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Purpose A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort. Methods An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included. Results A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score >= 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%. Conclusion Patients with a Shin score

The use of the Model of End-Stage Liver Disease (MELD) to predict morbidity and mortality after orthotopic liver transplant (OLT) is controversial. Acute and chronic liver failure-sequential evaluation of organ failure (CLIF-SOFA) is a new score that assess the patient's global status and that have been developed exclusively for patients with end-stage liver disease. The objective is to evaluate whether the CLIF-SOFA system predicts postoperative morbidity and mortality in the short and medium term.A cohort of 123 patients who underwent OLT in a tertiary care hospital between January 2016 and December 2017 was retrospectively analyzed. The patients were divided into 2 groups: group 1 with a CLIF-SOFA score7 and group 2 with a score CLIF-SOFA ≥7.Patients with a CLIF-SOFA ≥7 present, with statistical significance, had higher mortality at 1 and 3 years; longer duration of admission to the critical care unit; longer hospital stay; need for prolonged mechanical ventilation; surgical reintervention; higher rate of transfusion of blood products; pulmonary, neurologic, hemodynamic, surgical, infectious, kidney, metabolic, thrombotic, vascular, and graft complications; and need for kidney replacement therapy. However, no statistically significant differences were found in mortality in the first month, the need for hospital readmission, retransplant, digestive, endocrine, nutritional, hematologic, or biliary complications, and the presence of ascites.The role of CLIF-SOFA as a prognostic factor for mortality after OLT must be taken into account. Our results should be taken with caution, and more studies are necessary.

Bleeding is an intraoperative and postoperative complication of liver surgery of concern, and yet evidence to support utility and reproducibility of bleeding scales for liver surgery is limited. We determined the reproducibility of the clinician-reported validated intraoperative bleeding severity scale and its clinical value of implementation in liver surgery.In this descriptive and observational multicenter study, we assessed the performance of liver surgeons instructed on the clinician-reported intraoperative bleeding severity scale using training videos that covered all 5 grades of bleeding severity. Surgeons were stratified according to years of surgical experience and number of surgeries performed per year based on a median split in low and high values. Intraobserver and interobserver agreement was assessed using Kendall's coefficient of concordance (Kendall's W).Forty-seven surgeons from 10 hospitals in Spain participated in the study. The overall intraobserver concordance was 0.985, and the overall interobserver concordance was 0.929. For "high experience" surgeons, the intraobserver and interobserver agreement values were 0.990 and 0.941, respectively. For "low experience" surgeons, the intraobserver and interobserver agreement was 0.981 and 0.922, respectively. Regarding the annual number of surgeries, intraobserver and interobserver agreement values were 0.995 and 0.940, respectively, for surgeons performing35 surgeries per year, with 0.979 and 0.923, respectively, for surgeons who perform ≤35 surgeries year.The clinician-reported intraoperative bleeding severity scale shows high interobserver and intraobserver concordance, suggesting it is a useful tool for assessing severity of bleeding during liver surgery; years of surgical experience and number of annual procedures performed did not affect the applicability of the clinician-reported intraoperative bleeding severity scale.

Early extubation is a fundamental element integrated into enhanced recovery protocols in orthotopic liver transplantation (OLT). The aim is to evaluate whether early extubation influences short- and medium-term postoperative morbidity and mortality.A cohort of 209 patients who underwent OLT in a tertiary hospital in a period from January 2016 to December 2018 were retrospectively analyzed. Patients were divided into 2 groups: group 1: early extubation in the intensive care unit and group 2: delayed extubation. Mortality is compared between both groups in the first month and first and third year. Postoperative morbidity was also compared.Patients in group 1 (n = 165, 79.9%) presented, with statistical significance, lower mortality at 1 month, 1 year, and 3 years; shorter duration of admission to the critical care unit and of hospital stay; lower incidence of surgical reoperation and retransplant; lower rate of transfusion of blood products; fewer pulmonary, digestive, neurologic, cardiologic, hemodynamic, kidney, surgical, infectious, metabolic, thrombotic, vascular, and graft complications; less need for kidney replacement therapy; less refractory ascites; and greater infectious risk. However, no statistically significant differences were found in the need for hospital readmission; in biliary, endocrine, nutritional, hematologic, thrombotic, and hematologic complications; or in graft rejection. In group 1, 6.6% of patients required reintubation. In group 2, 97% of patients could be extubated during the first week; 7.8% required noninvasive mechanical ventilation type bilevel positive airway pressure and 8.1% high flow. Only 2.8% of patients required tracheotomy.The role of early extubation seems key to improve outcomes in OLT because it reduces the incidence of multiple complications and mortality, with low reintubation rates. It is a feasible and safe procedure.

Extended criteria donor livers are increasingly being accepted for transplant in an attempt to bridge the gap between the number of patients on the waiting list and the number of available donor livers. Our objective was to describe our first case of hepatic resuscitation by means of an ex situ perfusion machine in hypothermia with oxygen insufflation of a liver graft extracted from a donor in type 3 asystole after regional perfusion in normothermia.A 53-year-old woman with disabling polycystic liver disease was included on the liver transplant waiting list. Donation was offered in type 3 asystole with regional perfusion in normothermia. Given that it was an elderly donor with a low-weight graft, hepatic resuscitation was decided by means of an ex situ perfusion machine in hypothermia with oxygen insufflation.After performing the bench work, the injector is selectively cannulated via the portal to connect it to the hypothermic perfusion machine. The average temperature of the perfusate (3 L modified Belzer) was 10°C for 120 minutes at 250 mL/min. The implant was completed without the need for transfusion of blood products, postreperfusion Sd, or vasoactive support. Peak of GOT/GPT was 803/276 at 24 hours posttransplant.

Inadvertent perioperative hypothermia (IPH) leads to a series of deleterious effects that can be especially in complex procedures such as liver transplant. The implementation of a protocol is key to ensure the patient's normothermia.A cohort of 209 patients who underwent liver transplant in a tertiary hospital in a period between January 2016 and December 2018 was retrospectively analyzed. The patients were divided into 2 groups: group 1, patients with normothermia (core body temperature ≥ 36°C) and group 2, patients with hypothermia (core body temperature36°C). Mortality between both groups at 1 month, 1 year, and 3 years is compared. Postoperative morbidity is also compared.The incidence of IPH is 21.5%. Patients with normothermia present with statistical significance: a lower mortality at 1 year; a lower need for transfusion of platelets, plasma, fibrinogen consumption, or massive polytransfusion; and lower primary graft dysfunction, graft and surgical complications, rejection, hemodynamic complications, and metabolic and surgical reintervention. No significant differences were found in mortality at 1 month or 3 years in the need for prolonged mechanical ventilation; hospital readmission; length of stay in the intensive care unit or in hospital stay; rate of red blood cell transfusion; vascular, biliary, respiratory, or digestive complications; refractory ascites; or neurologic, kidney, hematological, endocrine, thrombotic, nutritional, or infectious issues.The incidence of IPH is relatively low in our patients, based on what is described in the literature, and in most cases it is mild. There is a reduction in complications fundamentally related to the consumption of blood products and the graft.

