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Objective: Liver transplantation is one of the treatments for patients with advanced stage chronic liver disease and for selected patients with hepatic tumors. Ultrasonography is the first-choice imaging technique to evaluate liver transplants. This article reviews the surgical technique, anatomy, and normal findings on ultrasonography in the immediate postoperative period in patients who have undergone liver transplantation, which will be used as a reference in follow-up studies., Conclusion: Early vascular (arterial and portal) complications can represent a threat for the graft or the patient. During the period after liver transplantation, the patient is recovering from surgery and the transplanted organ is adapting to its new environment. In this period, ultrasonography can show alterations in the parenchyma or Doppler findings that would be considered abnormal in other situations; these findings are usually transitory. Knowing how to interpret them is key to detecting or ruling out complications., (Copyright © 2019 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Extrahepatic portal vein obstruction (EPVO) is the principal cause of portal hypertension in children. The objective of this study was to analyze the capacity of the surgical technique that creates a mesoportal shunt to treat changes caused by EPVO., Methods: Retrospective review of patients with idiopathic EPVO who underwent a mesoportal shunt and analysis of the changes in the number of leucocytes, platelets, prothrombin time and spleen size one year after the surgery., Results: Twelve patients underwent surgery, out of which 10 had prior leukopenia, 11 thrombopenia, 9 longer prothrombin times and all had hypersplenism. One patient suffered a postoperative shunt thrombosis, was reoperated and underwent a change in the operative technique. The remaining patients (92%) have functioning shunts 4.3 ± 2.5 years after surgery, and none have suffered any episode of gastrointestinal bleeding. One year after surgery, there were significant changes in the number of platelets, prothrombin time and spleen size, with no significant changes in the number of leukocytes. However, the number of patients who went from a leukopenic to a normal state was significant, as happened with changes in prothrombin time., Conclusions: Mesoportal Rex shunt improves some of the disorders caused by portal hypertension in children suffering EPVO, with a high rate of surgical success. This technique should be of first choice in these patients.

Background: Liver transplantation in patients with liver cirrhosis, portal vein thrombosis, and cavernous transformation of the portal vein, is a complex procedure with high possibility of liver graft dysfunction. It is performed in 2-19% of all liver transplants, and has a significantly high mortality rate in the post-operative period. Other procedures to maintain portal perfusion have been described, however there are no reports of liver graft perfusion using right gastroepiploic vein., Clinical Case: A 20 year-old female diagnosed with cryptogenic cirrhosis, with a Child-Pugh score of 7 points (class "B"), and MELD score of 14 points, with thrombosis and cavernous transformation of the portal vein, severe portal hypertension, splenomegaly, a history of upper gastrointestinal bleeding due to oesophageal varices, and left renal agenesis. The preoperative evaluation for liver transplantation was completed, and the right gastroepiploic vein of 1-cm diameter was observed draining to the infrahepatic inferior vena cava and right suprarenal vein. An orthotopic liver transplantation was performed from a non-living donor (deceased on January 30, 2005) using the Piggy-Back technique. Portal vein perfusion was maintained using the right gastroepiploic vein, and the outcome was satisfactory. The patient was discharged 13 days after surgery., Conclusions: Liver transplantation was performed satisfactorily, obtaining an acceptable outcome. In this case, the portal perfusion had adequate blood flow through the right gastroepiploic vein., (Copyright © 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.)

