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The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted liver transplant (LT) activity across the world, with notable decreases in the number of donations and procedures in most Western countries, in particular throughout the first wave. The cumulative incidence of COVID-19 in LT recipients (with estimates ranging from 0.34% to 1.56%) appears to be at least comparable to that observed for the general population. Clinical and radiological features at presentation are also similar to non-transplant patients. The risk of death among LT recipients requiring hospital admission is high (from 12% to 19%), although some authors have suggested that overall mortality may be actually lower compared to the general non-transplant population. It is likely that these poor outcomes may be mainly influenced by the older age and higher comorbidity burden of LT recipients, rather than by the transplant status itself. In fact, it has been hypothesized that post-transplant immunosuppression would exert a protective role, with special focus on tacrolimus-containing regimens. There is scarce evidence to guide the optimal management of post-transplant COVID-19 and the use of antiviral or immunomodulatory therapies, although both clinical practice and guidelines support the dose reduction or withdrawal of anti-proliferative agents such as mofetil mycophenolate. Preliminary reports suggest that the antibody response to messenger RNA vaccines is significantly impaired as compared to non-immunocompromised individuals, in line with other transplant populations. Finally, it is foreseeable that the future will be conditioned by the emerging variants of severe acute respiratory syndrome coronavirus 2 with increased transmissibility among LT recipients.

Introduction The hepatic cystic tumour is a very rare neoplasm, representing about 5% of all cystic liver neoplasms. The preoperative diagnosis is difficult and can lead to confusion. The aim of this study is to analyze a number of cases operated at our centre with an histologic diagnosis of liver cystic neoplasms and also to describe the sintomathology, diagnosis and management as per the recent classification. Methods A retrospective analysis was performed including all the cystic liver neoplasms operated between January 2000 and December 2019. The study was performed based on the pre-existing pathology archives. The 2010 previous cases were reclassified following the new 2010 OMS classification. Results The study sample was of 10 patients, identifying 6 of them as mucinous cystic liver neoplasms, and the other 4 as intraductal papillary biliary neoplasms. The majority of the patients were women (8/10) and the median age was 47 years. Regarding the treatment, 3 hepatectomy and 7 enucleations were performed. Frozen section intraoperatively was not required in any case. In one case, variable cellular atypia with areas of adenocarcinoma was observed, and the patient received neoadyuvant chemotherapy with taxol and carboplatin. In all cases the resection margins were negative. Conclusion Cystic liver neoplasms are infrequent tumours with a difficult differential diagnosis. Therefore, with a high radiological suspicious, the treatment should be a complete resection to avoid recurrences and malignancies.

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.

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

BackgroundGeneral surgery is an area with a major incidence of adverse evets and entails increased use of resources, in addition to the injury caused to the patient. The preparation of specific tools in the field of patient safety and specifically to detect adverse events is a priority of healthcare systems. Regarding the hypothesis that the trigger tool is effective to detect adverse events in general surgery we set out this study with the aim to validate this and propose optimization.MethodsObservational, descriptive, retrospective and multicenter national study where trigger tool (40 triggers) was applied in patients who underwent surgery in general surgery departments. A descriptive analysis was performed. The tool’s sensitivity and specificity was studied by means of looking at predictive capacity. A prediction model was used for the proposed optimization by means of binary logistic regressionResults A total of 31 hospitals took part. The prevalence of adverse events was 31.53%.The tool revealed sensitivity and specificity of 86.27% and 79.55%, respectively. A total of 12 triggers comprised the optimized model. An area under the curve of 79.29% was obtained. Conclusions Trigger Tool is extremely effective to detect adverse events during surgery. The optimized model significantly reduces the number of triggers used and upholds

The protective capacity and duration of humoral immunity after SARS-CoV-2 infection are not yet understood in solid organ transplant recipients. A prospective multicenter study was performed to evaluate the persistence of anti-nucleocapsid IgG antibodies in liver transplant recipients 6 months after coronavirus disease 2019 (COVID-19) resolution. A total of 71 liver transplant recipients were matched with 71 immunocompetent controls by a propensity score including variables with a well-known prognostic impact in COVID-19. Paired case-control serological data were also available in 62 liver transplant patients and 62 controls at month 3 after COVID-19. Liver transplant recipients showed a lower incidence of anti-nucleocapsid IgG antibodies at 3 months (77.4% vs. 100%, p < .001) and at 6 months (63.4% vs. 90.1%, p < .001). Lower levels of antibodies were also observed in liver transplant patients at 3 (p = .001) and 6 months (p < .001) after COVID-19. In transplant patients, female gender (OR = 13.49, 95% CI: 2.17-83.8), a longer interval since transplantation (OR = 1.19, 95% CI: 1.03-1.36), and therapy with renin-angiotensin-aldosterone system inhibitors (OR = 7.11, 95% CI: 1.47-34.50) were independently associated with persistence of antibodies beyond 6 months after COVID-19. Therefore, as compared with immunocompetent patients, liver transplant recipients show a lower prevalence of anti-SARS-CoV-2 antibodies and more pronounced antibody levels decline.

