de manera electiva por enfermedad colorrectal. La PCR fue medida diariamente en los 5 primeros dias del postoperatorio. Se analizaron las complicaciones y, especialmente, la FA. Resultados Presentaron complicaciones 32 (45,7%) pacientes del abordaje abierto, 15 (18,7%) del laparoscopico y 12 (29,4%) en el grupo de convertidos a cirugia abierta (p = 0,002). Desarrollaron FA 9 pacientes del abordaje abierto, 5 de los del laparoscopico y ninguno del grupo que hubo que convertir (p = 0,15). Hubo diferencias estadisticamente significativas de los valores de PCR entre los 3 grupos (p = 0,03). Las curvas ROC mostraron un area bajo la curva (ABC) en el dia 3 para el abordaje abierto y laparoscopico de 0,731 y 0,760, respectivamente. En el dia 4 obtuvimos un ABC de 0,867 en el abierto y de 0,914 en el laparoscopico. Los puntos de corte en el dia 4 fueron: en abierto 159,2 mg/L; sensibilidad 75%, especificidad 89% y valor predictivo negativo (VPN) de 96% (p Conclusiones La PCR en el cuarto dia postoperatorio es util para diagnosticar FA; se deben tener en cuenta los diferentes puntos de corte en funcion del abordaje quirurgico utilizado.

Abdominal wall transplant is developed in the context of intestinal and multivisceral transplant, in which it is often impossible to perform a primary wall closure. Despite the fact that abdominal wall closure is not as consequential in liver transplant, there are circumstances in which it might determine the success of the liver graft, especially in situations that compromise the abdominal cavity and facilitate an abdominal compartment syndrome. Case 1 A 14-year-old girl suffering from cryptogenic cirrhosis with severe portal hypertension that causes ascites and severe malnutrition. Uneventful liver transplant, with a graft procured from a 14-year-old donor. At the time of wall closure it was decided to implant a nonvascularized fascia graft to supplement the right side of the transverse incision, with a 17 x 7 cm defect. This required reintervention after 4 months for biliary stricture. At that point, the wall graft was almost completely integrated into the native tissue. Case 2 A 63-year-old man, transplanted for hepatitis C virus+ hepatocellular carcinoma+ nonocclusive portal thrombosis. Thirty-six hours after transplant the patient developed portal thrombosis. Thrombectomy and closure with biological mesh were performed. After 24 hours he was reoperated on for abdominal compartment syndrome and temporary closure with a Bogota bag. Six days later he underwent omentectomy, intestinal decompression, and left components separation, identifying a 25 x 20 cm defect. For definitive closure, a nonvascularized fascia graft procured from a different donor was used, accomplishing a reduction in intra-abdominal pressure. Nonvascularized fascia transplantation is an interesting alternative in liver transplant recipients with abdominal wall closure difficulties.

Resumen Introduccion La enfermedad diverticular del apendice es infrecuente, con una incidencia que varia desde 0,004 a 2,1%. Suele presentarse entre la cuarta o quinta decada de vida, con ausencia de sintomas gastrointestinales y dolor abdominal insidioso. Los pacientes habitualmente consultan de forma tardia, con el consiguiente aumento de morbimortalidad. El objetivo de este estudio fue determinar las caracteristicas clinicas de la enfermedad diverticular del apendice. Metodos Se realizo un estudio retrospectivo de todos los pacientes operados de apendicectomia en un hospital terciario desde septiembre de 2003 hasta septiembre de 2013. Resultados Durante este periodo se realizaron 7.044 apendicectomias, encontrandose 42 casos de enfermedad diverticular del apendice, que representa una incidencia de 0,59%. De ellos, 27 pacientes fueron de sexo masculino. La edad media fue de 46,6 ± 21 anos. El promedio de la estancia hospitalaria fue de 4,5 dias. El 46% de los casos presentaban perforacion del apendice. En el 80% de los casos se realizo una prueba de imagen complementaria. La incidencia de neoplasia asociada a enfermedad diverticular fue de 7,1%. Conclusiones La enfermedad diverticular del apendice es un hallazgo incidental. En la fase aguda presenta sintomas indiferenciables de la apendicitis aguda. El tratamiento de eleccion es la apendicectomia. Presenta una mayor probabilidad de desarrollar neoplasias del apendice.

