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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, χ 2 , 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., (Copyright © 2018. Published by Elsevier Inc.)

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., (Copyright © 2017. Published by Elsevier Inc.)

Introduction: Obesity is a risk factor that increases the number of complications after orthotopic liver transplantation (LT). We sought to analyze the short-term respiratory complications in obese LT recipients and compare them with a control group of nonobese patients., Material and Methods: A retrospective analysis of LT patients in a hospital in the southeast of Spain (2007-2013), selecting the study cases using a body mass index (BMI) of >30 kg/m(2) and a control group (BMI < 30). Study variables were age, sex, indication for LT, demographic and clinical variables, respiratory complications during the first postoperative month, and mortality rate secondary to respiratory disease., Results: Of the 343 LT recipients, 74 were obese (21.6%): 59 patients had a BMI between 30 and 35 (grade I obesity) and among them, 5% presented with respiratory complications, with a 33% mortality rate. Fifteen patients had a BMI of >35 (obesity grade II), and 20% presented with respiratory complications, with a 33% mortality rate. In the control group (n = 30), 17% experienced respiratory complications and there was a 20% mortality rate. There were no differences in respiratory complications between the obese and nonobese groups, or the different kinds of obesity (P > .05)., Conclusions: There were no differences in short-term respiratory complications between obese LT recipients and those with a normal weight., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: The aim of this study was to analyze the correlation between 18-FDG positron emission tomography (PET)/computed tomography (CT), histological necrosis, and prognosis after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) patients undergoing orthotopic liver transplantation (OLT)., Patients: From January 2007 through December 2013, 81 patients with HCC and liver cirrhosis were included in our liver transplantation program. For this study we selected patients who underwent 18-FDG PET/CT pre-TACE and post-TACE. All patients underwent liver transplantation within 8 weeks after PET/CT., Results: Twenty patients with a median age of 58 years (range, 46-69 years) underwent an 18-FDG PET/CT before and after TACE. The median Standardized Uptake Value (SUV) before TACE was 3.8 (range, 2.6-8.7), with a median post-TACE SUV of 0% (range, 0-4). Among patients whose post-TACE SUV decreased to <3, >70% necrosis was observed upon study of a hepatectomy sample, with a survival rate of 100% and 80% at 1 and 3 years, respectively., Conclusion: In conclusion, performance of an 18-FDG PET/CT before and after TACE with comparison of SUV values among patients with HCC awaiting OLT provided valuable information regarding the effectiveness of TACE., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: In staged liver resections, associating liver partition and portal ligation for staged hepatectomy (ALPPS) achieves sufficient hypertrophy of the future liver remnant (FLR) in 7 days. This is based on portal vein ligation and transection, and on occlusion of intrahepatic collaterals. This article presents a new surgical technique for achieving rapid hypertrophy of the FLR, which also involves adding intrahepatic collateral occlusion to portal vein transection., Methods: Patients scheduled for two-stage liver resection for primary or secondary liver tumours, in whom the FLR was considered too small, were enrolled prospectively. In the first stage, a tourniquet was placed around the parenchymal transection line, and the right portal vein was ligated and cut (associating liver tourniquet and portal ligation for staged hepatectomy, ALTPS). The tourniquet was placed on the umbilical ligament if a staged right trisectionectomy was planned, and on Cantlie's line for staged right hepatectomy., Results: From September 2011, 22 ALTPS procedures were carried out (right trisectionectomy in 15, right hepatectomy in 7). Median FLR at 7 days increased from 410 to 700 ml (median increase 61 (range 33-189) per cent). The median duration of the first stage was 125 min and no patient received a blood transfusion. The median duration of the second stage was 150 min and five patients required a blood transfusion. Fourteen patients had complications, most frequently infected collections, and five patients developed postoperative liver failure. Two patients died., Conclusion: The ALTPS technique achieved adequate hypertrophy of the FLR after 7 days. It may provide a less aggressive modification of the ALPPS procedure., (© 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.)

