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Introduction Cephalic duodenopancreatectomy (CDP) is the treatment of choice in cancer of the head of the pancreas. However, it continues to have a high post-surgical morbidity and mortality. The aim of this article is to define variables that influence post-surgical morbidity and mortality after cephalic duodenopancreatectomy due to pancreatic adenocarcinoma (PA) cancer of the head of the pancreas (CHP). Material and methods The variables were prospectively collected form patients operated on between 1991 and 2007, in order to investigate the factors of higher morbidity. Results A total of 204 patients had been intervened due to PA, of whom 57 were older than 70 years. Of these patients, 119 had a CDP, 11 extended lymphadectomy, 66 with pyloric conservation, and 8 with extension to total pancreatectomy due to involvement of the section margin. Portal or mesenteric vein resection was included in 35 cases. Post-surgical complications were detected in 45% of cases, the most frequent being: slow gastric emptying (20%), surgical wound infection (17%), pancreatic fistula (10%), and serious medical complications (8%). Further surgery was required in 13%, and the over post-surgical mortality was 7%. A patient age greater than 70 years, post-surgical haemoperitoneum, gastroenteric dehiscence, and the presence of medical complications were post-surgical mortality risk factors in the multivariate analysis. Pancreatic fistula was not a factor associated with post-surgical mortality. Conclusions Cephalic duodenopancreatectomy is a safe technique but with a considerable morbidity. Patients over 70 years of age must be carefully selected before considering surgery. Serious medical complications must be treated aggressively to avoid an unfavourable progression.

Management of the cystic lesions of the pancreas is of interest to general and pancreatic surgeons and physicians of other disciplines: gastroenterology, internal medicine, endoscopy, radiology, pathology, etc. The majority of cystic lesions are inflammatory pseudo-cysts. Cystic neoplasms represents only 10% of cystic lesions of the pancreas and 1% of pancreatic tumours. Preoperative diagnosis is crucial given the differences in natural history of the spectrum of benign, malignant, and borderline lesions. Serous cystadenoma is a benign lesion that requires non-surgical management if there are no symptoms. Mucinous neoplasms are premalignant lesions that mainly require pancreatic resection. Despite improved radiographic imaging techniques, definitive diagnosis is only made after studying the resection sample. The pancreatic surgical risk is a problem for the appropriate management of these patients.

Surgery that preserves the duodenopancreatic region has become well-established in chronic pancreatitis (CP) and some groups have begun to use these techniques to treat benign tumors and even those with uncertain potential malignancy. However, the technical complexity of this type of intervention may be greater than that of cephalic duodenopancreatectomy and complications may be even more frequent and consequently the indications for these procedures are debated. The aim of this study was to evaluate the experience accumulated at our center over the past few years in the use of pancreatic surgery preserving the duodenopancreatic region (PS). MATERIAL AND METHODS. Between 1996 and 2006, we carried out PS in 24 patients with disease localized in the head of the pancreas. PS was defined as any of the following techniques: resection of the head of the pancreas with duodenal preservation (RHPDP), uncinatectomy (UC) and cystic tumor enucleation (EN).RHPDP was performed in 20 patients (83%), UC in 1 (4%) and EN in 3 (13%). Surgery was performed for CP in 11 patients, serous cystoadenoma in 4, intraductal papillary mucinous tumor in 5 and miscellaneous injuries in the four remaining patients. Overall, the series showed 54% morbidity with no post-operative mortality. The median length of postoperative hospital stay was 11 days (7-43).After analyzing the experience accumulated over the years, showing nil mortality and acceptable morbidity, we believe that the use of these 3 techniques for preserving the pancreatic parenchyma is useful when their suitability is rigorously indicated. Subsequent studies should look in depth at improving quality of life and physiological effects, depending on the technique used.

Cold ischemia time and the presence of postoperative hepatic arterial thrombosis have been associated with biliary complications (BC) after liver transplantation. An ABO-incompatible blood group has also been suggested as a factor for predisposal towards BC. However, the influence of Rh nonidentity has not been studied previously.Three hundred fifty six liver transplants were performed from 1995 to 2000 at our hospital. BC incidence and risk factors were studied in 345 patients.Seventy patients (20%) presented BC after liver transplantation. Bile leakage (24/45%) and stenotic anastomosis (21/30%) were the most frequent complications. Presence of BC in Rh-nonidentical graft-host cases (23/76, 30%) was higher than in Rh-identical grafts (47/269, 17%) (P=0.01). BC was also more frequent in grafts with arterial thrombosis (9/25, 36% vs 60/319, 19%; P=0.03) and grafts with cold ischemia time longer than 430 min (26/174, 15% vs 44/171, 26%; P=0.01). Multivariate logistic regression confirmed that Rh graft-host nonidentical blood groups [RR=2(1.1-3.6); P=0.02], arterial thrombosis [RR=2.6(1.1-6.4); P=0.02] and cold ischemia time longer than 430 min [RR=1.8(1-3.2); P=0.02] were risk factors for presenting BC.Liver transplantation using Rh graft-host nonidentical blood groups leads to a greater incidence of BC.

e15227 Background: Borderline resectable PA may benefit from resection when preceded by neoadjuvant therapy. Methods: We evaluated 22 consecutive patients (pts) with cytology confirmed PA. Borderli...