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.

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.

Introduction Transarterial chemoembolization (TACE) is considered a therapeutic option. It is mostly used in hepatocellular carcinoma or liver colorectal, neuroendocrine or melanoma metastases. Although it is considered a safe procedure, TACE presents complications, such as acute cholecystitis, which is the most common. Other procedure-related complications include pulmonary embolism, hepatic abscess, bile duct injury, gastric mucosa injury and, less frequently, acute pancreatitis. The aim of this study is to review the complications following TACE for liver tumors. Methods We performed a retrospective study including all the TACE procedures performed in a single center during the period between January 2013 and December 2016. Results Out of the 196 patients with liver tumors who had undergone 322 TACE, 258 (80%) were male and 64 (20%) were female. Mean patient age was 66.5 years. Major complications after chemoembolization included: decompensation with edema/ascites (6 patients), acute cholecystitis (4), acute pancreatitis (3), liver rupture (1), liver abscess (1) and renal failure (1). Postembolization syndrome appeared in 71 (20%) patients. On multivariate analysis, it was observed that concomitant cardiovascular disease (OR: 4.5; 95% CI: 1.2–17; P=.025) is a risk factor for the development of complications. Conclusions TACE is a safe and effective procedure for liver tumor treatment. The majority of the complications are rare and present a low incidence of mortality.

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.

The hepatic cystic tumour is a very rare neoplasm, representing about 5% of all cystic liver neoplasms. The preoperative diagnosis is difficult and can lead to confusion. The aim of this study is to analyze a number of cases operated at our centre with an histologic diagnosis of liver cystic neoplasms and also to describe the sintomathology, diagnosis and management as per the recent classification.A retrospective analysis was performed including all the cystic liver neoplasms operated between January 2000 and December 2019. The study was performed based on the pre-existing pathology archives. The 2010 previous cases were reclassified following the new 2010 OMS classification.The study sample was of 10 patients, identifying 6 of them as mucinous cystic liver neoplasms, and the other 4 as intraductal papillary biliary neoplasms. The majority of the patients were women (8/10) and the median age was 47 years. Regarding the treatment, 3 hepatectomy and 7 enucleations were performed. Frozen section intraoperatively was not required in any case. In one case, variable cellular atypia with areas of adenocarcinoma was observed, and the patient received neoadyuvant chemotherapy with taxol and carboplatin. In all cases the resection margins were negative.Cystic liver neoplasms are infrequent tumours with a difficult differential diagnosis. Therefore, with a high radiological suspicious, the treatment should be a complete resection to avoid recurrences and malignancies.

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.

Resumen Fundamento y objetivo La polineuropatia amiloidotica familiar (PAF) constituye el tipo mas prevalente de amiloidosis sistemica hereditaria. Es una enfermedad autosomica dominante que se caracteriza por el deposito de una variante anomala de la transtiretina. Tiene una distribucion mundial, con zonas endemicas localizadas en Portugal, Suecia y Japon. En Espana hay un foco endemico, localizado en Mallorca. El trasplante hepatico es la unica opcion curativa para los pacientes con PAF. El objetivo de este estudio fue describir las caracteristicas clinicas y demograficas de los pacientes trasplantados con diagnostico de PAF. Material y metodo Se evaluaron 6 pacientes trasplantados por PAF entre abril de 1986 y diciembre de 2012. Resultados La edad media fue de 57,7 + 16 anos, los pacientes de origen espanol eran mayores de 60 anos. Todos los pacientes presentaban sintomas progresivos en forma de polineuropatia mixta. En 2 pacientes se realizo un doble trasplante hepatocardiaco secuencial, efectuandose en primer lugar el trasplante hepatico. La supervivencia del paciente y del injerto fue del 80% a los uno, 3 y 5 anos. Conclusiones El unico tratamiento etiologico eficaz para la PAF es el trasplante hepatico. Una deteccion temprana es la clave para el tratamiento y el control, evitandose el dano organico irreversible.