An organ shortage is the reason why it is necessary to expand the pool of donors, which can be achieved by using elderly donors. The main goal of this study is to analyze the outcomes of liver transplant (LT) when it is performed with donors older than 75 years.We carried out a retrospective case-control study (N = 212) that included LTs with donors older than 75 years (group A, n = 106 cases) that were performed in our center between the years 2010 and 2020. This cohort has been paired off with a similar control group (group B, n = 106) whose donors were significantly younger. A survival analysis using the Kaplan-Meier model was performed.Average (SD) age of donors in group A was statistically greater than group B (A, 79.1 [3.0] years vs B, 54.4 [15.3], P.001). There were no differences either in the average age of the recipients or in the Model for End-Stage Liver Disease score of both groups. Indications for LT were distributed equally in both groups: the most common was cellular hepatocarcinoma followed by alcohol-related cirrhosis. Survival rates for group A were 81%, 78%, and 67%, in 1, 3, and 5 years, respectively, while in group B they were 85%, 76%, and 71%, respectively, without differences found between the groups (P = .57).Using elderly liver donors is safe, achieving good outcomes in terms of short- and midterm rates of survival.

Background & Aims: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. Methods: An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. Results: A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14–24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p

IntroductionTo date, no pancreatic stump closure technique has been shown to be superior to any other in distal pancreatectomy. Although several studies have shown a trend towards better results in transection using a radiofrequency device (radiofrequency-assisted transection (RFT)), no randomised trial for this purpose has been performed to date. Therefore, we designed a randomised clinical trial, with the hypothesis that this technique used in distal pancreatectomies is superior in reducing clinically relevant postoperative pancreatic fistula (CR-POPF) than mechanical closures.Methods and analysisTRANSPAIRE is a multicentre randomised controlled trial conducted in seven Spanish pancreatic centres that includes 112 patients undergoing elective distal pancreatectomy for any indication who will be randomly assigned to RFT or classic stapler transections (control group) in a ratio of 1:1. The primary outcome is the CR-POPF percentage. Sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1−β), expected POPF in control group of 32%, expected POPF in RFT group of 10% and a clinically relevant difference of 22%. Secondary outcomes include postoperative results, complications, radiological evaluation of the pancreatic stump, metabolomic profile of postoperative peritoneal fluid, survival and quality of life. Follow-ups will be carried out in the external consultation at 1, 6 and 12 months postoperatively.Ethics and disseminationTRANSPAIRE has been approved by the CEIM-PSMAR Ethics Committee. This project is being carried out in accordance with national and international guidelines, the basic principles of protection of human rights and dignity established in the Declaration of Helsinki (64th General Assembly, Fortaleza, Brazil, October 2013), and in accordance with regulations in studies with biological samples, Law 14/2007 on Biomedical Research will be followed. We have defined a dissemination strategy, whose main objective is the participation of stakeholders and the transfer of knowledge to support the exploitation of activities.Registration detailsClinicalTrials.gov Registry (NCT04402346).

Graphical Abstract fx1, Resumen español Introducción: La pandemia COVID-19 ha tenido una repercusión extraordinaria sobre los hospitales españoles, que han reorganizado sus recursos para tratar a estos pacientes, limitando su capacidad de atender otras patologías frecuentes. El presente estudio analiza la repercusión sobre el tratamiento de la colelitiasis y la colecistitis aguda. Métodos: Se ha realizado un estudio nacional descriptivo mediante una encuesta online voluntaria, realizada en Google Drive™, distribuida por correo electrónico desde la Asociación Española de Cirujanos (AEC) a todos los cirujanos miembros. Resultados: Se han recibido 153 encuestas (una por centro). El 96.7% de ellos han suspendido las colecistectomías electivas. El tratamiento conservador de la colecistitis aguda no complicada se ha realizado en un 90% de los casos (siendo previamente del 18%) y, en las colecistitis intervenidas, el 95% ha optado por abordaje laparoscópico. Un 49% realiza algún test preoperatorio para SARS-CoV-2, y el 57% comunican haber tenido casos de confirmación postoperatoria tras alguna intervención, con peor evolución postoperatoria en el 54%. Conclusiones: Esta encuesta revela que las mayorías de los centros están siguiendo las recomendaciones de las sociedades quirúrgicas durante la pandemia por COVID-19. Sin embargo, se observan algunos datos que precisan ser tenido en cuenta en la fase sucesivas de la pandemia.

The initial objective of this study is to analyze the impact on survival of the preservation solution used. Secondarily, the influence of donor age, underlying pathology, and graft ischemia time is investigated.A multicenter retrospective analytical observational study has been carried out. A population of 1822 liver transplant recipients is studied in 4 Andalusian hospitals between 1995 and 2014. Survival of the patient and graft is analyzed by groups based on the conservation solution used, the age of the donor, the pathology indicated for transplant and the ischemia time, and the relationship between the variables through a bivariate study. A descriptive and predictive multivariate analysis of the variables was performed.Comparison of the graft and patient survival functions for each preservation solution did not differ significantly. The bivariate analysis shows a significantly higher utilization of Celsior and histidine-tryptophan-ketoglutarate solution in graft loss. The comparison between donor age groups showed significant differences in favor of donor grafts younger than 50 years. In the multivariate analysis of patient and graft survival, the donor age obtained a hazard ratio of 1.008 (P.005) with donors older than 47.6 and 47.5 years, respectively.Survival analysis between pathology groups found significant differences, not obtaining predictive power for patient or graft survival in the multivariate study. No significant differences were found in survival according to ischemia time, but there was a relationship between early graft loss and longer mean cold ischemia times up to 18 hours.