Background: Surgery is currently the only potentially curative treatment for hepatic or pulmonary metastases from colorectal cancer. However, the benefit of surgery and the criteria for the inclusion of patients developing hepatic and pulmonary metastases are not well defined., Objective: The aim of this study was to describe the outcome for patients who undergo surgery for both hepatic and pulmonary metastases from colorectal cancer, to present a set of preoperative criteria for use in patient selection, and to analyze potential prognostic factors related to survival., Design: This was an observational study with retrospective analysis of data collected with a prospective protocol., Settings: This investigation was conducted at a tertiary centre., Patients: Between January 1996 and January 2010, of 319 patients who underwent surgery for hepatic metastases from colorectal cancer, 44 also had resection of pulmonary metastases. A set of strict selection criteria established by a panel of liver surgeons, chest surgeons, oncologists, and radiologists was used., Main Outcome Measures: Survival was estimated with the Kaplan-Meier method, and univariate analyses were performed to evaluate potential prognostic factors for survival, including variables related to patient, primary tumour, hepatic, and pulmonary metastases and chemotherapy., Results: The 44 patients received a total of 53 pulmonary resections: 36 patients had 1, 7 patients had 2, and 1 patient had 3 resections. There was no postoperative mortality and the morbidity rate after pulmonary resection was 1.8%. No patient was lost to follow-up. Overall survival was 93% at 1 year, 81% at 3 years, and 64% at 5 years. Factors related to poor prognosis in the univariate analysis were presence of more than 1 pulmonary metastasis (p = 0.04), invasion of the surgical margin (p = 0.006), and administration of neoadjuvant chemotherapy (p = 0.01 for hepatic metastases and p = 0.02 for pulmonary metastases)., Limitations: The study was limited by its observational nature and the relatively small number of patients., Conclusion: In patients with hepatic and pulmonary metastases from colorectal cancer selected according to strict inclusion criteria, surgical treatment performed in a specialized center is a safe option that offers prolonged survival.

Aim: In patients with two-stage hepatectomy (TSH) for multiple bilobar liver metastases from colorectal cancer, few clinical series compare functional remnant hypertrophy of the liver volume between right portal vein ligation (PVL) and embolisation (PVE). Our objective is to analyse the effectiveness of portal vein ligation to achieve hypertrophy of the functional remnant volume (FRV) of the liver and to compare the results with portal vein embolisation in a series of patients with multiple bilobar liver metastases from colorectal carcinoma., Patients and Methods: Between September 2001 and September 2011 we performed a TSH in 41 patients with multiple bilobar colorectal liver metastases. A right PVL was performed in 23 patients with an insufficient FRV (three patients did not complete the second stage due to tumour progression and were excluded). We prospectively compare these results with the increased remnant volume obtained in 18 patients with right PVE., Results: The median FRV was higher in the patients with PVE, rising from 501 ml (range 309-703) to 636 ml (range 387-649), than those with PVL, rising from 510 ml (range 203-824) to 595 ml (range 313-1213) (p < 0.05). The median %FRVI was higher in the patients with PVE (median 40%; range 21-65%) than those with PVL (median 30%; range 21-60%) (p < 0.05)., Conclusions: PVL and PVE were effective in all cases for obtaining hypertrophy of the FRV before major liver resection. Right PVE obtains better results and should be used where necessary to achieve a further increase in volume., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: Liver transplantation is the treatment of choice for various types of end-stage liver disease and the most appropriate alternative for the treatment of hepatocellular carcinoma (HCC)-associated liver cirrhosis. The aim of this study was to describe our initial experience with the use of 18-FDG positron emission tomography (PET)/computed tomography CT before and after transarterial chemoembolization (TACE) in HCC patients undergoing liver transplantation, seeking to predict the percentage of tumor necrosis achieved by TACE procedures., Patients and Methods: From January 2007 through December 2009, 39 patients with HCC and liver cirrhosis were included in our liver transplantation program. We selected the 6 subjects who underwent 18-fluorodeoxyglucose PET/CT (18-FDG PET/CT) pre- and post-TACE., Results: The median SUV (standardized uptake value) in the lesions studied were 4 (range, 2.79-6.95) before TACE with a median post-TACE SUV of 0 (range, 0-4). Among patients whose post-TACE SUV decreased to <3, the percentage of necrosis after studying the hepatectomy was >80%., Conclusion: Performance of an 18-FDG PET/CT before and after TACE and comparison of SUV in patients with HCC awaiting liver transplantation provided valuable information regarding the effectiveness of TACE., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To assess whether preoperative transarterial chemoembolisation (TACE) reduces haemorrhage during laparoscopic resection, thus making the Pringle manoeuvre unnecessary and avoiding any subsequent complications., Patients and Methods: We present 3 cirrhotic Child A patients with early hepatocellular carcinoma, all of whom had been given the same treatment involving resection by laparoscopy and preoperative TACE of the segments to remove. All the nodules were located in the right hepatic lobe. One case was treated using total laparoscopic surgery and the two remaining cases were converted to the hand-assisted technique. In the first case we carried out bisegmentectomy VI-VII; in the second, segmentectomy VI plus radiofrequency of a second nodule in segment VII, and in the third case, segmentectomy V., Results: There was no morbidity or mortality. Blood transfusion was not required by any of the patients; in fact blood losses were 100, 50 and 150 ml, respectively, and it was not necessary to carry out the Pringle manoeuvre. Surgical margin was greater than 1cm in the three cases and hospital stay was less than 3, 3 and 4 days, respectively., Conclusion: TACE prior to early hepatocellular carcinoma resection in cirrhotic patients seems to improve surgical safety with low blood losses without the use of the Pringle manoeuvre. Prospective random studies should be carried out on a larger number of patients in order to assess this technique.