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.

An increasing pressure on the liver transplant waiting list, forces us to explore new sources, in order to expand the donor pool. One of the most interesting and with a promising potential, is donation after cardiac death (DCD). Initially, this activity has developed in Spain by means of the Maastricht type II donation in the uncontrolled setting. For different reasons, donation after controlled cardiac death has been reconsidered in our country. The most outstanding circumstance involved in DCD donation is a potential ischemic stress, that could cause severe liver graft cell damage, resulting in an adverse effect on liver transplant results, in terms of complications and outcomes. The complex and particular issues related to DCD Donation will be discussed in this review.

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.

IntroductionTen years after the beginning of the donation after cardic death (DCD) programme in the University Hospital 12 de Octubre, we study the evolution of the results of said programme over time.ObjectivesTo compare the results of liver transplantation (LT) using grafts obtained from donors af

Laparoscopic liver resection is controversial, specially for tumors. The aim of our study is to report our initial experience.From October 2004 to October 2008, 15 patients underwent laparoscopic liver resection at our institution.Fifteen laparoscopic surgeries were performed on 15 patients. Five patients with hepatocellular carcinoma (HCC), six patients presented liver metastasis and four patients were diagnosed of hydatid cyst. In the HCC group two laparoscopic left lateral segmentectomies and 3 laparoscopic atypical resections were performed. Mean operative time was 230 minutes (95%CI 171-289). In the liver metastasis group six laparoscopic resections were performed. Two patients were converted to open surgery. The laparoscopic procedures were: 2 hand-assisted right hepatectomies, 1 left lateral segmentectomy and 1 atypical resection. The mean surgical time was 257.5 minutes, (95%CI 198-317). In the hydatid cyst group 4 laparoscopic surgeries were performed: three pericystectomies and one partial cystectomy. The mean operative time was 133.75 minutes, (95%CI 68-200). No re-operations were needed and no post-operative deaths occurred. In oncological resections surgical margins were free of tumor in all cases.When liver laparoscopic surgery is performed in selected patients, it may offer similar results to conventional surgery with all the benefits of the minimal invasive procedures.

We report five patients who underwent laparotomy for liver metastasis from breast cancer without extrahepatic spread, with the intention to perform liver resection. All these patients had been subjected to modified radical mastectomy following systemic chemotherapy and periodical consecutive investigations to detect distant spreading. After laparotomy, patients have been regularly followed. Case 1, right trisegmentectomy in a 53-year-old woman, 36.5 months after the mastectomy. In the 17th postoperative month she continues without relapse. Case 2, hepatic artery ligature in a 41-year-old woman, 15 months after the mastectomy. In the 17th postoperative month she died. Case 3, bisegmentectomy (VI-VII) in a 51-year-old woman, 24 months after the mastectomy. In the 17th postoperative month she died. Case 4, exploratory laparotomy in a 51-year-old woman, 91 months after the mastectomy. In the 31th postoperative month she remains alive. Case 5, segmentectomy (IV) in a 59-year-old woman, 112 months after the mastectomy. In the 33th postoperative month she continues without relapse. As a conclusion, the surgical resection of liver metastasis from breast tumors after chemotherapy must be used in selected cases.

The scarcity of ideal liver grafts for orthotopic liver transplantation (OLT) has led transplant teams to investigate other sources of grafts in order to augment the donor liver pool. One way to get more liver grafts is to use marginal donors, a not well-defined group which includes mainly donors > 60 years, donors with hypernatremia or macrosteatosis > 30%, donors with hepatitis C virus or hepatitis B virus positive serologies, cold ischemia time > 12 h, non-heart-beating donors, and grafts from split-livers or living-related donations. Perhaps the most practical and frequent measure to increase the liver pool, and thus to reduce waiting list mortality, is to use older livers. In the past years the results of OLT with old livers have improved, mainly due to better selection and maintenance of donors, improvements in surgical techniques in donors and recipients, and intra- and post-OLT management. At the present time, sexagenarian livers are generally accepted, but there still exists some controversy regarding the use of septuagenarian and octogenarian liver grafts. The aim of this paper is to briefly review the aging process of the liver and reported experiences using old livers for OLT. Fundamentally, the series of septuagenarian and octogenarian livers will be addressed to see if there is a limit to using these aged grafts.