Introduction: The benefit of pancreaticoduodenectomy (PD) with superior mesenteric-portal vein resection (PVR) for pancreatic adenocarcinoma (PA) is still controversial in terms of morbidity, mortality and survival. We conducted a retrospective study to analyze outcomes of PD with PVR in a Spanish tertiary centre., Methods: Between 2002 and 2012, 10 patients underwent PVR (PVR+ group) and 68 standard PD (PVR- group). Morbidity, mortality, overall survival (OS) and disease-free survival (DFS) were compared between PVR+ and PVR- group. Prognostic factors were identified by a Cox regression model., Results: Postoperative mortality was 5% (4/78), all patients in PVR- group. Morbidity was higher in the PVR- group compared to PVR+ (63 vs. 30%, P=.004). OS at 3 and 5 years was 43 and 43% in PVR+ group, 35 and 29% in PVR- group (P=.07). DFS at 3 and 5 years DFS were 28 and 15% in PVR+ group, 25 and 20% in PVR- group (P=.84). Median survival was 23.1 months in PVR- group, and 22.8 months in PVR+ group (P=.73). Factors related with OS were absence of adjuvant treatment (OR 2.9, 95%IC: 1.39-6.14, P=.003), R1 resection (OR 2.3, 95%IC: 1.2-4.43, P=.006), preoperative CA 19.9 level ≥ 170 UI/mL (OR 2.3, 95%IC: 1.22-4.32, P=.01). DFS risk factors were R1 resection (OR 2.6, 95%IC: 1.41-4.95, P=.002); moderate or poor tumor differentiation grade (OR 2.7, 95%IC: 1.23-6.17, P=.01); N1 lymph node status (OR 1.8, 95%IC: 1.02-3.19, P=.04); CA 19.9 level ≥ 170 UI/mL (OR 2.4, 95%IC: 1.30-4.54, P=.005)., Conclusions: PVR for PA can be performed safely. Patients with PVR have a comparable survival to patients undergoing standard PD if disease-free margins can be obtained., (Copyright © 2015 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Liver failure might be a cause of death after major hepatectomies. The ALPPS technique appears to be a promising strategy to avoid it, however no experimental studies supporting this procedure have been previously described. The aim was to develop an experimental model of ALPPS in rats., Method: Experimental. A total of 30 Sprague Dawley rats were used. To develop the ALPPS procedure, ligation of the left portal branch of the middle lobe (LM) was performed. This demarcates the left side (SILM) from the right side (SDLM); parenchyma transection was performed following the demarcated line. The animal's weight, volume and weight of both LM were analyzed. Sacrifice at 3, 7 and 14 days after the procedure (10 per group) was performed., Results: No bleeding or ascites were observed during the postoperative period. The LM increased by 24.1, 86.9 and 120.4% at 3, 7 and 14 days. The SDLM increased by 34.4, 78.8 and 102.0% at 3, 7 and 14 days. The SILM decreased 42.6, 64.8, and 79.3% at day 3, 7 and 14 days respectively., Conclusion: The ALPPS procedure can be performed in rats, achieving the expected results. Comparison studies to 2 staged hepatectomy will be necessary., (Copyright © 2013 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) achieves the hypertrophy of the future liver remnant in seven days. We achieved the same hypertrophy placing a tourniquet in the parenchimal transection line associating a right portal vein ligation (associating liver tourniquet and right portal vein ligation for staged hepatectomy-ALTPS). In perihiliar tumors a«non touch» technique should be performed. ALPPS y ALTPS do not comply with this technical aspect because a dissection of the hilum is carried out in both procedures during the portal dissection. To avoid this problem we devised a new method called sequential ALTPS. It consists of placing a tourniquet in the umbilical fissure without ligation of the right portal vein during the first stage. Subsequently, on the 4(th) postoperative day we perform a percutaneous right portal vein embolization. We present the first case of this new technique in which we have obtained a hypertrophy of 77% of the future liver remnant seven days after portal vein embolization. In the second stage a right trisectionectomy was performed with inferior vena cava resection with a goretex graft replacement., (Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy), in 2-stage liver resections, achieves hypertrophy of the functional liver remnant (FLR) in 7 days, and the objective of this technique is the occlusion of the intrahepatic collaterals. In March 2012 we published a new surgical technique associating the insertion of a tourniquet in Cantlie' line and right portal vein ligation (ALTPS: Associating liver tourniquet and right portal vein occlusion for staged hepatectomy). In this paper we present this ALTPS technique placing the tourniquet in the umbilical fissure to obtain hypertrophy of segments II-III. It was performed in a 51 year-old patient with a recurrent right renal hypernephroma which involved all the anatomic right lobe and inferior vena cava. Preoperative FLR was 380 ml (20% of the total volume) increasing 150% at 7 days (to 953 ml, 31% of the total). In the second step, we performed a right trisectionectomy and retrohepatic inferior vena cava resection, replacing it by a 2 cm-ring goretex graft., (Copyright © 2013 AEC. Published by Elsevier Espana. All rights reserved.)