INTRODUCTION Among the strategies designed to optimize the number of existing liver grafts for transplantation, the implementation of the graft assessment process is one of the least explored. The main objective is to identify the risk factors presented by liver donors for «NO validity». Secondly, we analyzed the coincidence between the surgeon's assessment and that of the anatomo-pathologist in the invalid donors. MATERIAL AND METHOD Retrospective study conducted from a prospective database that analyzes 190 liver donors, 95 valid and 95 NOT valid. The variables of each of them corresponding to the donation protocol of the National Transplant Organization are studied. Through a multivariate study we determine the independent risk factors of NO validity. We checked the causes of NO validity argued with the histopathological findings of these grafts. RESULTS The independent risk factors of non-validity in the multivariate study (P < .05) were: dyslipidemia, personal medical history other than cardiovascular and abdominal surgical risk factors, GGT, BrT, and the result of previous liver ultrasound. The 3 most frequent causes of NO validity were: steatosis, fibrosis and macroscopic appearance of the organ. 78% of the biopsies confirmed the NO validity of the graft (in 57.9% of the cases the histological findings coincided with those described by the surgeon). The 22.1% of the biopsies hadnt pathological findings. CONCLUSIONS The determination of the risk factors of NO validity will contribute to the design of future assessment scores that are useful tools in the process of liver graft assessment.).

Resumen Introduccion Entre las estrategias disenadas para optimizar el numero de injertos hepaticos existentes para trasplante, la implementacion del proceso de valoracion de injertos constituye una de las menos exploradas. El objetivo principal es identificar los factores de riesgo que presentan los donantes hepaticos para la «NO validez». Secundariamente analizamos la coincidencia entre la valoracion del cirujano y la del anatomopatologo en los donantes NO validos. Material y metodo Estudio retrospectivo realizado a partir de una base de datos prospectiva que analiza 190 donantes hepaticos, 95 validos y 95 NO validos. Se estudian las variables de cada uno de ellos correspondientes al protocolo de donacion de la Organizacion Nacional de Trasplantes. Mediante el estudio multivariante determinamos los factores de riesgo independientes de NO validez. Cotejamos las causas de NO validez argumentadas con los hallazgos histopatologicos de dichos injertos. Resultados Los factores de riesgo independientes de NO validez en el estudio multivariante (p Conclusiones La determinacion de los factores de riesgo de NO validez contribuira al diseno de futuros scores de valoracion que constituyan herramientas utiles en el proceso de valoracion de injertos hepaticos.

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.

Introduction: The access of surgeons to liver transplant teams in Spain is heterogeneous. This study aims to portray the current human resources of Spanish transplant teams, distribution of transplant duties among team members, how transplant team members acquire their skills, their leaders' view of their future, as well the motivations of Spanish General Surgery residents to choose transplantation as their future career choice. Methods: Two different surveys were created, one for head surgeons and one for residents, about the number of team members and their training, recruitment, organization of tasks and motivation to work in transplantation. The questionnaires were e-mailed to both the transplant program directors and the surgical residents. Results: There are on average 8 surgeons in each transplant unit. More than four surgeons perform the hepatectomy in 54.2% of the groups, while the graft implantation is performed by more than 4 surgeons at just 25% of the centers. Forty-two percent of the transplant chiefs advocated a fellowship training system, and 87.5% believe that generational turnover is guaranteed. Out of 525 residents, 101 responded. Regarding training, 12.8% had no interest in transplantation. Concerning their work preferences, 37.6% were not interested in transplantation because it is excessively demanding, and 52.5% would not like to be part of a liver transplant team in the future. Conclusions: The generational turnover seems to be guaranteed according to liver transplant program directors. The new generations of surgeons generally opt for other areas of surgery other than transplantation. Studies with a greater number of responses are necessary to validate these results (C) 2019 AEC. Published by Elsevier Espana, S.L.U. All rights reserved.

Resumen Introduccion El acceso de los cirujanos a los equipos de trasplante hepatico en Espana se realiza de manera heterogenea. El objetivo de este estudio ha sido cuantificar los recursos humanos de los equipos de trasplante espanoles, la distribucion de las diferentes tareas del trasplante entre los miembros del equipo, el mecanismo mediante el cual se adquieren las habilidades, la vision de sus lideres sobre su continuidad, asi como las motivaciones de los residentes de cirugia general espanoles para elegir el trasplante como su futura carrera profesional. Metodos Se elaboraron dos encuestas diferentes, para los jefes de equipo y para residentes, sobre numero de personas, capacitacion, reclutamiento, organizacion de tareas y motivacion para trabajar en trasplantes. Los cuestionarios se enviaron por correo electronico tanto a los directores de programa de trasplante como a los residentes de cirugia. Resultados Hay en promedio 8 cirujanos en cada unidad de trasplante. Mas de 4 cirujanos realizan la hepatectomia en el 54,2% de los grupos, mientras que el implante lo realiza mas de 4 cirujanos en solo el 25% de los centros. El 42% de los jefes de trasplante hepatico aboga por un sistema tipo fellowship y el 87,5% cree que el recambio generacional esta garantizado. De los 525 residentes, 101 respondieron. Respecto a la formacion, un 12,8% no tiene interes en el trasplante. En cuanto a sus preferencias laborales, el 37,6% no esta interesado en el trasplante por ser excesivamente exigente, y el 52,5% no desea ser parte de un equipo de trasplante de higado en el futuro. Conclusiones El recambio generacional parece estar garantizado segun los directores de programa de trasplante de higado. Las nuevas generaciones de cirujanos generalmente optan por otras areas de cirugia diferentes al trasplante. Son necesarios estudios con mayor numero de respuestas para validar estos resultados.

Background Liver retransplantation can be classified as urgent (when performed in the first week after the transplantation) or elective, which may be considered as early (first month post-transplantation) or late (after the first month). The time in which retransplantation takes place is determined by the cause that makes it necessary. The goal of this study is to analyze the causes and results of early retransplantation in our center. Methods A retrospective analysis of liver retransplantations performed within the first month after the original transplantation in our center between 2007 and 2017 was carried out. The variables analyzed were demographic, causes of the first transplant and retransplantation, and the complications and mortality resulting from the latter. Results A total of 698 liver transplants were performed, including 67 patients who required retransplantation (8.9%). Among these, 37 were late elective retransplantations and 30 were early retransplantations. Regarding the latter, the causes that led to the first transplant were hepatocellular carcinoma (46.7%) and noncholestatic cirrhosis (30%). On the other hand, the main precipitants of the retransplantation were hepatic artery thrombosis (60%) and primary graft failure (13.3%). The reoperation rate was 16.7%, and the perioperative mortality rate was 16.7%. The 1-, 2-, and 5-year survival rates were 83.3%, 76.7% and 59.9%, respectively. Conclusion Despite the high perioperative morbidity of liver retransplantation, its results in terms of survival are similar to those of the global series of liver transplantation.