Background and objective Familial amyloid polyneuropathy (FAP) is the most prevalent type of hereditary systemic amyloidosis. It is an autosomal dominant disease characterized by the deposition of an abnormal variant transthyretin. It has a worldwide distribution, with localized endemic areas in Portugal, Sweden and Japan. In Spain there is an endemic focus, located in Mallorca. Liver transplantation is the only curative option for patients with FAP. The aim of this study was to describe the clinical and demographic characteristics of patients transplanted with a diagnosis of PAF. Material and method Six patients with PAF underwent liver transplantation between April 1986 and December 2012. Results The mean age was 57.7 + 16 years, patients of Spanish origin were older than 60 years. All patients had progressive symptoms as mixed polyneuropathy. In 2 patients, combined heart–liver transplants sequentially were performed. Patient survival and graft was 80% at 1, 3 and 5 years. Conclusions The only effective treatment for etiologic PAF is liver transplantation. Early detection is the key to the treatment and control, avoiding the irreversible organ damage.

Anastomotic leak (AL) is a serious complication in colorectal surgery due to its increase in morbidity and mortality. The aim of this prospective non-randomised study is to determine whether C-reactive Protein (CRP) is useful as a predictor of AL in patients undergoing open versus laparoscopic surgery.A total of 168 patients undergoing elective colorectal surgery were included. CRP was measured daily during the first 5postoperative days. Complications, specially AL, were analysed.Following an open approach 32 patients (45.7%) presented complications, 15 (18.7%) in the laparoscopic group and 12 (29.4%) in the converted group (P=0.153). Following open surgery 9 patients experienced AL, 5 were detected in the laparoscopic group and none in those converted (P=0.153). There were significant differences in CRP values between the 3 groups (P=0.03). ROC Curves showed AUC for the open and laparoscopic approach of 0.731 and 0.760 respectively. On day 4 the AUC was 0.867 for the open group and 0.914 for the laparoscopic group. Cut-off points on day 4 were: Open: 159.2mg/L; sensitivity 75%, specificity 89% and NPP 96% (P0.001). Following laparoscopic surgery the cut-off point was 67.3%; sensitivity 100%, specificity 89.5% and NPP 100% (P=0.016).CRP on day 4 is useful to diagnose AL. Different cut-off values should be taken into account depending on the approach used.

Resumen La presion en lista de espera de trasplante hepatico obliga a la exploracion de nuevas fuentes de donacion, siendo la utilizacion de injertos procedentes de donantes despues de muerte cardiocirculatoria una de las que reunen un potencial mas prometedor e interesante. Inicialmente, este recurso ha sido utilizado en Espana a traves de la llamada categoria II de Maastricht, previamente denominada asistolia no controlada tipo II . Diferentes motivos han conducido a reconsiderar la donacion despues de la llamada muerte cardiocirculatoria controlada en el territorio nacional. El fenomeno distintivo en este tipo de donacion es el estres isquemico al que se exponen los organos del donante con sus importantes implicaciones sobre los resultados. Los aspectos particulares de esta modalidad de trasplante hepatico son el objeto de este trabajo.

There is no scientific evidence to show which surgical technique should be used in treating hydatidosis of the liver; nor is there consensus on whether laparoscopy should be used in hydatidosis, because of the risk of dissemination or anaphylaxis. We conducted a multicenter study of laparoscopic radical surgery for hydatidosis of the liver (LRSH). The main objectives of the study were to determine the feasibility of LRSH, to examine the associated morbidity, and to evaluate the associated recurrence rate. The present report is based on a retrospective multicenter study of patients with hydatid disease of the liver treated by LRSH. The study period was from January 2000 to April 2012. There were 37 patients (46 % male) with 43 cysts. The median age was 53.1 years. Median cyst size was 5.8 cm. The most common location of the cyst was the left lateral sector (62 %). The median number of trocars used was 4. Protective scolicide-soaked swabs were used in 57 % of patients. We performed 24 total closed cystectomies, 12 left lateral sectionectomies, and 4 liver resections. The median operating time was 185 min and the mean blood loss was 184 mL. The conversion rate was 8 %. Morbidity was 16 % and mortality 0 %. The length of hospital stay was 4.8 days. No cyst recurrence was observed after a follow-up of 30.6 months. Despite the limitations and biases of a retrospective multicenter study, we believe that LRSH is feasible in favorable segments but is technically demanding. The low morbidity and absence of recurrence suggest that LRSH should be performed whenever feasible.

