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Introduction The aim of this paper is to analyze the validity and safety of a new robotic approach implantation program in the corporocaudal pancreatectomy (PCC) in a Bilio-Pancreatic Unit, evaluating morbi-mortality and hospital stay. Methods Given the controversy of which is the best therapeutic option in distal pancreatectomy in clinical process surgery tributaries, we designed this prospective, non-randomized, single-center study of pancreatic resection with Robotic approach). Ten patients (7 women and 3 men) were included, with a mean age of 57.8 years, (range 36–73 years). In all patients, the body mass index was higher than 30 and the diagnosis was made with a preoperative computed tomography. Results The robotic approach was successful in all cases, performing a corporal-caudal pancreatectomy associated with splenectomy. Blood loss was minimal during intervention, not requiring any blood transfusion. The mean operative time was 135.8 minutes. Conversion to open surgery was not necessary. Three patients had postoperative complications when a CT scan diagnosed an intra-abdominal collection in the left hypocondrium. It was resolved by percutaneous radiological drainage. Median hospital stay was 4 days (3–15). There was not perioperative mortality at 90 days. Anatomopathological study showed 5 mucinous cystic neoplasms, 2 adenocarcinomas of the pancreas and 3 well-differentiated neuroendocrine tumors. Mean size of the lesions were 4.8 cm (2.4–9). Conclusions Robotic distal pancreatectomy is an effective and safe technique. In addition, postoperative morbidity and hospital stay decreases.

Introduction The aim of this paper is to analyze the validity and safety of a new program for the implementation of a robotic approach in the treatment of choledocholithiasis (CD) in a Bilio-Pancreatic Unit, evaluating morbi-mortality and hospital stay. Methods Given the controversy of which is the best therapeutic option in CD: preoperative ERCP followed by laparoscopic cholecystectomy (LC) or laparoscopic approach to the bile duct, we designed this prospective, non-randomized and single-center study with a robotic approach to the bile duct. 25 patients were included (14 women /11 males), with a mean age of 71.4 years. Preoperative abdominal ultrasound and cholangioresonance were performed in all patients. Results The robotic approach was effective in all cases: cholecystectomy and cleaning the bile duct. In the first three cases a radiological exploration was performed through the cystic duct during intervention. In all cases an exploration of the bile duct with a flexible choledoscope after choledochotomy was performed too. The mean operative time was 128.8 +/-16.9 minutes. Choledocholithiasis was confirmed in all patients. Furthermore, a patient had a papillary tumor of the distal common bile duct associated. One patient who had advanced cholecystitis had a biliary fistula. It was resolved conservatively by placing an endoscopic plastic biliary prosthesis. If we exclude the patient with the biliary fistula, the hospital stay postoperative period was 2 days. Conclusions Robotic approach in the treatment of choledocholithiasis is an effective and safe technique. In addition, postoperative morbidity and hospital stay decreases.

Iatrogenic bile duct injuries (IBDI) with intrahepatic involvement are a serious and challenging surgical complication that can have disastrous consequences in terms of morbidity and mortality. We collected the patients with IBDI type (E4) between January 1991 and March 2020 in our hospital. The objective of the study was to present the long-term results of a extraglissonian approach and intraglissonian biliary reconstruction in a series of patients with intrahepatic bile duct injuries after cholecystectomy. We also detail our preoperative management and the standardization of the technique. An extraglissonian approach with partial hepatic resection of the base of segments 4b and 5 and intraglissonian Roux-en-Y hepaticojejunostomy for biliary reconstruction using to several branches was performed in 10 patients with E4 Strassberg type intrahepatic lesions. Only one patient had postoperative bile leak (Clavien 3a). Surgical time was 260 min (IQR, 210–490). We left transanastomotic catheter (between 2 and 5) in situ for 3 and 6 months after surgery. The patients remained asymptomatic over a median follow-up of 169 months (IQR 129–234). This biliary reconstruction technique obtains positive long-term outcomes in patients with severe intrahepatic lesions.

