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The increase of quality of life, the improvement in the perioperative care programs, the use of the frailty index, and the surgical innovation has allowed to access of complex abdominal surgery for elderly patients like liver resection. Despite of this, in patients aged 70 or older there is a limitation for the implementation ERAS protocolos. The aim of this study is to evaluate the implementation ERAS protocol on elderly patients (≥70 years) undergoing liver resection.A prospective cohort study of patients who underwent liver resection from December 2017 to December 2019 with an ERAS program. We compare the outcomes in patients ≥70 years (G ≥ 70) versus70 years (G 70). The frailty was measured with the Physical Frailty Phenotype score.A total of 101 patients were included. 32 of these (31.6%) were patients ≥70 years. 90% of the both groups had performed70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were quicker in70 years group. The hospital stay was similar in both groups (3.07days/2.7days). Morbidity and mortality were similar; Clavien I-II(G ≥ 70:41% vs G 70:30,5%) and Clavien ≥ III (G ≥ 70:6% vs G 70:8.5%), like hospital readmissions. Mortality was1%. ERAS protocol compliance was associated with a decrease in complications (ERAS 70%:80% vs ERAS 90%:20%; p = 0.02) and decrease in severity of complications in both study groups. Frailty was found in 6% of the elderly group; the only patient who died had a frailty index of 4.Implementation of ERAS protocol for elderly patients is possible, with major improvements in perioperative outcomes, without an increase in morbidity, mortality neither readmissions.

Primary graft dysfunction is a common postoperative complication, lacking consensus regarding diagnostic criteria. Olthoff criteria are the most used, based on blood parameters in the first 7 postoperative days. This lack of consensus and late diagnosis evidence the need of early parameters. This study proposes factor V (FV) as a marker in the first 3 postoperative days for primary graft dysfunction.Within a 500-patient database, 27 patients with graft loss in the first 90 days were chosen and compared with a group of 54 patients composed of the immediately preceding and following transplant to each case. Through receiver operating characteristic curves, FV and maximum glutamic pyruvic transaminase (GPT) predictive value on the first 3 postoperative days were assessed. The best threshold value was selected according to the Youden index.FV was significantly higher in the control group, with second postoperative day as the highest discriminative one (area under the curve = 0.893). In addition, a cutoff point of FV 37.50 exhibited a specificity of 92% and sensibility of 69% in predicting allograft failure in the first 3 months. GPT showed a lower validity with area under the curve = 0.77, and a GPT of 1539 presented a specificity of 82% and sensibility of 67%. Combining FV37.5 and GPT1539, a specificity of 98% and sensibility of 55% was reached.FV could postulate as an early marker of primary graft dysfunction because of its high specificity despite having a lower sensibility. With de association of FV and GPT the maximum specificity for predicting graft loss in the first 3 months was reached, becoming a promising parameter for further analysis.

The so-called grafts or donors with extended criteria are a risk factor for the development of liver transplant activity. One source comes from controlled donation after circulatory death (cDCD). The hypothesis was to verify the improvement in results by comparing DCD liver transplants performed with postmortem normothermic regional perfusion (NRP) vs super-rapid recovery (SRR), the current standard for cDCD. A prospective study comparing both techniques was carried out.A total of 42 transplants were performed with cDCD, 22 of which were with SRR and 23 with NRP from April 2014 to September 2019.Differences were found in early allograft dysfunction (68.1% in the SRR group vs 25% in the NRP group; P .01) and biliary complications (22.7% vs 5%, respectively; P = .04). Differences were also found, although not statistically significant, in ischemic cholangiopathy (13.6% in the SRR group vs 5% in the NRP group; P = .09), and retransplant rate (9.1% vs 0%, respectively; P = .3).With the use of NRP machines, results are similar to the standard donation with donors in brain death in terms of rate of early allograft dysfunction and survival of the patient and graft attempted, reducing the rate of ischemic cholangiopathy compared with SRR.