Aim: Open surgery (OS) is currently the ''gold standard'' for liver metastasis (LM) treatment. However, in order to evaluate the efficiency of laparoscopic surgery (LS) for LM treatment, it is necessary to carry out studies to demonstrating that this technique can obtain the same results as OS. In this study the current position of LS for LM is presented., Methods: The authors carried out a bibliographical search of all the series of LM resected using LS from the following sources: Medline, Embase, Ovid and Cochrane. The following aspects of LM treatment using LS were examined: intraoperative objectives, postoperative morbidity and mortality and follow-up (5-year survival rate)., Results: In selected cases for LS, there are similar postoperative morbidity and mortality rates with LS and OS. However, LS does not meet the intraoperative objectives because there is under staging of the abdominal cavity and of the liver. Therefore, hand-assisted laparoscopic liver surgery (HALLS) could be a valid alternative. There are few studies that have shown survival rates at 5 years, although in selected cases, the results of LS and OS are similar., Conclusions: OS continues to be the ''gold standard'' for the surgical treatment of LM. HALLS is a valid alternative to totally LS so long as there is no improvement in the pre and intraoperative means of staging.

Unlabelled: The use of OLT in the management of liver metastases of any origin is highly controversial, as most patients receiving a transplant for this indication display poor results owing to early tumor spread secondary to the effects of immunosuppression. However, as they have a better biological behavior, neuroendocrine (NE) tumors may be a good indication for OLT. Our aim was to present our experience in the management of unresectable liver metastases of tumors of NE origin., Patients and Methods: Between January 1996 and April 2006, 10 patients underwent OLT for unresectable liver metastases of a neuroendocrine origin, accounting for 1.2% of all transplants performed to date in our unit (n = 626). The most common location of the primary tumor was the pancreas in six cases: three in the pancreatic tail--one carcinoid tumor, one gastrinoma, and one nonfunctioning NE [NF-NE] tumor; and three cases in the pancreatic head--three NF-NE tumors. In the remaining four cases, including three carcinoid tumours and one NF-NE tumors, two were located in the small bowel (at the ileum and ileocecal valve) and two in the lung. The liver metastases were synchronous with the primary tumor in seven cases and metachronous in three cases., Results: The morbidity rate was 75% and the mortality rate, 10% (n = 1). The tumor recurrence rate was 33% with 1- and 3-year survival rates of 86% and 57%, respectively.