Gastrointestinal stromal tumours (GISTs) located in the jejunum or ileum (JI-GIST) are considered worse prognosis compared to those of gastric (G-GIST) location. It has been suggested that this dogma should be revised. The aim of this study was to describe the characteristics of jejunoileal GISTs and its prognosis and to compare them with G-GISTs in the era of imatinib. We retrospectively reviewed the clinical histories of all the patients diagnosed with GISTs between January 2000 and November 2016: Clinical and pathological data, as recurrence, metastatic state, disease-free survival (DFS) as well as overall survival (OS) rates of patients were reviewed. JI-GIST patients comprise 29 cases (37.7%). Compared to G-GIST, JI-GIST patients had undergone emergency surgery more frequently (37.9% vs. 10.4%, p = 0.007). According to the NIH-Fletcher classification, the low or very-low risk group represents 17.2% of JI-GISTs as opposed to 37.6% of G-GISTs (p

Our main objective was to compare liver transplant (LT) results between donation after circulatory death (DCD) and donation after brainstem death (DBD) in our hospital and to analyze, within the DCD group, the influence of age on the results obtained with DCD donors aged >70 years and up to 80 years. All DCD-LTs performed were analyzed prospectively. The results of the DCD group were compared with those of a control group who received a DBD-LT immediately after each DCD-LT. Later, the results obtained within the DCD group were analyzed according to the age of the donors, considering 2 subgroups with a cut-off point at 70 years. Survival results for LT with DCD and super rapid recovery were not inferior to those obtained in a similar group of patients transplanted with DBD livers. However, the cost of DCD was a higher rate of biliary complications, including ischemic cholangiopathy. Donor age was not a negative factor.

Background Donation after circulatory death (DCD) is related to a warm ischemia time and more complications compared with traditional donors (donation after brain death [DBD]). Methods This study included biopsy samples retrospectively collected from November 2014 to December 2018 to compare histologic and biological markers of DCD and DBD liver grafts. The analysis includes marker of early apoptosis (p21), senescence (telomerase reverse transcriptase [TERT]), cell damage (caspase-3 active), endothelial damage (vascular endothelial growth factor), stem cell (CD90), hypoxia (HIF1A), inflammatory activation (COX-2), and cross-organ allograft rejection (CD44). A propensity score matching (PSM) was used to match patients receiving DCD livers to those receiving DBD livers. We analyzed the immunohistochemical initial liver damage–related warm ischemia time. Results Positive staining expression of liver damage biomarkers (COX-2, CD44, TERT, HIF1A, and CD90) was found, but no significant differences were found between DCD and DBD and with ischemic cholangiopathy. After PSM, there was a significant relationship between CD90 and male donors (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.07-0.91), TERT with donor sodium (OR, 1.11; 95% CI, 1.02-1.2), HIF1A with steatosis (OR, 0.33; 95% CI, 0.13-0.83), and CD44 with donor vasoactive drugs (OR, 0.36; 95% CI, 0.13-1) and glutamic oxaloacetic transaminase 1 week increase (OR, 1.01; 95% CI, 1-1.03). Conclusions DCD immunohistochemical initial liver damage was found to behave similarly to DBD. The increase in complications and cholangiopathy associated with warm ischemia could be related to a different later phenomenon.