Background Sarcopenia (SP) and preoperative muscle mass are independent predictive factors for short- and long-term outcome of liver transplantation. Objective To assess the influence of muscle mass index (MMI) and preoperative SP on the prognosis of patients who underwent liver transplantation in our hospital. Methods Ninety-seven patients who underwent liver transplantation in the Regional University Hospital of Malaga from September 2013 to March 2016 were analyzed. SP was determined based on the MMI, as assessed by psoas muscle area at the L4 level measured by computed tomography (CT), with adjustment for patient sex. Two cohorts were differentiated: 54 patients without SP and 42 patients with SP. Postoperative complications, graft survival, and patient survival were assessed. A 3-year follow-up was carried out. Results Recipient characteristics were similar in both cohorts, except for MMI ± SD (group without SP: 94.03 ± 15.43 cm2/m2 vs group with SP: 56.99 ± 13.59 cm2/m2; P = .001). The incidence of postoperative complications (Clavien ≥ 3) in patients with and without SP was 39.5% and 24.1%, respectively (P = .08). SP was not associated with poorer long-term graft or patient survival. Conclusions SP, determined by preoperative measurement of MMI, was identified as a predictive factor associated with a higher incidence of postoperative complications. Since MMI can be easily determined by CT, it should be assessed in all candidates for liver transplantation.

Simultaneous pancreas-kidney transplantation is the treatment of choice for insulin-dependent diabetes that associates end-stage diabetic nephropathy, since it achieves not only a clear improvement in the quality of life, but also provides a long-term survival advantage over isolated kidney transplant. However, pancreas transplantation still has the highest rate of surgical complications among organ transplants. More than 70% of early graft losses are attributed to technical failures, that is, to a non-immunological cause. The so-called technical failures include graft thrombosis, bleeding, infection, pancreatitis, anastomotic leak and pancreatic fistula. Pancreatic graft thrombosis leads these technical complications as the most frequent cause of early graft loss. Currently most recipients receive postoperative anticoagulation with the aim of reducing the rate of thrombosis. Hemoperitoneum in the early postoperative period is a frequent cause of relaparotomy, but it is not usually associated with graft loss. The incidence of hemoperitoneum is clearly related to the use of anticoagulation in the postoperative period. Post-transplant pancreatitis is another cause of early postoperative complications, less frequent than the previous. In this review, we analyze the most common surgical complications that determine pancreatic graft losses.

Background Liver transplantation (LT) is a curative treatment for patients with hepatocellular carcinoma who are not candidates for resection. Despite the generalized use of the Milan criteria and up-to-seven criteria, new markers have been proposed to predict recurrence after LT. Biomarkers such as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), and scores such as the Model of Recurrence After Liver transplantation (MORAL) are used as predictors of post-LT recurrence. Objective We aim to compare NLR, PLR, and MORAL score with Milan criteria and up-to-seven criteria. Methods A descriptive study of 99 patients who underwent LT for hepatocellular carcinoma in our hospital between April 2010 and April 2016. The 5 prognostic models were applied to the patients to stratify them into risk groups. We used a Kaplan-Meier survival plot to measure recurrence-free survival in each model. Receiver operative curves were used to compare the models. Results Three-year recurrence-free survival in MORAL was 91.1% for the low-risk group, 89.8% for the moderate-risk group, 60% for the high-risk group, and 75% for the very high-risk group (P = .003). The combined MORAL score was superior in predicting 1- and 3-year recurrence with the area under the curve 0.684 (95% confidence interval [CI]: 0.52-0.85) compared with Milan (0.536 [95% CI: 0.37-0.70]), up-to-seven (0.601 [95% CI: 0.43-0.77]), PLR (0.452 [95% CI: 0.30-0.61]), and NLR (0.542 [95% CI: 0.37-0.71]). Conclusions A model based only on pre-LT radiological signs leads to underdiagnosis of tumor load; therefore, the risk of recurrence must be recalculated after LT. The combined MORAL score was the best prognostic model of 1- and 3-year recurrence after LT in our study.

Biliary complications after liver transplantation have a high incidence of and a significant impact on morbidity and mortality. The primary aim of this study was to assess the influence of bile duct diameter on biliary complications and to determine whether a critical diameter for such complications could be determined. The secondary aim was to identify additional factors associated with biliary complications. Two hundred and seventy-three recipients of liver transplantation with biliary anastomosis without a T-tube were analyzed from December 2013 to December 2018. Patients with a follow-up of less than 6 months were excluded, except for those with biliary complications (including death). Intraoperative measurements of bile duct diameter and other variables potentially related to complications were recorded prospectively, and their association with biliary complications was analyzed. Our results show that neither donor nor recipient bile duct diameters were risk factors for the development of biliary complications. However, bile duct size mismatch between recipient and donor was found to be a risk factor. Additional associated risk factors were arterial ischemia time, arterial complications, bench arterial reconstruction, and intraoperative blood transfusion.