The aim of this study was to determine the methodological quality of articles on therapeutic procedures published in Cirugía Española and to study its association with the publication year, center, and subject-matter.A bibliometric study that included all articles on therapeutic procedures published in Cirugía Española between 2001 and 2004 was performed. All kinds of clinical designs were considered, excluding editorials, review articles, letters to editor, and experimental studies. The variables analyzed were: year of publication, center, design, and methodological quality. Methodological quality was determined by a valid and reliable scale. Descriptive statistics (calculation of means, standard deviation and medians) and analytical statistics (Pearson's chi2, nonparametric, ANOVA and Bonferroni tests) were used.A total of 244 articles were studied (197 case series [81%], 28 cohort studies [12%], 17 clinical trials [7%], 1 cross sectional study and 1 case-control study [0.8%]). The studies were performed mainly in Catalonia and Murcia (22% and 16%, respectively). The most frequent subject areas were soft tissue and hepatobiliopancreatic surgery (23% and 19%, respectively). The mean and median of the methodological quality score calculated for the entire series was 10.2 +/- 3.9 points and 9.5 points, respectively. Methodological quality significantly increased by publication year (p0.001). An association between methodological quality and subject area was observed but no association was detected with the center performing the study.The methodological quality of articles on therapeutic procedures published in Cirugía Española between 2001 and 2004 is low. However, a statistically significant trend toward improvement was observed.

PRESERVATION injury (PI) is a major contributor to primary allograft failure after liver transplantation (LT). However, few studies have analyzed the predictive value of postreperfusion liver biopsies for the development of graft dysfunction and late complications. Extended cold preservation has been associated with biliary strictures. Consequently, it has been postulated that the ischemiareperfusion injury may play a role in the pathogenesis of some biliary complications. This study was performed to assess whether the presence of histologic lesions on postreperfusion (0Post) allograft biopsy is a predictive factor of postoperative biliary complications. Other secondary objectives were to examine the possible relationship between 0Post biopsy features and donor data, and to correlate postreperfusion histologic findings with graft and patient outcome.

HE SCARCITY OF donors and the increase in the number of transplant candidates have stimulated research to minimize the loss of donated organs. Preservation solutions are available to conserve the organs for a determinate period. In liver transplant (LT) Belzer and Brettschneider solutions give satisfactory results. However, graft malfunction remains a problem and other solutions are being examined. This randomized comparative study aims to examine the hepatic function of grafts perfused with Celsior solution (CS) and Belzer solution (BS) following liver transplant in adults.

THE SHORTAGE of donor livers for transplantation means that the use of liver grafts must be optimal. To ensure efficient use of the resources available, a precise definition of the causes of mortality (CMs) in these patients is essential. In the literature on the subject there are major discrepancies regarding the incidence of the CMs. This is so because the immediate cause (IC) of death is generally considered more important than other previous circumstances that contribute to the IC. We term the circumstances involved in the lead-up to death the principal cause (PC). It should also be stressed that the incidence of different CMs changes according to the follow-up time since transplantation. The objectives of the present study are first, to present a retrospective description of the global CMs in our patients and, second, to assess the distribution of mortality in different periods of the follow-up.

PRESERVATION INJURY is a major contributor to primary allograft dysfunction and failure after liver transplantation. Several studies have shown that cold ischemia (CI) can damage the sinusoidal liver cells. During this process many inflamatory mediators are released locally and to the blood stream. The damaged endothelial cells produce the activation and adhesion of leukocytes. Finally, the infiltration of polymorphonuclear cells increases the cold ischemic lesion. Platelet-activating factor (PAF) is an inflammatory mediator produced by many cell types. It has been implicated in the microcirculatory failure after cold and warm ischemia. PAF antagonist BN-52021 is a natural compound extracted from ginkgo-biloba tree. Its beneficial effect has been reported in ischemia reperfusion injury of many organs. The objective of our study was to demonstrate that the PAF antagonist BN-52021 can attenuate the preservation injury. The isolated perfused rat liver model was employed for reperfusion evaluation.