Introduction The technical, human, scientific and treatment characteristics of the Units that manage complex pathologies have not been studied in depth. Methods Multi-institutional descriptive study (survey) developed jointly by the Hepatobiliary-Pancreatic Division of the Spanish Association of Surgeons and the Spanish Chapter of the IHPBA (International Hepatopancreatobiliary Association) on the characteristics of the Units where pancreatic surgery is performed in Spain. Results 82 surveys were sent. 69 medical centers responded (84%), belonging to 16 autonomous regions of Spain. The total population of these regions was 23 183 262 (50% of the Spanish population). The average number of beds per hospital was 673. The unit that performs pancreatic surgery is a Hepatobiliary-Pancreatic Surgery Unit or HPB and Liver Transplant Surgery Unit in 56 hospitals (77%). The average number of surgeons is 4.5 per Unit. Fifty-five Units (80%) lack specific anesthetists. The number of pancreatectomies performed during 2017 at the hospitals surveyed was 1315 pancreaticoduodenectomies (PD), 566 distal pancreatectomies (DP) and 178 total pancreaticoduodenectomies (TPD). The mean per hospital was 19.1 PD, 8.2 DP and 2.6 TPD. PD was usually performed using a classic approach, with pancreatojejunostomy, single-loop technique, antecolic gastrojejunostomy and using two drain tubes. Only 7 units performed PD laparoscopically and only 13 units did not perform laparoscopic DP. Conclusions This survey provides updated information about the majority of the Units where pancreatic surgery is performed in Spain and could also serve as a starting point for prospective multicenter studies.

Spanish Pancreatic Surgery Group (AEC CE-IHPBA)., [EN]: [Introduction] The technical, human, scientific and treatment characteristics of the Units that manage complex pathologies have not been studied in depth. [Methods] Multi-institutional descriptive study (survey) developed jointly by the Hepatobiliary-Pancreatic Division of the Spanish Association of Surgeons and the Spanish Chapter of the IHPBA (International Hepatopancreatobiliary Association) on the characteristics of the Units where pancreatic surgery is performed in Spain. [Results] 82 surveys were sent. 69 medical centers responded (84%), belonging to 16 autonomous regions of Spain. The total population of these regions was 23183262 (50% of the Spanish population). The average number of beds per hospital was 673. The unit that performs pancreatic surgery is a Hepatobiliary-Pancreatic Surgery Unit or HPB and Liver Transplant Surgery Unit in 56 hospitals (77%). The average number of surgeons is 4.5 per Unit. Fifty-five Units (80%) lack specific anesthetists. The number of pancreatectomies performed during 2017 at the hospitals surveyed was 1315 pancreaticoduodenectomies (PD), 566 distal pancreatectomies (DP) and 178 total pancreaticoduodenectomies (TPD). The mean per hospital was 19.1 PD, 8.2 DP and 2.6 TPD. PD was usually performed using a classic approach, with pancreatojejunostomy, single-loop technique, antecolic gastrojejunostomy and using two drain tubes. Only 7 units performed PD laparoscopically and only 13 units did not perform laparoscopic DP. [Conclusions] This survey provides updated information about the majority of the Units where pancreatic surgery is performed in Spain and could also serve as a starting point for prospective multicenter studies., [ES]: [Introducción] Las características técnicas, humanas, científicas y asistenciales de las Unidades que atienden una patología compleja son poco estudiadas y conocidas. [Métodos] Estudio descriptivo multiinstitucional (encuesta) desarrollado conjuntamente por la sección Hepatobiliopancreática de la Asociación Española de Cirujanos y el capítulo español de la IHPBA (Asociación Internacional Hepatopancreatobiliar) sobre las características de las Unidades donde se realiza cirugía pancreática en España. [Resultados]Se enviaron 82 encuestas. Respondieron 69 centros (84%) pertenecientes a 16 comunidades autónomas. La suma de habitantes de las áreas propias fue 23.183.262. El número medio de camas por hospital fue 673. La Unidad que realiza la cirugía pancreática es la Unidad de Cirugía Hepatobiliopancreática o Cirugía HPB y Trasplante Hepático en 56 hospitales (77%). El número medio de cirujanos es 4,5 por Unidad. Cincuenta y cinco Unidades (80%) carecen de anestesistas específicos. El número de pancreatectomías realizadas durante 2017 en los centros encuestados fue 1.315 duodenopancreatectomías cefálicas (DPC), 566 pancreatectomías distales (PD) y 178 duodenopancreatectomías totales (DPT). La media por centro fueron 19,1 DPC, 8,2 PD y 2,6 DPT. La DPC más habitual se realiza mediante abordaje clásico, con pancreatoyeyunostomía, montaje en un asa, con gastroyeyunostomía antecólica y 2 drenajes. Solo 7 Unidades efectúan la DPC por laparoscopia y solamente 13 Unidades no realizan PD laparoscópica. [Conclusiones]Esta encuesta proporciona información actualizada del trabajo asistencial y científico de un gran porcentaje de las Unidades donde se realiza cirugía pancreática en España, y además puede servir de punto de partida a trabajos multicéntricos prospectivos.

Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy as "difficult". The aim of this study is to achieve a national expert consensus on this issue.A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale. Inter-rater agreement was defined as "unanimous" when 100% of the participants gave an item the same rating on the Likert scale; as "consensus" when ≥80% agreed; as "majority" when the agreement was ≥70%. The delta of change between the two rounds was calculated.After the two rounds, the criteria that reached "consensus" were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%).The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.

Background Optimal haemostasis management in orthotropic liver transplant (OLT) could reduce blood loss and transfusion volume, improve patient outcomes and reduce cost. Methods We performed a study including 336 OLTs to evaluate the clinical and cost effectiveness of a new point-of-care (POC)-based haemostatic management approach in OLT patients. Results In terms of health benefit we found that the new approach showed a significant reduction in transfusion requirements (red blood cell transfusion units were reduced from 5.3±4.6 to 2.8±2.9 [p Conclusions POC haemostatic monitoring during OLT is cost effective.

Objective To assess the importance of intraoperative portal vein flow measurement during liver transplantation in relation to postoperative complications and graft and patient survival. Materials and methods Retrospective review including 291 patients who had all the information and covering a period of 10 years (2007–2017). Using a receiver operating characteristic curve, a cut-off point that would have the greatest impact on the probability of being alive at 5 years was established. In relation to this value, 2 groups were formed (low and high flow) and demographic variables, intraoperative variables, postoperative complications, and graft and patient survival were compared. Results A portal flow of 123 mL/min per100 g of liver tissue was established (area under the curve = 0.58), obtaining a low-flow (n = 129) and a high-flow group (n = 162). The 2 groups were similar in their preoperative characteristics, except for a higher proportion of preoperative ascites, a higher Model for End-Stage Liver Disease score and a lower weight of donors in the high-flow group. The arterial and portal flows were significantly higher in the high-flow group. In the postoperative period, the high-flow group presented a higher rate of ascites. The 5-year survival rate of patients was significantly higher in the high-flow group (76% vs 84%, P = .03). Conclusions Patients undergoing liver transplantation with an intraoperative portal vein flow measurement >123 mL/min per 100 g present a greater 5-year survival rate.