Chylous ascites is infequent after abdominal surgery. We describe the case of a 43-year-old man with portal cavernomatosis who underwent surgery to insert a splenorenal shunt, which was not placed due to the absence of signs of portal hypertension. On postoperative day 20, the patient developed abdominal distension and mild dyspnea and was diagnosed with chylous ascites, which was related to the surgery. The patient was initially treated with diet and diuretics, with no clinical response, and consequently octreotide therapy was started. Four days later, the ascites was almost resolved and an ultrasound scan at 4 months showed its complete disappearance. This article demonstrates the effectiveness of octreotide in the treatment of postsurgical chylous ascites., (Copyright © 2012 Elsevier España, S.L. and AEEH y AEG. All rights reserved.)

Cephalic pancreaticoduodenectomy (CPD) with mesentericoportal venous resection increases the resectability rate of pancreatic tumors. When performed in selected patients and by experienced surgical teams, this technique shows the same long-term rates of morbidity, mortality and survival as CPD without vascular resection, provided that negative surgical margins are obtained. This procedure is contraindicated by complete thrombosis of the portal or superior mesenteric veins, invasion of the superior mesenteric artery or celiac trunk, and distant or periaortic lymph node involvement. Venous reconstruction can be performed through lateral suture, termino-terminal anastomosis, or by graft placement. We believe that intercalation of the autologous internal jugular vein facilitates resection and minimizes phenomena of venous stasis. We present a case of adenocarcinoma of the pancreatic head infiltrating the superior mesenteric-portal vein confluence that underwent surgery in our hospital. CPD with mesentericoportal venous resection and reconstruction using autologous internal jugular vein were performed. The most important technical features are discussed.

Liver transplantation (LT) is probably the biggest surgical aggression that a patient can endure. It was considered only as a last option in the era of experimental LT, yet it evolved into the definitive treatment for some types of acute and chronic end stage liver disease. In terms of technique LT is the most complex of all types of transplantations. The surgical procedure in itself is well established and has changed little through time. Liver transplantation owes its improvement to better and more systematic anesthetic procedures and to perioperative care more than being due to improvement of the surgical technique. The first surgical procedure was described by Thomas Starzl in 1969. His initial work has been strengthened with the development of venous bypass, the refinement in vascular and biliary reconstruction technique and the development of the split liver. Up to date technical aspects of orthotopic liver transplantation are described in the present article.

Background: The Kasai procedure, portoenteroanastomosis (PEA) didn't reach international spreading until the seventy's decade, making difficult to find long-term results from children with ABE successfully treated with this technique. At our institution in the last fifteen years all the therapeutics procedures for these patients can be offered, including the liver transplant., Aim: To show the evolution of our patients with ABE treated with the PEA and that survive long-term without being transplanted., Methods: The clinical course of 22 patients that survive more than 10 years after the PEA with their own liver is reviewed. The hepatic survival indexes of (success, death or transplant) are beyond the tenth year. The problems raised during the follow-up are analysed., Results: From 99 patients with ABE treated primarily in our center, 22 reached the 10 year-old age after the PEA without a liver transplant. In the follow-up, seven if the these finally needed the transplant. Their median age was 12.2 year-old (range: 10.5-13.8) for a progressive hepatocellular damage in 5 cases associated to syndrome hepatopulmonar in two cases. The other fifteen patients have a compensated hepatopathy. Five of them do not have hyperesplenisme and the serum bilirrubine levels are lower than 1.3 mg/dL. The medium age of these patients at the end of the follow-up was 14.8 years., Conclusions: In spite of the reestablishment of the biliary flow with the PEA, few are the patients with ABE that preserve their hepatic function lapsed long periods of time. Nevertheless the prognosis of these patients is excellent.