Resumen: Una de las características singulares de la enfermedad de Parkinson (EP) es la gran variabilidad clínica en relación con el tratamiento que puede acontecer en un mismo paciente. Esto sucede tanto con el tratamiento específico para la EP como con otra serie de fármacos que pueden empeorar la función motora. Por esta razón, el manejo perioperatorio de la EP requiere experiencia y sobre todo una planificación adecuada. En este artículo se revisan las peculiaridades de la EP y su tratamiento, y se plantea una estrategia para el perioperatorio de estos pacientes. Abstract: One of the particular characteristics of Parkinson's disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and a strategy is set out for the perioperative management of these patients. Palabras clave: Enfermedad de Parkinson, Manejo perioperatorio, Riesgos perioperatorios, Keywords: Parkinson's disease, Perioperative management, Perioperative risks

Lesions produced in the graft mucosa due to harvesting, storage, and implantation must be graduated to assess the subsequent protocolized biopsy specimens. The aim is to identify type and intensity of graft mucosal lesions observed immediately after implantation. Congestion, hemorrhage, microthrombi, neutrophilic infiltrates, shortening of villi, epithelial detachment, erosion, and crypt loss were separately evaluated by two pathologists in mucosal biopsy specimens from 13 grafts. Each change was assessed as normal, mild, moderate, or severe and by splintering the summation of points a global score was designed. Cold ischemia time was registered. Correlation between the pathologists' evaluations and between final preservation injury degree and cold ischemia time was determined using the "index of correlation rho (ρ)" (Spearman's test). The same changes were assessed in 19 biopsy specimens from day 2 to day 6 (3.6 ± 1.1) to determine their evolution. Congestion was found in 7 biopsy specimens, microthrombi in 2, hemorrhage in 4, neutrophils in 6, villous atrophy in 8, epithelial detachment in 9, erosions in 2 and/or crypt loss in 2. The maximum degree of preservation injury was expressed as intense congestion and hemorrhage associated with epithelial detachment and villous atrophy. The global preservation score was grade 3 in 2 cases, grade 2 in 5, grade 1 in 2, and grade 0 in 4. There was positive correlation (ρ = 0.915) in the evaluation between pathologists (P .01), total agreement in 9 biopsy specimens, and partial agreement (only 1 point disagreement) in 4. Mean cold ischemia time was 327 ± 101 min. (135-480). There was positive correlation (ρ = 0.694) between preservation score and cold ischemia time (P .01). In the follow-up biopsy procedures, histological injury decreased by at least one grade in every case. Additionally, karyorrhexis was observed in 3 grafts and very occasional apoptosis in 2 others. This scale achieves good reproducibility and allows graduate preservation injury in intestinal transplantation.

Total mesorectal excision (TME) of the rectum has been advocated as the gold standard surgical treatment of middle and lower third rectal cancer. Laparoscopy has gained acceptance among surgeons in the treatment of colon malignancies, while scepticism exists about laparoscopic TME in terms of safety and its oncological adequacy.To evaluate the impact of laparoscopic TME on surgical and oncological outcome in a group of consecutive unselected patients.One hundred and thirty-two patients with middle or inferior rectal cancer were admitted to our unit and underwent TME from December 1998 to February 2008. Eighty-nine patients were approached with laparoscopy. Patients staged cT3/4 cTxN+ or uTxN+ were submitted to neoadjuvant treatment. Postoperative complications and oncological outcomes were registered.In the laparoscopic group 80 anterior resections (including 4 intersphincteric resections and manual colo- anal anastomosis) and 9 abdominal-perineal resections were performed. 33.3% of patients were enrolled in "long-course" neoadjuvant chemo-radiotherapy (partial and complete response rates 88.2% and 11.8%, respectively). Protective lateral ileostomy was performed in 72% of patients. Mean operative time was 254.3+/-38.3 min and mean blood loss was 215+/-180 ml. Conversion rate was 12.7%. Morbidity rate was 39.3% without mortality. The rate of anastomotic leaks was 13.48%, reoperation rate 13.48%, recovery rate 3.1+/-1.4 days and hospital stay 10.4+/-4.6 days. Concerning adequacy of oncologic resection, mean distance of the tumour from the anal verge was 4.3+/-2.2 cm. Nodal sampling of 12.4+/-4.8 were obtained. Six patients (6/89, 6.74%) had a R1 margin: 3 distal and 3 circumferential. Median follow-up was 29 months and local recurrence rate was 5.79%. Four-year cumulative overall survival was 78% and disease-free survival was 63% (Kaplan-Meier method).Laparoscopic approach for rectal tumour is a technically demanding procedure, but it is oncologically safe.