Many centers implement everolimus-based immunosuppression in liver transplant patients with hepatocellular carcinoma. We aimed to explore the potential impact of early initiated everolimus on tumor recurrence after liver transplantation.This study included 192 patients with hepatocellular carcinoma undergoing liver transplantation among who 64 individuals were prospectively enrolled (2012-2015) and received early initiated everolimus (ie, started between postoperative day 15 to 21), whereas the remaining 128 patients acted as historical controls without everolimus. Propensity score matching was performed to ensure comparability. Multivariate Cox regression and competing risks analysis were used to control for potential confounders.Patients with and without everolimus were comparable in terms of number of nodules (P = 0.37), total tumor diameter (P = 0.44), Milan criteria fulfillment (P = 0.56), and histological differentiation (P = 0.61), but there were increased microvascular invasion rates in the everolimus group (26.5% vs 13.3%; P = 0.026). Tumor recurrence rates were similar with and without everolimus (10.9% vs 9.9% at 36 months respectively; P = 0.18). After controlling for microvascular invasion among other potential confounders, everolimus had no significant impact on tumor recurrence, neither in the multivariate Cox regression (relative risk = 3.23; P = 0.09), nor in the competing risks analysis for tumor recurrence-death (relative risk = 1.02; P = 0.94). Patients receiving everolimus had reduced tacrolimus trough concentrations and lower serum creatinine within the first 18 months postliver transplantation.Everolimus may not be universally prescribed to prevent tumor recurrence in liver transplant patients with hepatocellular carcinoma. Future randomized trials should be focused on patients with histological features of increased tumor aggressiveness, in whom the potential benefit would be higher.

Sin financiación 2.242 JCR (2021) Q3, 123/213 Surgery 0.262 SJR (2021) Q3, 300/492 Surgery No data IDR 2021 UEM

Graphical abstract, Introduction The extraordinary impact of COVID-19 pandemic on Spanish hospitals has led to a redistribution of resources for the treatment of these patients, with a decreased capacity of care for other common diseases. The aim of the present study is to analyse how this situation has affected the treatment of cholecystitis and cholelythiasis. Methods It is a descriptive national study after online voluntary distribution of a specific questionnaire with Google Drive™ to members of the Spanish Association of Surgeons (AEC). Results We received 153 answers (one per hospital). Elective cholecystectomies have been cancelled in 96.7% of centres. Conservative treatment for acute cholecystitis has been selected in 90% (previously 18%), and if operated, 95% have been performed laparoscopically. Globally, only 49% perform preoperative diagnostic tests for SARS-CoV-2, and 58.5% recognize there have been cases confirmed postoperatively after other surgeries, with worse surgical outcomes in 54%. Conclusions This survey shows that most of the Spanish centers are following the surgical societies suggestions during the pandemic. However, some data requires to be taken into account for the next phase of the pandemic.

The underlying causes of chronic rejection (CR) after liver transplantation (LT) are not completely known. The main aim of this study was to explore the involvement of the minor histocompatibility antigen glutathione S-transferase T1 (GSTT1) in CR. We retrospectively studied 611 patients who underwent LTs at University Hospital Virgen del Rocío between 2003 and 2016 with a median follow-up of 7.4 ± 4.2 years. The GSTT1 genotype was determined by polymerase chain reaction. We defined GSTT1 mismatch as a specific donor/recipient combination in which a recipient who was homozygous for the deletion allele received a transplant from a positive donor. The prevalence of CR in our whole cohort was 11.6% (71/611), and the prevalence in the GSTT1-mismatched group was 18.8% (16/85) versus 10.5% (55/526) in the GSTT1-matched group. In the cyclosporine A (CsA) group, the prevalence was 26.3% (26/99), much higher than the 8.8% (45/512) observed in the tacrolimus (Tac) group. For statistical analysis, the patients were distributed into 2 groups: group 1, regarded as GSTT1 mismatched, which included the donor (D)+/recipient (R)− allelic combination; and group 2, regarded as GSTT1 matched, which included the other allelic combinations of D+/R+, D−/R−, and D−/R+. All relevant clinical information was collected, and a diagnosis of CR was always confirmed by liver biopsy. GSTT1 mismatch (hazard ratio [HR], 1.99; 95% confidence interval [CI], 1.08-3.66; P = 0.03) and use of CsA/Tac (P ' 0.001) were independent risk factors for CR. CR increased the risk of mortality (HR, 2; 95% CI, 1.2-3.6; P = 0.01). Out of the 71 CR patients, 12 (16.9%) needed retransplantation. In conclusion, the GSTT1 D+/R− allelic mismatch is an independent risk factor for CR. A long follow-up of LT patients is recommended because the incidence of CR in adults seems to be underestimated., This work was supported by the Instituto de Salud Carlos III (PI‐17/01403) and cofunded by Fondo Europeo de Desarrollo Regional (FEDER) from the Regional Development European Funds (European Union).

11th Congress of the Andalusian Society of Organ and Tissue Transplantation. Liver transplantation., [Background] The presence of collateral circulation in liver cirrhosis patients with portal hypertension is quite frequent due to re-permeabilization of closed embryonic channels. In some cases, these shunts could measure over 1 cm wide, therefore, containing a significative blood flow. Its management during liver transplantation could be challenging due to possible complications resulting from either ligation of the shunts or from ignoring them. We present the case of a patient with recurrent hepatic encephalopathy (HE) and a large spontaneous portosystemic shunt (SPSS) who submitted to liver transplant and review the literature identifying options, complications, and outcomes with the aim of facilitating decision making., [Material and Methods] A 68-year-old, Spanish man diagnosed with liver cirrhosis with portal hypertension and recurrent episodes of HE is proposed for LT. The patient’s Child-Pugh score was A6-B7, and the Model for End-stage Liver Disease score was 12. Preoperatively, a computed tomography scan showed a large SPSS running to the inferior cava vein. During the surgery, a small-sized portal vein and a large shunt measuring almost 3 cm wide were identified. After reperfusion, portal vein flow was 1000 to 1100 mL/min. Owing to the previous HE and the risk of low portal flow, the shunt was closed increasing the portal flow to 1800 mL/min. The patient was discharged without any complications., [Conclusions] The presence of large SPSSs are frequent during LT. Decision making intraoperatively can be challenging due to possible complications derived from ligation of the SPSS or from ignoring it. Either preoperative assessment of a further HE risk or portal vein flow measurement after reperfusion are essential to achieve a correct resolution.