Objective: To improve the technique of stenosing ligation of the portal vein, frequently used to obtain a prehepatic portal hypertension model in the rat, by increase the initial resistance to the blood flow., Methods: In this experimental work portal stenosis by three equidistant stenosing ligatures which are fixed in a plastic guide is proposed as an alternative technique., Results: Triple stenosing ligation of the portal vein does not produce mortality and causes splenomegaly as well as a larger degree of collateral venous circulation, particularly of splenorenal type, in relation to rats with a simple stenosing ligation., Conclusion: Increase of the stenosed tract length of the portal vein in the rats with triple ligation increases the initial resistance to the portal flow and then the posterior evolution would be impaired and this mechanism could be involved in a larger degree of collateral venous circulation.

A retrospective and transversal study of our patients with portal cavernomatosis is developed, with the aim of comparing the evolution and the present status of the patients that have undergone different therapeutical approaches. Between 1975 and 1995, 15 patients with portal cavernomatosis have been treated. Personal history, signs and symptoms at the moment of diagnosis, and treatment were analyzed. Now, the controls have been made by physical examination and ECO-Doppler of the espleno-portal system. In 6 cases the absence of bleeding made surgery unnecessary. In the 9 patients with digestive haemorrhage, it could be controlled pharmacologically, with a later surgical approach. Now, all non-operated and 6 operated patients show splenomegaly, without bleeding. The ECO-Doppler shows colateral flow, the splenomegaly in the non-operated and the surgical shunts and the hepatofugal circulation in the operated patients. Looking at our results, we believe that prophylactic surgery is not indicated. In those cases of digestive bleeding, surgery after the complete resolution of the acute disease shows good results at a short and long term.

Veno-venous bypass (VVB) by the percutaneous introduction of cannulas in the right internal jugular vein during liver transplantation may reduce the complications derived from the classical method of axillary vein dissection. The results and complications observed over a two and a half year period in 126 consecutive patients submitted to liver transplantation in whom preparation for femoral-portal-jugular veno-venous bypass was carried out are reported. Twelve complications (9.5%) were observed in the 126 patients. All the complications were due to jugular cannulation and were divided as follows: in 7 patients (5.5%) some of the guide introductions were unsuccessful following multiple punctures; in 2 patients (1.6%) the right carotid artery was punctured; 2 hemothorax (1.6%) were observed and one pneumothorax (0.8%). Forty patients required veno-venous bypass. The blood flows obtained during VVB were suffice in all the cases with a mean +/- standard deviation of 2.21 +/- 0.44 l/min-1. The technique of femoral-portal-jugular veno-venous bypass is a good alternative to the classical method of the axillary approach. It has advantages such as in the speed of installation of VVB and the utility of the large jugular vein during the remainder of the surgery for rapid fluid transfusions. Although the number of complications is low, they may be important thereby hindering intra management and post operative of the patients.

The authors present 14 patients affected with portal cavernoma, diagnosed and controlled over the last 12 years. The splenomegaly (60%) and the digestive hemorrhages (40%) were the initial study causes. The cavernoma appeared idiopathic in 10 patients or secondary either to a catheterization of umbilical vein (3 cases) or onfalitis (1 case). The first clinical manifestation oscillated between the ages of 3 months to nine years. The diagnosis was performed in the initial cases (4 cases) using splenoportography (3 cases) and superior mesenteric arteriography (SMA) in the other. In the remaining cases the ultrasonography together with the endoscopic evidence of the varies backed up the diagnosis. Before the intervention, a SMA was performed in all cases. The surgical decision was taken with regards to the persistence of the digestive bleeding after the start of medical treatment with propranolol, cimetidine, and sucralfate, along with the existence of dangerous varices. Eight patients were operated on, two by the Warren technique, four by mesocaval jugular graft interposition (MJI) and two by azigo portal disconnection (APD). The shunts initially controlled the bleeding in all cases. There was one rebleeding instance at eleven months in a patient operated on by MJI, and in another by APD. Four patients continue medical treatment without problems, and two are free of treatment. Our experience with varies sclerosis is limited to two cases, although since the beginning of the treatment, one year ago, neither of them has bled.