INTRODUCTION Postoperative pancreatic fistula (POPF) remains the most important cause of morbidity after cephalic pancreaticoduodenectomy (PD), affecting up to one third of cases. The aim of this paper is to present a prospective single-center study with 16 patients undergoing PD in whom a biodegradable stent was placed, analyzing morbidity and mortality, the presence of POPF and the correct position and degradation time of the stent. MATERIAL Y METHODS A duct-to-mucosa end-to-side anastomosis was performed for the pancreaticojejunal anastomosis and the biodegradable stent (“Archimedes”, amg International GmbH, Germany) was placed from the pancreatic duct to the jejunum (Figure 1). The stent has a helical shape that facilitates the flow of pancreatic juice. POPF was defined as drainage fluid amylase value of > 5000 U/L on the first day after surgery. RESULTS Only one patient developed POPF in the postoperative period and it was successfully treated with interventional radiology drainage and somatostatin analogues. There was no mortality at 30 days after PD. An abdominal radiograph was performed to asses well-positioning of the stent on postoperative day 7. To evaluate the degradation after three months we used the CT scan. A complete degradation was defined as CONCLUSION The use of resorbable internal pancreatic stent could be a valid alternative to prevent the development of pancreatic fistula after a pancreaticoduodenectomy.

INTRODUCTION The aim is to analyze the validity and safety of a new program of laparoscopic common bile duct exploration (LCBE) in the treatment of choledocholithiasis (CD), evaluating hospital stay and cost-effectiveness. MATERIAL AND METHODS Today, there is controversy over which is the best therapeutic option in choledocholithiasis: preoperative ERCP followed by laparoscopic cholecystectomy (LC) versus LCBE. We designed this prospective, non-randomized, single-center study with 118 patients (67 women and 51 men, a mean age of 69.8 ± 17.3 years old). Sixty-six patients began a two-stage management (ERCP + LC), failing to clean the bile duct by endoscopy in 15 cases. LCBE was performed in 59 patients (49 at the beginning and 11 after ERCP failure). Seven of them required conversion to open surgery. RESULTS LCBE approach was more effective in cleaning the bile duct than ERCP (88.1% vs 72.7%; p = 0.032) with no statistics differences in terms of postoperative morbidity or mortality. In the multivariate analysis, the LCBE was an independent factor in the reduction of hospital stay and the economic costs derived from the management of these patients, reducing it 6.13 days (CI95% 2.98 - 9.27; p CONCLUSION LCBE is an effective and safe technique. It significantly reduces hospital stay and costs derived from the management of the patients with choledocholithiasis.

Next-generation three-dimensional modelling software for personalized surgery allows spatially accurate depiction of the hepatic and vasculature anatomy based on the complexity and individual variation in each patient, and could facilitate decision-making about preoperative strategy in perihilar cholangiocarcinoma.

Gastrointestinal stromal tumours (GISTs) located in the jejunum or ileum (JI-GIST) are considered worse prognosis compared to those of gastric (G-GIST) location. It has been suggested that this dogma should be revised. The aim of this study was to describe the characteristics of jejunoileal GISTs and its prognosis and to compare them with G-GISTs in the era of imatinib.We retrospectively reviewed the clinical histories of all the patients diagnosed with GISTs between January 2000 and November 2016: Clinical and pathological data, as recurrence, metastatic state, disease-free survival (DFS) as well as overall survival (OS) rates of patients were reviewed.JI-GIST patients comprise 29 cases (37.7%). Compared to G-GIST, JI-GIST patients had undergone emergency surgery more frequently (37.9% vs. 10.4%, p = 0.007). According to the NIH-Fletcher classification, the low or very-low risk group represents 17.2% of JI-GISTs as opposed to 37.6% of G-GISTs (p 0.005). When the AFIP-Miettinen system was used the low or very-low group represented 17.2% of JI-GISTs vs. 58.4% in the G-GISTs group (p 0.001). Both local recurrence (24.1% vs. 12.5%, p 0.05) and metastatic rate (34.5% vs. 22.9%, p 0.05) were higher in the JI-GIST group than in G-GIST. 5- and 10-year DFS and 10-year OS rate were lower for JI-GIST (54.5% and 39.6% vs. 77.2% and 60.8%, and 57.9% vs. 65%, respectively, p 0.05).The observed differences between both groups in DFS and OS rates at long term could be attributed to the effect of imatinib.