11th Congress of the Andalusian Society of Organ and Tissue Transplantation. General transplantation topics., [Background] Health care–associated infection (HAI) represent a global health problem with an increase in hospital stays, deaths, and monetary costs. Recipients of solid organ transplants are a population at risk. The objectives of the study were to characterize the incidence of HAI in renal and hepatic transplant recipients as well as to compare them with the population without transplants in intensive care units (ICU)., [Methods] The data on the incidence of HAI, localization, microorganisms, and demographics were taken from the patients admitted between the years 2013 to 2018 (n = 4307) from the registration of the Project for the Reduction of Nosocomial Infection in Intensive Care Units. The variables were compared with those of renal transplant (n = 96) and liver transplants (n = 68) recipients., [Results] Renal transplant recipients showed 26% incidence of HAI. The most frequent were surgical site infection (SSI), urinary tract infection, and primary bacteremia; the most frequent microorganism was Staphylococcus spp, mortality 3.8%. Liver transplant recipients showed 41% incidence of HAI. The most frequent were tracheobronchitis associated with mechanical ventilation, SSI, and primary bacteremia; the most frequent microorganism was Staphylococcus spp, mortality 37%. The population without transplants in the ICU showed 17% incidence of HAI. The most frequent were respiratory infections associated with mechanical ventilation, primary bacteremia, and SSI; the most frequent microorganism was Acinetobacter spp, mortality 21%., [Conclusions] HAI in recipients of solid organ transplants (renal and hepatic) have a higher incidence than in a population without transplants. The location and causal microorganisms have particularities that must be taken into account for the development of prevention protocols.

Objective Obesity is one of the main growing epidemics of the last century and is responsible for many deaths worldwide. The aim of this study is to analyze the impact of the body mass index (BMI) of the recipient on survival and morbidity after liver transplantation (LT). Material and methods We conducted a retrospective cohort study of all transplanted recipients in a third-level hospital between 2006 and 2018. The following donor variables were analyzed: age, sex, weight, BMI, cause of death. Additionally, the following recipient variables were analyzed: age, sex, weight, height, BMI, procedure indication. Finally, outcome variables were analyzed: postoperative complications, early mortality, graft loss, and overall survival. This study strictly complies with the Helsinki Congress and the Istanbul Declaration regarding donor source. Results We analyzed 825 of 837 LTs from January 2006 to December 2018. These were grouped by BMI categories: 271 (29%) normal, 322 (34.3%) overweight, and 228 (24.3%) obesity. The overall survival at 5 years was 83% in the normal group, 76% in the overweight group, and 71% in the obesity group. These differences were statistically significant (P = .027). The early mortality rate was 4.42% in the normal weight group, 6.5% in the overweight group, and 5.26% in the obesity group. No differences were found between groups in terms of postoperative complications: hemorrhagic, vascular, biliary, respiratory, hemodynamic, digestive, renal, neurologic, rebel ascites, and infections. No differences were found regarding the need for re-operation. Conclusions In this study, overall survival in LT decreases as the BMI of recipient increases; but overweight and obesity do not constitute a risk factor for early morbidity and mortality in LT.

[Background/Aims] Orthotopic liver transplantation (OLT) is the recommended treatment for patients at early stages of hepatocarcinoma (HCC) with portal hypertension and/or increased bilirubinemia, but without vascular-associated diseases. Tumor recurrence, which is the main drawback for the survival of patients submitted to OLT for HCC, has been related to tumor-related variables and the immunosuppressive therapies. We have previously shown that Tacrolimus (FK506) exerts a more potent pro-apoptotic and anti-proliferative effects than the mammalian target of rapamycin (mTOR) inhibitors (Sirolimus and Everolimus) in liver cancer cells. This study identified the role of the immunosuppressant partners such as FK506-binding proteins (FKBPs) in the induction of cell death and arrest of cell proliferation by immunosuppressants in two representative liver cancer cells., [Methods] The regulation of endoplasmic reticulum (ER) stress, apoptosis/autophagy, cell proliferation, and FKBPs expression was determined in Tacrolimus-, Sirolimus- and Everolimus-treated primary human hepatocytes, and hepatoma HepG2 and Huh7 cell lines. The functional repercussion of FKBPs on cell death and proliferation was also addressed using the siRNA technology. The assessed antitumoral properties of the immunosuppressants were associated to microRNAs (miRNAs) pattern., [Results] The enhanced pro-apoptotic and anti-proliferative properties of Tacrolimus versus mTOR inhibitors were associated with increased protein kinase RNA-like endoplasmic reticulum kinase (PERK)-related ER stress, Ser15P-p53/p53 ratio and p21 protein expression that may counterbalance the risk of proliferative upregulation caused by enhanced Thr172P-Cdk4/Cdk4 activation in liver cancer cells. The inhibition of the mTOR pathway by Sirolimus and Everolimus was related to an induction of autophagy; and at a high dose, these drugs impaired translation likely at a very early step of the elongation phase. Tacrolimus and mTOR inhibitors increased the protein expression of FKBP12 and FKBP51 that appeared to play pro-survival role. Interestingly, the administration of immunosuppressants yields a specific pattern of miRNAs. Tacrolimus and mTOR inhibitors decreased miR-92a-1-5p, miR-197-3p, miR-483-3p and miR-720, and increased miR-22-3p, miR-376a-3p, miR-663b, miR-886-5p, miR-1300 and miR-1303 expressions in HepG2 cells., [Conclusion] The more potent pro-apoptotic and anti-proliferative properties of Tacrolimus versus mTOR inhibitors were associated with an increased activation of PERK and p53 signaling, and p21 protein expression. FKBP12 and FKBP51 appeared to be the most relevant partners of Tacrolimus and mTOR inhibitors exerting a pro-survival effect in HepG2 cells. The observed effects of immunosuppressants were related to a specific miRNA signature in liver cancer cells., We thank the Institute of Health Carlos III (ISCiii) cofinanced by the European Regional Development Fund “A way to achieve Europe” (ERDF) (PI13/00021, P16/00090 and PI19/01266), as well as the Andalusian Ministry of the Economy, Innovation, Science and Employment (CTS-6264) and Andalusian Ministry of Health (PI13/00025, PI16/0198, PIP-0215-2020 and PI-0216-2020) for their financial support to J.M. We also thank the Spanish Ministry of Economy and Competitiveness (MINECO) cofinanced by the ERDF (BFU2016-75352-P AEI/FEDER, EU) for their financial support to J.d.l.C. We thank Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd) founded by the ISCiii and cofinanced by the ERDF for their financial support. E.N-V. acknowledges IFI18/00014 fellowship from the ISCiii. P.d.l.C-O. acknowledges FPU17/00026 fellowship from the Spanish Ministry of Education (MEC). L.C. acknowledges FPU16/05127 fellowship from the MEC.