Introduction: Laparoscopic liver surgery in solid tumors presents a number of difficulties. This type of surgery is indicated especially in tumors of less than 5 cm located in the left lobe and in anterior segments of the right lobe. Access to posterior lesions of the right lobe (segments VII and VIII) and performing major regulated hepatectomies (more than 3 segments) are at present difficult for liver surgeons., Objective: To present a regulated right hepatectomy (RH) and left hepatectomy (LH) performed via hand-assisted laparoscopic surgery (HALS) using an original technique., Patients and Method: RH was performed in a 70-year-old man with hepatic metastases from colorectal carcinoma (pT2N0M1 sigmoid adenocarcinoma). LH was performed in a 44-year-old woman with a 16-cm hemangioma that had shown tumoral growth. Dissection of the hepatic artery was performed between ligations, and the portal vein was sectioned between ligations or with a vascular endostapler. Division of the bile duct and suprahepatic veins was performed with a vascular endostapler. Parenchymal dissection was carried out with a harmonic scalpel and dissection of intrahepatic veins of over 3 mm was performed with a 10-mm Ligasure Atlas., Results: The operating time for RH was 360 min, with no transfusion or complications, and length of hospital stay was 5 days. The operating time for LH was 240 min, requiring 2 U of blood, with no morbidity and a length of hospital stay of 4 days., Conclusions: HALS allows major liver resections to be performed with low morbidity and mortality and with the advantages of laparoscopic surgery.

Introduction: Laparoscopic liver resection (LLR) of solid liver tumors (SLT) has not become widespread due to technical problems, the risk of air embolism, and possible tumoral spread in malignant lesions. We present our experience of LLR in SLT., Patients and Method: Between January 2003 and May 2005, we performed the laparoscopic approach in 16 patients with SLT. Preoperative diagnosis was liver metastases from colorectal carcinoma in 11 patients and benign tumor in the remaining five patients. Five of the lesions were located in the left lobe, another 10 in the right lobe (two in S. V, four in S. VI and four in S. VII) and the remaining lesion was bilobar (S. III and VI). LLRs were performed by complete laparoscopic hepatectomy (CLH) (n=8) and assisted laparoscopic hepatectomy (ALH) (n=8). LLR was completed in 13 patients (81%). Surgical technique (n=13) consisted of three left lobectomies, one with partial resection of S. IV, three bisegmentectomies (two of S. VI and VII and one of S. III and IV, the latter associated with metastasectomy in S. VIII), five segmentectomies (one of S. II, two of S. V and two of S. VI, one of the latter associated with metastasectomy in S. VII) and two local resections of benign tumors., Results: There was no intra- or postoperative mortality. With CLH the LLR was completed in five patients (62%), whereas with ALH there were no conversions. Only one of the 13 resected patients required transfusion. Seventeen nodules were excised in the 13 LLR, and 12 of 17 required the Pringle maneuver. The mean length of hospital stay was 4.9 days (3-14 days). Only one female patient (7.7%) developed an infected hematoma, requiring radiological drainage., Conclusion: LLR of benign SLTs shows all the advantages of laparoscopy. In the case of malignant lesions, greater experience is needed to confirm the safety and effectiveness of the open approach.

Introduction: Neuroendocrine tumors are rare neoplasms that present bilateral liver metastases at diagnosis. Because of the good initial results obtained, liver transplantation is considered as a potentially curative treatment., Objective: Present our experience of the use of liver transplantation in the management of unresectable bilateral neuroendocrine metastases., Patients and Methods: We retrospectively reviewed the medical records of eight patients (four men and four women), with a mean age of 45 years, who underwent liver transplantation due to bilateral neuroendocrine liver metastases between January 1996 and January 2005. The most frequent location of the primary tumor was the pancreas in five patients (one carcinoid, one gastrinoma and three non-functioning tumors). The remaining three tumors were located in the small bowel (two) and in the lung., Results: Only one patient died due to technical complications related to the transplant, representing a mortality rate for the entire group of 14%. After a median follow-up of 3 years (range: 1 month-6 years), two patients died due to tumoral recurrence at 15 and 17 months, representing a tumoral recurrence rate of 33%. The survival rate at 1 and 3 years was 86% and 57%, respectively., Conclusions: Despite the initial promising results obtained with liver transplantation in the management of unresectable neuroendocrine liver metastases, our results indicate that careful patient selection is required. The key to obtaining good results is individualization of the indication for this procedure.