The increase in indications for liver transplantation has meant that waiting lists are growing ever longer. For this reason, broadening the donor pool is a priority for most groups.The objective of this study was to analyze the predictive value of post-reperfusion biopsy in the evolution of graft function after liver transplantation.One hundred and forty-eight liver biopsies, obtained after graft reperfusion, were analyzed. Eight pathological variables and thirty-seven clinical variables of the donors were recorded. Risk factors for presenting primary graft non-function or dysfunction were studied with logistic regression models. Factors associated to the long-term graft failure were studied using Cox analysis and actuarial survival curves.Microvesicular steatosis greater than 50% was the only risk factor associated to graft dysfunction in the multivariate logistic regression model. Microvesicular steatosis greater than 30%, severe hepatocyte necrosis and presence of abundant neutrophilic leukocytes were risk factors associated to graft failure in the univariate study. Only steatosis remained as an independent risk factor in the multivariate study. These grafts also presented poorer long-term survival. Abundant polymorphonuclear infiltrate was associated to a higher frequency of biliary complications.Microvesicular steatosis implies a better evolution than macrovesicular steatosis. Neutrophilic infiltrate and hepatocellular necrosis lead to poorer initial graft function and reduced long-term survival.

Biliary complications after orthotopic liver transplantation (OLT) may occur because of preservation injury (PI). In this study, we examine findings on routine reperfusion biopsy specimens in relation to the occurrence of biliary complications and graft outcome. From 1997 to 2000, a total of 193 OLTs were performed in our center. Postreperfusion biopsy specimens were analyzed and histological lesions were graded. For analysis, grafts were grouped into 2 categories: the presence or absence of PI (severe to moderate lesions versus mild or no lesions). Histological evidence of PI was present in 17% of the biopsy specimens. The incidence of grafts with PI and ischemia time longer than 12 hours was 38% compared with 14% in PI and short ischemia time ( P = .02). Biliary complications were also more frequent in the PI group (28% v 14%; P = .03). Study of risk factors by means of logistic regression analysis confirmed that the PI group had a greater risk for biliary complications (relative risk, 2.8; 95% confidence interval, 1 to 7.4; P = .03). Moreover, moderate macrovesicular steatosis was found in 6% of the grafts, resulting in a 40% graft loss rate. We found that an increased presence of neutrophilic infiltrates in the postreperfusion biopsy specimen, indicating PI, was related to an increased incidence of biliary complications. Moreover, moderate macrovesicular steatosis was associated with increased graft loss. Therefore, postreperfusion biopsies are useful in anticipating post-OLT complications. ( Liver Transpl 2001;7:432-435 .)

AFTER A previous study that analyzed early graft function, we conclude that donor age had a direct influence on the univariate analysis, but this did not happen on an independent basis. Following the conclusions of the above-mentioned study, donor’s age was not a contraindication for liver donation in our center. The aim of this study was to assess the impact of donor age on graft and patient survival.

s / Pancreatology 13 (2013) e1–e19 e10 Aim: To evaluate the accuracy of CEA, Ca 72.4 and Ca 15.3, obtained by EUS-FNA in CPL in the detection of pre/malignant lesions. Methods: Prospective and consecutive inclusi on of patients submitted to perform an EUS-FNA in the work-up of a CPL. Final diagnosis is based in histology of surgical specimens or in the clinical-radiological, cytological and intracystic markers global evaluation, with a minimum period of follow-up of 6 months. Statistical analysis: t student. S,E,PPV and NPV were calculated after drawing the correspondent ROC curves. Results: 34 patients (mean age 66 years, range 37-86, 13 males) were included. Final diagnosis: 17 IPMN 3 mucinous cystoadenomas, 5 serous cystoadenomas, 4 pseudocysts and 5 adenocarcinomas with cystic degeneration. Mean values obtained for Ca 15.3, Ca 72.4 and CEA in adenocarcinomas (ADC) and mucinous lesions (ML) were 66,4 U/ml, 31,4 U/ml y 3645,5 ng/ml against values for benign lesions (BL): 3,8 U/ml, 5,6 U/ml and 63,6 ng/ml, only with statistical significance for the CEA levels (p 0.011). Cut-off point of CEA of 116.8 ng/ml distinguishes BL from PML with a S,E,PPV and PNV of 75%, 90.9%, 94.7% and 60%. Conclusions: Ca 72.5, Ca 15.3 and CEA levels are higher in PML than BL. CEA levels higher than 116.8 ng/mL differentiates BL from PML with high specificity and PPV.