Pancreatic arteriovenous malformation (PAVM) is a rare case of upper gastrointestinal bleeding (UGIB), but it must be recognized in clinical practice, as it may be a potentially lethal condition in case of rupture and haemorrhage. This anatomic alteration is extremely rare as less than a hundred cases are reported in the scientific literature. The aim of this work is to report a case of PAVM presented as upper gastrointestinal bleeding (UGIB) and successfully treated by transarterial embolization.

Background The outcome of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) is excellent if it is performed within the Milan criteria (ie, single tumor less than 5 cm or 3 tumors less than 3 cm each one and no macrovascular invasion). However, after a few studies, it has become possible to have a similar survival expanding those criteria. The aim of this study is to evaluate the survival of patients with advanced HCC who, after downstaging, did not met the Milan criteria although they were within the “up to seven” benchmark, and were transplanted at our center in the last 5 years. Patients and Methods This is a retrospective study of patients who underwent OLT for HCC in the last 5 years in our center exceeding Milan criteria despite remaining within the “up to seven” benchmark. An observational study of associated factors with overall survival based on patient characteristics after OLT was performed. For the statistical study, the statistical program SPSS v. 17.0 (Chicago, Illinois, United States) was used. Results We studied 95 patients who had been transplanted for HCC in this period, 11 of whom met the study requirements. There were 10 (91%) males and 1 female. The mean age of the patients was 54.73 ± 8.75 years, with an average waiting list time of 279 days. Nine patients had a Child A status, with a mean Model for End-stage Liver Disease score of 9.64 (range, 6 to 16). The most frequent etiology of cirrhosis was hepatitis C virus infection in 6 patients (50%) followed by hepatitis B virus infection and ethanolic and cryptogenic cirrhosis. Ten patients (91%) had at least one pretransplantation transarterial chemoembolization. The survival of patients after 1 year was 75%, whereas after 4 years that rate decreases to 25%. At this time, we do not have any patients with a 5-year survival rate. The longest survival rate is 55 months. Conclusions Although the expanded indication of transplantation in HCC raises controversies, especially after downstaging, it is possible to provide acceptable survival rates for patients within the expanded criteria of “up to seven” after locoregional therapies. The performance of a liver transplant in the patient profile shown in this article should also be evaluated from the perspective of the relative lack of organs for transplantation.

Introduction Orthotopic liver transplantation (LT) is considered to be one of the few curative treatments available for early stages of hepatocellular carcinoma (HCC). Alfa-fetoprotein (AFP) is the most-used biomarker for HCC despite low sensitivity and specificity. Matrix metalloproteinase 1 (MMP-1) has been considered to be involved in the process of vascular invasion of the malignant cells. The objective of this study was to assess the use of MMP-1 for the management of HCC patients for LT. Methods Levels in serum of MMP-1 (ng/mL) and AFP (ng/mL) were assessed in 20 HCC patients (Milan criteria) before and 1, 6, and 12 months after LT. Results There was a strong significant correlation between levels of MMP-1 and levels of AFP (ρ = .954; P ≤ .05). There were statistical differences in the levels of MMP-1 and APF between the pre-transplantation and post-transplantation groups (1 and 12 months). Increments of both markers 6 months after LT compared with the levels 1 month after LT were detected in 4 of the 20 HCC patients. The detection of recurrence by means of imaging was coincident with the increment of both markers 6 months after LT in 3 of those 4 patients. Conclusions After 12 months of follow-up, levels of MMP-1 were comparable to AFP levels after LT. Levels of both markers increase 6 months after LT in patients showing recurrence, indicating discriminatory power to predict relapse and thus serving as valuable markers for HCC monitoring. MMP-1 could be useful in the management of HCC after LT.

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.