Introduction: Total hepatectomy with temporary porto caval shunt involves an anhepatic phase until liver transplantation. The severity of the patient's state is conditioned by the physiopathologic alterations occurred during the anhepatic phase and the availability or not of organs in the short term. Methods: We report the case of a male patient undergoing liver transplantation for liver failure caused by the hepatitis C virus (HCV). Until liver transplantation, the patient experienced an anhepatic phase of 22 hours secondary to acute vascular failure during surgery. The patient is alive at five follow-up years. Conclusions: Total hepatectomy with temporary portocaval anastomosis in combination with appropriate management of physiopathologic alterations at the Intensive Care Unit improve survival in severely-ill patients awaiting transplantation.

Resumen Se estudian las complicaciones arteriales (CA) ocurridas en 400 trasplantes realizados entre 1997 y 2006. Se dividen en 2 grupos segun el tipo de tratamiento realizado: grupo i : tratamiento invasivo (tratamiento sobre la arteria o retrasplante), y grupo ii : tratamiento conservador o sintomatico. Se analizan el impacto del tratamiento sobre la supervivencia y las complicaciones biliares (CB). Resultados Se han presentado 18 CA (4,5%), 10 complicaciones precoces (7 trombosis y 3 estenosis) y 8 complicaciones tardias (5 trombosis y 3 estenosis). El 90% de las complicaciones precoces se trato de forma invasiva (4 trombectomias urgentes, un retrasplante, 3 angioplastias y una ligadura de arteria hepatica), y el 25% de las complicaciones tardias se trato con retrasplante (3); el 75% restante recibio tratamiento sintomatico. La supervivencia a 12 y 60 meses fue inferior en el grupo ii (el 57 y el 42%) que en el grupo i (el 90 y el 68%), aunque sin alcanzar significacion estadistica. La tasa global de CB de enfermos con trombosis arterial fue del 50%. En el grupo i del %, significativamente menor que el grupo ii con el 71% (p Conclusiones El tratamiento invasivo de las CA en el trasplante hepatico se asocia a una mayor supervivencia a corto plazo y reduce de forma significativa la aparicion de CB. En nuestra experiencia, los pacientes se benefician de un diagnostico precoz y un tratamiento intensivo en este tipo de complicaciones.

Resumen Objetivos Evaluar la incidencia y el tipo de complicaciones biliares en el trasplante hepatico tras la reconstruccion biliar con y sin tutor biliar. Material y metodo Estudio prospectivo no aleatorizado en el que se incluyo a 128 pacientes consecutivos sometidos a trasplante hepatico electivo, excluyendo del estudio los retrasplantes, trasplantes urgentes, hepaticoyeyunostomia y pacientes fallecidos durante los primeros 3 meses por causas distintas de las complicaciones biliares. En el grupo I (n = 64) se realizo coledococoledocostomia terminoterminal sobre tubo de Kehr y en el grupo II (n = 64), coledococoledocostomia sin tubo de Kehr. Se analizan las complicaciones, los procedimientos terapeuticos, reintervenciones y supervivencia libre de complicaciones biliares. Resultados La tasa general de complicaciones biliares es del 15% (el 17% en el grupo I y el 14% en el grupo II). En relacion con el tipo de complicaciones (grupo I contra grupo II) se observo: fistulas, 4% (el 6 contra el 3%); estenosis, 8% (el 4 contra el 12%); disfunciones del tubo de Kehr, 3%. La media de procedimientos terapeuticos, incluidos colangiografia endoscopica, colangiografia transhepatica, colangiografias trans-Kehr y drenaje de colecciones, es 2,1 frente a 2 por paciente complicado. La tasa general de reintervenciones es del 5% (el 2 contra el 9%) (p Conclusiones No se ha encontrado diferencias estadisticamente significativas de complicaciones tras la anastomosis coledococoledoco con y sin tutor biliar. Sin embargo, el grupo de pacientes en los que no se utilizo tutor biliar ha precisado para el tratamiento de la complicaciones procedimientos mas complejos, asi como mayor numero de reintervenciones.

Recent advances in liver surgery have reduced post-hepatectomy mortality to less than 5% in most units specialized in hepato-pancreatic-biliary surgery. Possibly, the single most important factor contributing to these improved results has been the reduction in intraoperative bleeding during liver parenchymal transection. Liver transection is the most risky part of the intervention due to the risk of massive hemorrhage. Some technological advances and refinements to the surgical technique have contributed to making this critical phase of liver surgery safer. Among these advances, the most notable are detailed knowledge of the surgical anatomy of the liver, vascular control techniques and methods of liver parenchymal transection. The present review describes current transection techniques, as well as their advantages and disadvantages. Until there is solid evidence on the best method, the choice of technique and instrument for liver transection depends mainly on the surgeon's personal preference. Nevertheless, some factors can influence the choice of method, such as the surgeon's experience, anesthetic management, type of hepatectomy (central, peripheral), type of approach (open, laparoscopic), quality of the liver (normal, cirrhotic, steatotic) and the availability of the instruments in the center.