Sorafenib and Regorafenib are the recommended first- and second-line therapies in patients with advanced hepatocellular carcinoma (HCC). Lenvatinib and Cabozantinib have shown non-inferior antitumoral activities compared with the corresponding recommended therapies. The clinical trials have established recommended doses for each treatment that lead different blood concentrations in patients for Sorafenib (10 µM), Regorafenib (1 µM), Lenvatinib (0.1 µM), and Cabozantinib (1 µM). However, very low response rates are observed in patients attributed to intrinsic resistances or upregulation of survival signaling. The aim of the study was the comparative dose–response analysis of the drugs (0–100 µM) in well-differentiated (HepG2, Hep3B, and Huh7), moderately (SNU423), and poorly (SNU449) differentiated liver cancer cells in 2D/3D cultures. Cells harbors wild-type p53 (HepG2), non-sense p53 mutation (Hep3B), inframe p53 gene deletion (SNU423), and p53 point mutation (Huh7 and SNU449). The administration of regular used in vitro dose (10 µM) in 3D and 2D cultures, as well as the dose–response analysis in 2D cultures showed Sorafenib and Regorafenib were increasingly effective in reducing cell proliferation, and inducing apoptosis in well-differentiated and expressing wild-type p53 in HCC cells. Lenvatinib and Cabozantinib were particularly effective in moderately to poorly differentiated cells with mutated or lacking p53 that have lower basal oxygen consumption rate (OCR), ATP, and maximal respiration capacity than observed in differentiated HCC cells. Sorafenib and Regorafenib downregulated, and Lenvatinib and Cabozantinib upregulated epidermal growth factor receptor (EGFR) and mesenchymal–epithelial transition factor receptor (c-Met) in HepG2 cells. Conclusions: Sorafenib and Regorafenib were especially active in well-differentiated cells, with wild-type p53 and increased mitochondrial respiration. By contrast, Lenvatinib and Cabozantinib appeared more effective in moderately to poorly differentiated cells with mutated p53 and low mitochondrial respiration. The development of strategies that allow us to deliver increased doses in tumors might potentially enhance the effectiveness of the treatments., We thank the predoctoral i-PFIS IIS-enterprise contract in science and technologies in health granted by the Institute of Health Carlos III (ISCiii; IFI18/00014; to E.N.-V.); the ISCiii (PI16/00090 and PI19/01266), the Andalusian Ministry of Health (PI-0198-2016), the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd) founded by the ISCiii and co-financed by European Development Regional Fund “A way to achieve Europe” (ERDF) (to J.M.), and ISCiii (PI19/00838) and Valencian Ministry of Education, Culture and Sports (PROMETEO/2019/027) (to V.M.V.) for their financial support.

Resumen Introduccion La mayor supervivencia del paciente trasplantado viene acompanada del aumento en la tasa de tumores de novo (TN) que representan la complicacion tardia mas frecuente. Podemos distinguir entre tumores de piel no melanoma (TPNM), sindrome linfoproliferativo postrasplante (SLPT) y tumores de organo solido (TOS). Nuestro objetivo es determinar la incidencia de los distintos TN, el tiempo trascurrido hasta su diagnostico y su supervivencia en nuestro medio. Material y metodo Realizamos un estudio retrospectivo de 1.071 trasplantados hepaticos desde 1990 hasta 2015 en nuestro centro. Analizamos las variables demograficas, la incidencia de TN y la supervivencia. Resultados Se desarrollaron 184 TN en 1.071 pacientes trasplantados (17%), en el 19% de los varones y en el 13% de las mujeres (p = 0,004). Los TN mas frecuentes fueron los TPNM (29%), pulmon (18%), cabeza y cuello (16%), SLPT (10%) y gastrointestinales (8%). La mediana del tiempo de diagnostico fue de 7,9 anos en los TPNM, 3,9 anos en SLPT y de 9,8 anos en TOS. Los pacientes con TPNM tuvieron significativamente mejor supervivencia que aquellos con SLPT o TOS. La incidencia de los tumores de novo (excluidos TPNM) fue 1.889/100.000 trasplantados/ano. Por genero, el cancer de pulmon fue el TOS mas comun en varones y el cancer de mama en mujeres. Conclusion En nuestro medio, excluidos los TPNM, la incidencia es 8,8 veces la estimada para la poblacion general, con una alta tasa de cancer de pulmon por lo que deberiamos implementar estrategias preventivas y diagnosticas.

Between 1991 and 2013, 1,000 liver transplantations were performed at Virgen del Rocio Hospital (Seville, Spain). A retrospective study was conducted, analyzing the characteristics of recipients and donors, indications, surgical technique, complications and survival in 2 different stages (1991-2002 vs. 2003-2013) coinciding with the implementation of the MELD scale as a prioritization model. The most frequent indication were of hepatopathy of hepatocellular origin in 48.8%. There was a significant increase in the indications for hepatocarcinoma (8.6% and 24.1% P=0.03), and the rate of retransplantation (5.9% vs 9.6%, P=0.04). There was a change in the age of donation, going from 27.7 years in 1990 to 62.9 years in 2012 (P=0.001). The percentage of patients who did not require blood transfusion doubled (6.16 vs. 14.31%, P=.001). Survival of all patients after one, 5 and 10 years was 77, 63.5 and 51.3%, respectively.