Patients who underwent orthotopic liver transplantation (OLT) frequently develop chronic kidney disease, with those who present postoperative acute kidney failure and require renal replacement therapy (RRT) at higher risk. The objective of the study was to assess the kidney function and long-term survival of patients who underwent OLT and required RRT during or in the immediate postoperative period. Medical records of OLT and postoperative RRT patients with over 6-month survival were reviewed between January 1, 2005, and December 31, 2015. A variance analysis was carried out for repeated measurements to compare the estimate glomerular filtration rate (eGFR) baseline with the different periods (statistical significance level P .05). Kaplan-Meier estimator was used to estimate the survival rate. Of 539 patients, 20 (3.7%) met the selection criteria. The basal eGFR at 6 months and 1, 3, 5, and 7 years was 93.41 ± 25, 78.28 ± 33, 73.06 ± 29, 65.96 ± 19, 79.81 ± 28, and 59.06 ± 24 mL/min/1.73 m

The aging of the population has changed some of the approaches to the organ donation and transplant (ODT) process, such as considering elderly people as potential donors. We aimed to assess social and family discussions among the elderly about ODT and its effect on their attitude toward organ donation.A study was carried out at 2 publicly-funded social centers for the elderly. Contact was made with individuals65 years of age (n = 120) to seek their participation in the study. A questionnaire was distributed to them with questions about ODT. A descriptive assessment was performed with the Student t test and χThe completion rate was 87% (n = 104). Of the respondents with a partner and children, 48% had discussed the topic of ODT. It was found that talking about the subject with one's partner, children, or friends had a favorable influence on attitude compared with when this was not done (93%, 86%, and 83% vs 19%, 30%, and 31%, respectively; P .001). In addition, the opinion of one's partner and children toward ODT also had an influence; if favorable, the respondent's attitude was more favorable, compared with when they did not know their opinion (92% to 88% vs 58% to 37%, respectively; P .001). Other ODT-related variables did not affect their attitude (P.05).Almost half of the elderly people had discussed ODT socially or with their family. This discourse has a favorable influence on their attitude toward organ donation and, therefore, it is important to encourage social and family dialog among this group.

Introduction In rural areas it is common to find unfavorable attitudes toward organ donation, and therefore it is important to find out the attitude and profile of new generations for improving predisposition to organ donation in these areas. Our objective was to analyze the attitude toward organ donation and the related variables of teenagers in a rural area. Materials and methods Students in the final year of compulsory education (mostly 15–16 years of age) were selected from secondary schools in a rural area in southeastern Spain (n = 319; population density Results There was a completion rate of 96% (n = 306). Overall, 65% (n = 200) were in favor of donating their organs, 30% (n = 90) were undecided, and 5% (n = 16) were against. Attitude toward the donation of one's own organs was related with sex (P = .015), previous experience of organ donation or transplantation (P = .046), comment on the topic of organ donation within the family (P = .003; odds ratio 2.155), knowing one's mother's opinion about the matter (P = .021), knowing the correct concept of brain death (P = .012; odds ratio 2.076), and religion (P = .014). Conclusions A favorable attitude of teenagers in rural areas toward organ donation is slightly higher than in the adult population and is determined by many psychosocial variables, above all family discussion about organ donation and transplantation and correct knowledge of the brain death concept.

We present the case of a male diagnosed with a giant hepatic artery aneurysm, which first presented with pain and hemorrhage due to a partial rupture of the aneurysm. After discarding treatment with a stent or surgery due to the wide extension, we chose to embolize the hepatic artery with coils. However, the progress was unfavorable after the procedure, with the appearance of liver failure that was resolved by an urgent liver transplantation. Giant hepatic artery pseudoaneurysms are an infrequent entity and their management is a great challenge. The diagnosis is usually delayed due to non-specific clinical signs and the life of the patient may be threatened in the case of rupture. Thus, endovascular or surgical treatment is recommended. Aneurysm embolization or ligation has been described in the literature as a valid treatment option in cases where revascularization by stent or bypass is not possible, as it preserves the viability of the liver due to the portal flow and collateral arteries. However, in the case of the failure of these treatments, liver transplantation is a rescue option.