Introduction: Liver resection (LR) morbidity and mortality rates have dropped in recent decades. Mortality is now below 5% and morbidity is less than 30%. Our objective was to present a series of 200 LRs without mortality and to analyze the factors that may be related to complications., Patients and Method: Between January 1996 and October 2003, 200 LRs were performed in 177 patients. The most common indication was liver metastases in 123 patients (61.5%), primary malignant liver tumors in 27 patients (13.5%), bile duct tumors in 27 patients (13.5%) and benign disease in 23 patients (11.5%). Fifty-one percent of the resections were performed under hemihepatic vascular control and 49% were resections of central segments, segmentary and atypical resections. We studied the association between morbidity and age, sex, previous comorbidity, liver status, indication for surgery, number of resections, major and minor resections, resection extended to other organs, type of vascular occlusion, transfusion requirements, operating time, length of hospital stay and experience of the surgical team., Results: There was no postoperative mortality. The morbidity rate was 17.5% (35 patients) and the most common complications were biliary (8%). Morbidity was related to transfusion (transfused patients presented more complications) (P < .001). Transfusion was greater in major resections, the first 100 resections and prolonged operations. Among the segmentary resections the Pringle maneuver reduced transfusion requirements but this difference was not statistically significant. Morbidity decreased in the second 100 resections, without significant differences., Conclusion: LRs can be performed with low mortality and morbidity. Biliary complications and blood transfusion should be avoided whenever possible.

Objective: To assess the real utility of orthotopic liver transplantation (OLT) in patients with cholangiocarcinoma, we need series with large numbers of cases and long follow-ups. The aim of this paper is to review the Spanish experience in OLT for hilar and peripheral cholangiocarcinoma and to try to identify the prognostic factors that could influence survival., Summary Background Data: Palliative treatment of nondisseminated irresectable cholangiocarcinoma carries a zero 5-year survival rate. The role of OLT in these patients is controversial, due to the fact that the survival rate is lower than with other indications for transplantation and due to the lack of organs., Methods: We retrospectively reviewed 59 patients undergoing OLT in Spain for cholangiocarcinoma (36 hilar and 23 peripheral) over a period of 13 years. We present the results and prognostic factors that influence survival., Results: The actuarial survival rate for hilar cholangiocarcinoma at 1, 3, and 5 years was 82%, 53%, and 30%, and for peripheral cholangiocarcinoma 77%, 65%, and 42%. The main cause of death, with both types of cholangiocarcinoma, was tumor recurrence (present in 53% and 35% of patients, respectively). Poor prognosis factors were vascular invasion (P < 0.01) and IUAC classification stages III-IVA (P < 0.01) for hilar cholangiocarcinoma and perineural invasion (P < 0.05) and stages III-IVA (P < 0.05) for peripheral cholangiocarcinoma., Conclusions: OLT for nondisseminated irresectable cholangiocarcinoma has higher survival rates at 3 and 5 years than palliative treatments, especially with tumors in their initial stages, which means that more information is needed to help better select cholangiocarcinoma patients for transplantation.

Introduction: Due to the scarcity of donors and the fact that size is the main prognostic factor, Milan criteria have been used since 1996 to select hepatocellular carcinoma (HCC) patients for liver transplantation. In 2001 UCSF criteria showed that including layer tumors did not reduce the survival results. The objective of this paper was to evaluate whether HCC tumor sizes exceeding the Milan criteria adversely influence survival rates., Patients and Methods: Between May 1988 and July 2001, 53 patients were transplanted due to HCC and cirrhosis. The etiology of cirrhosis was HCV in 23 cases and HBV in 6. In 11 cases the HCC were incidental by discovered namely, a mean/ diameter of 1.8 cm (versus 2.6 cm in nonincidental HCC). Sixty-two percent of tumors met the Milan criteria, and 68% the USCF criteria., Results: The actuarial survival was 79% at 1 year and 62% at 5 years. The survival of patients with incidental HCC was 82% at 1 year and 82% at 5 years, which is better than the survival of those with nonincidental HCC (78% at 1 year and 57% at 5 years, P<.05). According to Milan criteria, the survival patients with early tumors was 82% at 1 year and 68% at 5 years, and for advanced tumors (NS), 75% and 54%, respectively. Comparison of early versus advanced tumors according to UCSF criteria showed survivals of 84% versus 64% at 1 year (P<.05) and 67% versus 48% at 5 years (P<.05), respectively., Conclusion: Increasing the HCC size among LT according to the California criteria did not reduce survival rates compared with the Milan criteria.