Resumen Los hamartomas quisticos retrorrectales (tailgut cysts) son tumores congenitos poco frecuentes derivados de remanentes embrionarios postanales del intestino. La mayoria de los hamartomas quisticos son multiquisticos y aparecen como masas asintomaticas en mujeres de mediana edad. El tratamiento de eleccion es la extirpacion completa. Las complicaciones mas frecuentes son la infeccion y el desarrollo de fistulas cutaneas y la degeneracion maligna. El diagnostico diferencial incluye una extensa variedad de patologias que pueden existir en el espacio retrorrectal. En este articulo presentamos 3 pacientes con hamartomas quisticos y realizamos una revision de su etiopatogenia, las manifestaciones clinicas, las tecnicas de diagnostico, sus complicaciones y los diagnosticos diferenciales. Asimismo, se discuten las diferentes tecnicas quirurgicas posibles para su abordaje quirurgico.

Background/Purpose Severe gastrointestinal dysmotility (GID) impairs patients' quality of life and is almost uniformly fatal after complications of parenteral nutrition. Intestinal and multivisceral transplants have been used as alternative treatment of these disorders. We studied patients with GID treated with transplantation in our center, and reviewed their outcome to determine the therapeutic efficacy of multivisceral transplants. Methods The transplant database was searched for patients with GID from 1994 to 2001. We excluded patients with Hirschsprung disease, scleroderma, and diabetic enteropathy. We reviewed explanted organs, histochemistry, and immunohistochemistry and classified cases by etiology. Results We selected 12 children with GID from 124 patients transplanted. Nine presented before 1 year and 3 started with symptoms between 2 and 8 years. By combined clinical and histopathological features, 6 were classified as megacystis microcolon intestinal hypoperistalsis syndrome, 4 as chronic idiopathic intestinal pseudoobstruction, and 2 as intestinal neuronal dysplasias. Six patients died during the follow-up from 21 to 546 days after transplant. The Kaplan-Meier actuarial survival rates were 66.7% at 1 year and 50% at 3 years. Conclusions Multivisceral transplantation is a valuable therapeutic alternative for children with severe GID who cannot be adequately managed with parenteral nutrition.

Among 283 orthotopic liver transplantations made during the last 6 years at our institution, 22 (7.77%) were done on 19 patients with unresectable hepatic malignant tumors [hepatocellular carcinoma (17), angiosarcoma (1), and cholangiocarcinoma (1)]. None of them showed extrahepatic invasion, and only one had lymph node involvement. Cyclosporin A, corticosteroids, and azathioprine were administered for 3 months after the procedure, and maintenance therapy involved the first two drugs. Acute rejection rate and hospital stay were not significantly different compared with non–tumoral grafted patients. Three patients were retransplanted, one with uncontrolled acute rejection and two with chronic rejection. Intraoperative mortality was zero. Eight patients (42.1%) were alive at a mean follow-up of 31 months (range, 6–74). Four 22.2%) died with tumor recurrence, three of sepsis, two of respiratory insufficiency, one of hepatitis recurrence with cirrhosis, and one of primary lung neoplasia. If adequately selected, primary liver tumor patients may benefit from liver transplantation. Future research with adjuvant therapies will improve the results. © 1993 Wiley-Liss, Inc.

Chronic biliary obstruction with repeated bouts of cholangitis adversely affects quality of life and may lead to secondary biliary cirrhosis with liver failure. We reviewed our experience with chronic biliary complications after surgical treatment of various diseases that at the end needed a liver transplantation. Twelve patients with previous biliary surgery developed secondary biliary cholangitis, secondary biliary cirrhosis, or both. Seven had surgery for liver hydatid disease by Echinococcus granulosus, another four had complicated biliary surgery unrelated to hydatid disease, and one had a history of a traffic accident with liver trauma and hepatectomy with chronic biliary fistula. The repeated cholangitis attacks and in two cases of hydatid disease the development of biliary-bronchial fistulas made these patients' lives miserable. All had had previous surgical procedures that made the transplantation procedure more difficult. Nevertheless, patient survival and graft actuarial survival after liver replacement were 75.0% and 69.2%, respectively, at 5 years.