AIM: To investigate the role of glutathione S-transferase T1 donor-specific T lymphocytes in plasma cell-rich rejection of liver allografts. METHODS: The study group included 22 liver transplant patients. Among them, 18 patients were mismatched for the glutathione S-transferase T1 (GSTT1) alleles (don+/rec-), and 4 were matched (don+/rec+). Seven of the mismatched patients produced anti-GSTT1 antibodies and developed plasma cell-rich rejection (former de novo immune hepatitis). For the detection of specific T lymphocytes, peripheral blood mononuclear cells were collected and stored in liquid nitrogen. The memory T cell response was studied by adding to the cell cultures to a mix of 39 custom-made, 15-mer overlapping peptides, which covered the entire GSTT1 amino acid sequence. The specific cellular response to peptides was analyzed by flow cytometry using the markers CD8, CD4, IL-4 and IFNγ. RESULTS: Activation of CD8+ T cells with different peptides was observed exclusively in the group of patients with plasma-cell rich rejection (3 out of 7), with production of IL-4 and/or IFNγ at a rate of 1%-4.92% depending on the peptides. The CD4+ response was most common and not exclusive for patients with the disease, where 5 out of 7 showed percentages of activated cells from 1.24% to 31.34%. Additionally, two patients without the disease but with the mismatch had cells that became stimulated with some peptides (1.45%-5.18%). Highly unexpected was the finding of a double positive CD4+CD8low T cell population that showed the highest degree of activation with some of the peptides in 7 patients with the mismatch, in 4 patients with plasma cell-rich rejection and in 3 patients without the disease. Unfortunately, CD4+CD8low cells represent 1% of the total number of lymphocytes, and stimulation could not be analyzed in 9 patients due to the low number of gated cells. Cells from the 4 patients included as controls did not show activation with any of the peptides. CONCLUSION: Patients with GSTT1 mismatch can develop a specific T-cell response, but the potential role of this response in the pathogenesis of plasma cell-rich rejection is unknown.

Recently, there has been a large discrepancy between the number of patients on the waiting list for a liver transplant and the availability of deceased donors, with an increase in annual wait list mortality rates. Elderly donor livers are thought to be marginal grafts; however, in recent years, their utilization has constantly increased. The aim of this study is to evaluate the utilization of elderly donors in Andalusia and post-transplant outcomes. This retrospective observational study of 2408 liver transplants, performed in Andalusia between 2000 and 2014, analyzes the outcomes from donors aged 70 plus (n = 423) in terms of survival rates of the graft and the recipient, the type of transplant, donor age, and D-MELD score (product of donor age and preoperative Model for End-stage Liver Disease score). The most frequent indications for transplant were alcoholic cirrhosis (49.2%), hepatitis C cirrhosis (13%), and hepatocellular carcinoma (12.5%). The overall survival at 5 years was 64%, with a significant fall in survival for recipients with a D-MELD greater than 1500 (57%; P = .045). In the 70-year-old-plus donor group, the overall patient survival was 58.4%. The retransplant rate increased proportionately with donor age. In the alcoholic cirrhosis recipient subgroup, the overall survival at 5 years was 67.6% (P < .05) compared with 33.5% in patients with hepatitis C. Use of elderly donors is a safe strategy to reduce the scarcity of donors, provided that a D-MELD score below 1500 is obtained. Retransplant rates increase progressively with donor age. It is necessary to carefully screen recipients of older organs, taking into account that the best results are obtained for alcoholic cirrhosis, negative viral load hepatitis C, and a D-MELD score below 1500.

The goal of this work has been to analyze the first 1000 liver transplantations (LTs) performed in the Virgen del Rocio Hospital of Seville and to evaluate the changes in that time. We included 916 patients who had 1000 LTs. We distinguish 2 stages in the follow-up: the first stage, between 1990 and 2002, and the second, from 2003 to 2013 (Model for End-stage Liver Disease [MELD] stage). We analyzed recipient features, LT indications, donation criteria, surgical technique, complications, and survival both for patients and grafts. The median age of recipients was 53.50 ± 46.49 years old, with a noticeable increase after 2000. There were 3 times as many men as women. The most frequent indications for LT were hepatocellular disease (48.8%), followed by hepatocarcinoma (17.8%), retransplantation (8.1%), and cholestatic diseases (3.6%). Donors of Andalusian centers accounted for 88.2% of LTs, and 8.3% of LTs presented some arterial or venous complication. Biliary complications occurred in 15.6%. Patient survival at 1, 5, and 10 years was 77%, 63.5%, and 51.3%, respectively. In conclusion, some of the factors that negatively influenced survival of the patient were stage of the LT, hepatitis C virus–positive recipient, emergency cases, hepatocarcinoma, high consumption of blood products, and second transplantations.

Blood loss remains a major concern during surgery and can increase the morbidity of the intervention. The use of topical haemostatic agents to overcome this issue therefore becomes necessary. Fibrin sealants are promising haemostatic agents due to their capacity to promote coagulation, but their effectiveness and applicability need to be improved. We have compared the haemostatic efficacy of a novel nanostructured fibrin‐agarose hydrogel patch, with (c‐NFAH) or without cells (a‐NFAH), against two commercially available haemostatic agents in a rat model of hepatic resection. Hepatic resections were performed by making short or long incisions (mild or severe model, respectively), and haemostatic agents were applied to evaluate time to haemostasis, presence of haematoma, post‐operative adhesions to adjacent tissues, and inflammation factors. We found a significantly higher haemostatic success rate (time to haemostasis) with a‐NFAH than with other commercial haemostatic agents. Furthermore, other relevant outcomes investigated were also improved in the a‐NFAH group, including no presence of haematoma, lower adhesions, and lower grades of haemorrhage, inflammation, and necrosis in histological analysis. Overall, these findings identify a‐NFAH as a promising haemostatic agent in liver resection and likely in a range of surgical procedures., This work was supported by preclinical research funds from the Regional Government of Andalusia through the Andalusian Initiative for Advanced Therapies.

The access of surgeons to liver transplant teams in Spain is heterogeneous. This study aims to portray the current human resources of Spanish transplant teams, distribution of transplant duties among team members, how transplant team members acquire their skills, their leaders' view of their future, as well the motivations of Spanish General Surgery residents to choose transplantation as their future career choice.Two different surveys were created, one for head surgeons and one for residents, about the number of team members and their training, recruitment, organization of tasks and motivation to work in transplantation. The questionnaires were e-mailed to both the transplant program directors and the surgical residents.There are on average 8 surgeons in each transplant unit. More than four surgeons perform the hepatectomy in 54.2% of the groups, while the graft implantation is performed by more than 4 surgeons at just 25% of the centers. Forty-two percent of the transplant chiefs advocated a fellowship training system, and 87.5% believe that generational turnover is guaranteed. Out of 525 residents, 101 responded. Regarding training, 12.8% had no interest in transplantation. Concerning their work preferences, 37.6% were not interested in transplantation because it is excessively demanding, and 52.5% would not like to be part of a liver transplant team in the future.The generational turnover seems to be guaranteed according to liver transplant program directors. The new generations of surgeons generally opt for other areas of surgery other than transplantation. Studies with a greater number of responses are necessary to validate these results.