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 overall recommended because it entails an added risk. However, DCD in selected patients shows acceptable results. OBJECTIVE The objective was to analyze the characteristics, early outcomes, and survival at 1 year post-LT from a single institute (January 2015 to May 2017). MATERIALS AND METHODS We included 18 DCD-LTs and compared them with a control group of 18 donation after brain death (DBD) LTs. We analyzed pre- and posttransplant variables related to donors, recipients, and intraoperative early outcomes within patients transplanted due to hepatocellular carcinoma (HCC). A descriptive analysis, Mann-Whitney U test, χ2, or Fisher test was performed when appropriate, as well as multivariate analysis in case of statistical significance. A variable is considered as statistically significant when it reaches a value of P < .05. RESULTS In DBD, we found a lower length of stay in the intensive care unit before retrieval and a higher rate of alcoholism and diabetes mellitus, Model for End-Stage Liver Disease score, and Child B and C score (P < .05). Most of the DCD were originally from the same LT recipient center, and a higher donor mean post-LT alanine aminotransferase level was found (P < .05). Survival for the DBD group was 88% and 75% in the DCD group at 1 year post-LT, being not significant (NS). CONCLUSION HCC recipients who are transplanted with good quality DCD livers do no worse than those transplanted with livers from DBD donors, although a good selection of them is crucial.

Acetaminophen poisoning continues to be a major cause of liver failure that can lead to liver transplantation. N-acetylcysteine (NAC) is the cornerstone of treatment. Some authors use a Molecular Adsorbent Recirculating System (MARS) system in acetaminophen poisoning. It is reported that the MARS system eliminates acetaminophen more efficiently than conventional dialysis. It is theoretically possible that treatment with MARS administered after NAC will increase the effectiveness of treatment.The first patient, a woman of 14 years old, presented blood levels of 112 mg/dL 12 hours after ingestion of 15 g of acetaminophen. Treatment with NAC was initiated. At 17 and 23 hours after ingestion, blood levels were 23.5 μg/mL and 5.9 μg/mL, respectively. The second patient, a woman of 28 years old, presented blood levels of 115 mg/dL 4 hours after ingestion of 40 g of acetaminophen. Treatment with NAC was initiated. At 14 and 23 hours after ingestion, blood levels were 15.8 μg/mL and 2 μg/mL, respectively. In both patients, we performed MARS after completing treatment with NAC, and after the first session, blood levels were below the lower limit of detection (≤2 μg/mL).The correct timing of MARS to avoid interactions with the administered dose of NAC in acetaminophen overdose is essential so as to not impair the effectiveness of this treatment. These considerations in the management of this entity help in the resolution of liver failure, thus avoiding the need for a liver transplant.

Treixadura wines from the 1998 vintage were obtained from traditional vinification in a winery. After alcoholic fermentation, the wine was subjected to ageing in oak barrels for three months. One part of the wine is placed in barrels of American oak and the other part in French oak (Allier oak). Wine stored simultaneously in a stainless steel tank was used as a control. Chemical composition and volatile compounds of wines were analysed. There were no appreciable differences in alcohol and tartaric acid among the wines stored under different conditions, but differences were observed in pH, total and volatile acidity, reducing sugars, malic and lactic acids. Ageing in oak barrels resulted in an increase in volatile acidity and Folin—Ciocalteu index, and a decrease of free and total sulphur dioxide. Various monoterpenes, norisoprenoids, hexenols, sulphurs, volatile phenols, acetals and lactones increase their content notably when aged in barrels of both American and French oak. On the other hand, some acetates, ethyl esters and fatty acids were present in higher concentrations in the wine stored in stainless steel tank. Sensory results indicated that the wine aged in French (Allier) oak was better scored than when aged in American oak, as it provided subtle and delicate nuances of wood, which did not mask the fruity aroma of the Treixadura wine but contributed to its aromatic complexity.