In the immunosuppression of orthotopic liver transplant recipients, steroids are used despite their unspecific action and long-term side effects. Few studies have been carried out on steroid withdrawal and many aspects remain to be elucidated.A prospective study was performed to analyse the effect of steroid withdrawal on 86 patients with stable graft function, more than 1 year after orthotopic liver transplant. Thirty patients had chronic hepatitis in the graft. Seventy-two continued with cyclosporine (CsA) and 14 with CsA-azathioprine (AZA) therapy. The follow-up was 23.2 +/- 8.1 months (range 12-52 months). A paired t-test was used for statistical analysis.No acute or chronic rejection occurred, and steroids were not reinstituted. There were no changes in serum transaminase levels, but bilirubin levels decreased (p0.01). At the end of the follow-up, we found improvements in blood pressure in hypertensive patients (systolic 156.1 +/- 8.4 mmHg vs. 139.4 +/- 8.7 mmHg, p0.001); body weight (72 +/- 13.5 kg vs. 70.8 +/- 13 kg, p0.05); serum cholesterol (211.3 +/- 42 mg/dl vs. 191.6 +/- 43.5 mg/dl, p0.001) and bone mineral density in lumbar spine (0.823 +/- 0.13 g/cm2 vs. 0.893 +/- 0.135 g/cm2, p0.001). Four of ten diabetic patients were no longer insulin-dependent and insulin requirements decreased in the remaining six. No significant biochemical changes were found in patients with hepatitis in the graft, and we found an improvement in inflammatory activity in the nine biopsied patients.Steroid withdrawal with CsA monotherapy is feasible, safe and beneficial in patients who have stable liver graft function 1 year after orthotopic liver transplant. We consider that AZA therapy is not necessary unless drastic reduction of CsA levels is required because of renal dysfunction.

Introduction Everolimus is a potent immunosuppressant with several advantages over calcineurin inhibitors, such as good tolerance, preventive effects on cardiovascular morbidity, and mortality and cancer prevention as it inhibits cell proliferation. Patients and Methods Between April 1986 and December 2010, we performed 1500 liver transplants (OLT) in 1341 recipients, including 57 patients who were prescribed everolimus 24 (42.1%) as monotherapy and 33 (57.9%) as treatments combined with other immunosuppressants. We performed a retrospective analysis of our experience with conversion to everolimus in OLT recipients. Results The 43 men and 14 women had a mean overall age at transplantation of 59.1 ± 10 years. The most frequent indication for OLT was hepatocellular carcinoma (HCC; 53.8%). Everolimus was introduced to prevent HCC recurrence (53%), development of de novo tumors (33%), address renal dysfunction (7%), or overcome side effects of other immunosuppressants (7%). We observed a significant improvement in renal function using the estimated glomerular filtration rate (Crockcroft-Gault formula) from 68.5 mL/min before to 74.5 mL/min after switching to everolimus. The 72% of recipients who developed ≥1 adverse event, most frequently showed hyperlipidemia (34.4%). Conclusion Both monotherapy and combined everolimus regimens were well-tolerated immunosuppressive regimens in liver transplant recipients with recurrent or de novo malignancies. Everolimus improved renal function. The most common side effects were hyperlipidemia, edema, and mouth ulcerations, which were well controlled with anti-lipidemic agents or decreased everolimus dosages.

Background Sexual and reproductive abnormalities affect up to 50% patients with terminal liver failure. However, these functions recover quickly after orthotopic liver transplantation (OLT). Thus, 80%–90% of OLT women of childbearing age recover menstruation within a few months after transplantation. The aim of our study was to analyze the impact of pregnancy among liver transplant recipients at our center, as well as to analyze the effects of immunosuppression on the fetus. Methods From April 1986 to April 2011, we performed 1500 OLT in 1341 recipients. Among these recipients, 18 patients (1.2%) become pregnant during the follow-up. Results The most frequent causes of terminal liver failure were as follows: chronic parenchymal disease (n = 9; 50%), cholestatic disease (n = 3; 16.6%), acute liver failure (n = 5; 27.7%), and metabolic disease (n = 1; 5.5%) The average recipient age at the beginning of pregnancy was 21.2 (±7.3) years. Sixteen patients (88%) became pregnant beyond a year after OLT. The 30 pregnancies in our study resulted in the following: newborns alive (NBA; n = 20; 66.6%) abortions (n = 8; 26.6%) or fetal deaths (n = 2; 6%). The most common immunosuppressant used during pregnancy was tacrolimus (75%) followed by cyclosporine (25%). There were no maternal deaths during pregnancy or the postpartum period. Discussion We did not observe significant differences between immunosuppression type and maternal complications, pregnancy duration, and childbirth type. Although pregnancy is potential risk, the literature and our results suggest that at a year or more after OLT it usually is safe and successful.