Introduction The long term survival of patients with resectable pancreatic cancer (PC) is appalling, so data regarding what factors may influence outcome, following attempted curative resection is essential in order to optimize the treatment options for patients. Our aims were to analyze prognostic factors influencing survival in patients with resected PC in our institution. Methods Eligible participants included all persons diagnosed with pancreatic cancer from June 2004 to August 2008 that underwent pancreaticoduodenectomy for adenocarcinoma of only pancreatic head at the Surgical Department in Bellvitge Hospital. Risk factors associated with overall survival (OS) and Progression Free Survival (PFS) were assessed with the Kaplan-Meier survival method and the log-rank test. Demographic, tumour, and clinical variables were assessed using the Cox proportional hazards model. We also examined plasmatic VEGF (pVEGF) levels in these patients to evaluate the prognostic significance of these levels and correlate the results with the clinic- pathological features, microvascular density and K-RAS gene status. Results The median follow-up was 17.8 months for all patients. The median follow-up for living patients was 40 months (range 3-83 months). The median survival time for all patients was 21.26 months (95% confidence interval 13.29-29.24 months).The median Progression Free Survival for all patients was 15.76 months (95% confidence interval 4.99-26.54 months). Pathological stage was unfavorable prognostic factor in our pancreas cancer patients by univariate and multivariate analysis for OS and PFS. Perineural and vascular invasion as well as R1 resection were also negative prognostic factors for PFS. There was no survival correlation between high levels of p-VEGF and the remaining clinico-pathological features (including the number of resected nodes, microvascular density or K-RAS gene status). Conclusion Our results are consistent with the most important published studies and tumor characteristics remain the best significant features influencing survival after pancreatic cancer surgery.

THE SHORTAGE of organ donors and the increased demand for orthotopic liver transplantation (LTX) has led to new strategies to increase the availability of grafts for transplantation. In LTX because of familial amyloid polyneuropathy (FAP), the reuse of the liver for a patient aged more than 60 years was suggested by our group in 1993. The first was performed in Portugal and it is called domino liver transplantation (DLTX) or sequential LTX. We describe our experience in six cases of DLTX for FAP performed in our unit between February 1999 and September 2000.

Background: Splanchnic thrombosis is a surgical challenge in liver transplantation (LT). The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution. Aim: The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution. Patients and methods: Between 1999 and 2004, 366 liver transplants were performed in 335 patients. Forty-two patients [12.5%: portal vein thrombosis (PVT) group] had portal thrombosis at the time of LT. We analyzed the technical aspects and compared their evolution with a group of patients without portal thrombosis (n = 293; no-PVT group). Retransplantations were excluded. Results: Of the 42 patients with thrombosis, 18 had partial thrombosis and 16 complete thrombosis [six included the proximal superior mesenteric vein (SMV) and in two the whole splanchnic system]. In 12 cases, usual T-T anastomosis was performed and in 16 cases a thrombectomy was carried out; there were five cases of anastomosis at confluence of the SMV, five cases of anastomosis to a collateral vein, three cases of venous graft, and one case of cavoportal hemitransposition. The operative time was higher in PVT group (417 ± 103 min vs. 363 ± 83; p = 0.0005), as RBC transfusion (2.4 ± 3.1 vs. 1.9 ± 2.3; p = 0.04), and hospital stay (20.9 ± 14.9 d vs. 15.1 ± 10.6; p = 0.002). However, there were no differences in hospital mortality (4% vs. 7.8%; p = 0.98), primary dysfunction (4.8% vs. 7.8%; p = 0.44), or three-yr-actuarial survival (75% vs. 77%; p = 0.95). The incidence of post-transplant thrombosis was higher in the PVT group (15% vs. 2.4%; p = 0.0005). Conclusions: Portal thrombosis is associated with greater operative complexity and rethrombosis, but has no influence on overall morbidity and mortality.

The Histologic Pattern of “Biliary Tract Pathology” in Postoperative Biopsies and the Study of Postperfusion Biopsy Are Accurate for the Diagnosis of Biliary Complications Juli Busquets;Teresa Serrano;Jaume Torras;Juan Figueras; The American Journal of Surgical Pathology

THE INTRODUCTION of new immunosupression therapies in the last two decades has led to great improvements in patient and graft survival after liver transplantation (OLT). Thus, the development of complications of chronic immunosuppressive therapy, such as atherosclerotic cardiovascular complications, have become a major concern. Some previous studies have suggested a reduced cardiovascular risk profile in patients with a tacrolimusbased treatment, but most studies are based on dual or monotherapies. The purpose of this study was to evaluate the safety and efficacy of a quadruple tacrolimus-based immunosuppression, mainly in relation to cardiovascular risk factors.