Aims: The aim of the present study was to evaluate the hemodynamic effects of venovenous bypass (VVB) and its possible protective action during the clamping of the hepatic vessels carried out in the anhepatic phase of the orthotopic liver transplantation., Patients and Methods: Forty-one liver transplant patients, 15 of whom were operated with VVB, were studied. VVB consisted of a bridge from the primitive iliac veins and the portal vein to the left axillary vein. The hemodynamic, metabolic and biologic variables as well as the components of reposition and the drugs administered were measured. The results obtained in both groups were statistically compared and analyzed., Results: During the anhepatic phase the values of cardiac output did not modify in the patients operated with VVB, while these values significantly decreased in other patients. Peripheral resistances increased less in the VVB group. During the reperfusion phase there were no significant differences between the hemodynamic parameters of either group. The decrease in temperature during the anhepatic phase was significantly greater in the VVB group., Conclusions: Venovenous bypass offers greater hemodynamic stability during the anhepatic phase of orthotopic liver transplantation.

The partial or complete obstruction of portal vein and or one of its branches is the most frequent cause of portal hypertension in children. A patient with extrahepatic portal hypertension and progressive course is presented, with great development of esophagogastric varices and multiple episodes of upper gastrointestinal hemorrhage. At the age of 9 years he was submitted to an azygos-portal disconnection by abdominal route, with manual transection of the esophagus, covered and protected by a gastric fundoplication. Postoperative endoscopic control demonstrated significant reduction in the size of esophageal varices and disappearance of gastric varices. Eleven months after surgery the patient was asymptomatic and a new endoscopic control showed no recurrence of varices.

A case of hepatic rupture in 32 years old woman with severe preeclampsia is presented. She was definitively treated by right hepatic arterial occlusion and right porta branch occlusion. There were no postoperative complications, and the patient is still alive. This is the first case report of right hepatic arterial occlusion and right porta branch in severe preeclampsia.

The cumulative experience in liver transplantation since the introduction of cyclosporine A has confirmed its efficacy in the treatment of diverse liver diseases in children and adults. In the present study we review the surgical aspects of 45 transplants performed in 39 patients (17 children and 22 adults). Immunosuppressive treatment consisted of cyclosporine A, steroids and monoclonal antibodies (OKT3) in rejection unresponsive to steroids. The actuarial survival rate one year after transplantation was 74%. In the course of development of the program, the elective use of veno-venous bypass during the anhepatic phase in adults was confirmed as useful. Among pediatric transplantations there were numerous arterial malformations (31.5%) in donor organs, which, with the malformations associated in receptors, made allograft reconstruction difficult. Our results confirm those reported by other groups, as well as the importance of specialized training for this type of intervention.

Many procedures are described to solve the problem of the massive hemorrhages due to esophageal varices in children with Portal Hypertension in which it's not possible to do a porto-systemic shunt by cause of the age. It's possible to treat them by sclerotherapy but in case of massive hemorrhages in which the patient life is at risk we have used the azygo-portal disconnection following the SUGIURA technique making the esophageal transection with autosuture instrument. We believe that this technical simplification account for more instances in which it's indicated. And it could be preferred to other procedures used with the same objective. We have done it in two male patients which came to our Center in several occasions due to massive hemorrhages. In both cases the Portal Hypertension is of extrahepatic cause. Follow up it is been satisfactory in both cases. Being one of them more than 3 1/2 years without hemorrhagic episodes, remaining under clinical and endoscopic controls. We have used in this cases the Proximate ILS of 21 mm. of Ethicon.

One of the main drawbacks attributed to azygoportal disconnection operations in the surgical treatment of bleeding esophageal varices is recurrence of hemorrhage. The present paper reviews the results obtained as regards hemorrhage recurrence in 4,975 patients who underwent azygoportal disconnection in 41 series published in the western literature in recent years. An analysis is also made of the factors that, according to different authors, could be related to the failure of these procedures to prevent eventual variceal hemorrhage.