Background. Biliobronchial fistula (BBF) is a rare complication in the natural history of liver hydatid disease by Echinococcus granulosus. We present a case of BBF after resection of a giant liver hydatid cyst in a 72-year-old woman. Case Report. A total cystpericystectomy was done, leaving the left lateral section of the liver that was fixed to the diaphragm. Postoperatively, the patient developed obstructive jaundice. An ERCP showed an obstruction at the junction of the left biliary duct and the main biliary duct and contrast leak. At reoperation, the main duct was ischemic, likely due to torsion along its longitudinal axis. A hepatotomy was done at the hilar plate, and the biliary duct was dissected and anastomosed to a Roux-en-Y jejunal loop. She was discharged without complications. Five months later, the patient developed cholangitis and was successfully treated with antibiotics. However, she suffered repeated respiratory infections, and four months later she was admitted to the hospital with fever, cough, bilioptysis, and right lower lobe pneumonia. The diagnosis of BBF was confirmed with Mebrofenin scintigraphy. At transhepatic cholangiography, bile duct dilation was seen, with a biliothoracic leak. She underwent dilatation of cholangiojejunostomy stricture with placement of an external-internal catheter. The catheter was removed 3.5 months later, and two years later the patient remains in very good condition. Conclusion. An indirect treatment of the BBF by percutaneous transhepatic dilation of the biliary stenosis avoided a more invasive treatment, with satisfactory outcome.

Between April 1986 and August 1990, 151 liver transplantations were performed at our institution, 16 (11%) of them in 14 patients with primary hepatic tumors. There were 12 hepatocellular carcinomas, 1 angiosarcoma, and 1 Klatskin tumor. None of the tumors was resectable, and there was no preoperative evidence of extrahepatic tumoral extension. Exploratory laparotomy was performed prior to transplantation in three patients and selective embolization of the tumor in six patients. There was no difference in the intraoperative requirements for blood or plasma in the patients with hepatic tumors when compared with other transplant recipients (28.6 +/- 23.6 units packed red blood cells [PRBC] versus 20.1 +/- 17.8 units PRBC, and 17.9 +/- 12.2 units plasma versus 17.1 +/- 10.5 units plasma, respectively). Extracorporeal venovenous bypass was used in all but one patient. There was no significant differences in the incidence of acute rejection or in the length of hospitalization in these patients when compared with other transplant recipients. All patients received triple immunosuppressive therapy (corticosteroids, azathioprine, and cyclosporin A). Intraoperative mortality was zero. At a mean of 13.3 months' follow-up (range: 1 to 47 months), 2 of 14 patients had died of sepsis and 1 of terminal cirrhosis (autopsies revealed no evidence of tumor recurrence); 3 patients (21%) had recurrences of the tumor (1 in the central nervous system and liver, and the other 2 in the lung). One of the three patients with a recurrent tumor is still alive after 16 months. The remaining nine patients (64%) are still alive.

Summary The association between donor age and the severity of recurrent hepatitis C and, whether there is any donor age above which severity of recurrence increases significantly, were analyzed. A total of 131 liver grafts of hepatitis C virus (HCV)-infected recipients were selected for the study. Distribution of donor age was compared between grafts with and without severe recurrence. The risk of developing severe recurrence as well as the hepatitis-free, severe hepatitis-free and HCV-related graft survival was compared between different donor age groups. Mean donor age was higher for grafts with severe recurrence (P ¼ 0.007). The risk of developing severe recurrence within 2 years post-transplant increased with donors aged ‡50 years (RR ¼ 1.34) and donors aged ‡70 years (RR ¼ 1.61). Five-year severe hepatitis-free survival rates decreased progressively when donor age was over 50 years (P < 0.001). The study shows 50 and 70 years as the donor age cut-off points above which the evolution of HCVinfected recipients worsens.