To assess the incidence and type of biliary complications in liver transplantation after biliary reconstruction with or without a biliary tutor.A prospective, non-randomized study of 128 consecutive patients undergoing elective liver transplantation was performed. Retransplantations, emergency transplantations, hepaticojejunostomy and patients who died within 3 months of causes other than biliary complications were excluded. Group I (n = 64) underwent termino-terminal choledochocholedochostomy with a Kehr tube and group II (n = 64) underwent choledochocholedochostomy without Kehr tube. Complications, therapeutic procedures, reoperations and survival free of biliary complications were analyzed.The overall rate of biliary complications was 15% (17% in group I and 14% in group II). Types of complication (overall and in groups I and II, respectively) consisted of fistulas 4% (6% vs. 3%), stenosis 8% (4% vs. 12%), and Kehr dysfunction 3%. The mean number of therapeutic procedures, including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, trans-Kehr cholangiography and drainage of collections, was 2.1 vs. 2 per complicated patient. The overall reoperation rate was 5% (2% vs. 9%) (p0.05). One-year survival free of biliary complications was 85% vs. 82% (Log Rank = 0.5).No statistically significant differences were found in complications after choledocho-choledocho anastomosis with or without a biliary tutor. However, the patient group that did not receive a biliary tutor required more complex procedures for treatment of complications, as well as a greater number of reoperations.

Hepatocellular carcinoma is a frequent complication of cirrhosis. Liver transplantation is a valid therapeutic option for this disease providing that certain morphologic selection criteria (Milan criteria) are fulfilled.To evaluate the accuracy of pretransplantation imaging examinations in the detection and characterization of neoplastic lesions in cirrhotic candidates for liver transplantation.We performed a retrospective study of 250 cirrhotic patients who underwent liver transplantation. The preoperative radiological diagnosis was compared with the definitive pathological diagnosis, allowing the diagnostic sensitivity of the different techniques, as well as the degree of agreement between pre- and postoperative tumoral staging, to be identified.Analysis of 250 specimens from total hepatectomy identified 58 patients with hepatic tumors, with a total of 136 nodules. Fifty-three patients had hepatocarcinoma, nine of which were found incidentally. There were six radiological false positive diagnoses. Sixty-two percent of patients with hepatocarcinoma had multiple lesions. The most sensitive technique for the diagnosis of tumors smaller than 1 cm was magnetic resonance imaging. Agreement between pre- and postoperative staging was found in only 63.6% of cases; consequently, 43% of the patients who exceeded the Milan criteria (20% stage T3 and 23% stage T4a) underwent transplantation.Currently used imaging techniques lead to a substantial proportion of incorrect stagings in terms of the size and number of lesions in cirrhotic patients.

Pancreatic transplantation is currently the only therapeutic alternative able to restore normal blood glucose levels in diabetic patients. Moreover, this procedure can halt or even reverse diabetes-related complications. The aim of this study was to present our experience and the results of the first 4 years of a pancreatic transplantation program in our center.From February 2000 to June 2004, 43 pancreatic transplantations were performed in 42 recipients in the Carlos Haya Regional Hospital in Malaga (Spain). In all patients, the technique of enteric drainage of exocrine pancreatic secretions and systemic venous shunting of endocrine secretions (to the inferior vena cava) was used.There were 37 (88.1%) simultaneous pancreas-kidney transplantations, 4 (9.5%) in patients with prior kidney transplantation and 1 retransplantation (2.4%). In all patients, glycosylated hemoglobin and C-peptide levels returned to normal. Patient and pancreatic graft survival were 91% and 84%, respectively, with a median follow-up of 19 months. The reintervation rate was 31%, with an overall rate of graft loss of 16%.The results obtained in our series are similar to those reported for large series.

A study was made of the arterial complications documented in 400 transplants performed between 1997 and 2006. The patients were divided into two groups according to the type of treatment provided. Group I: invasive management (arterial treatment or re-transplant), and Group II: conservative or symptomatic management. The impact of management on survival and biliary complications was analysed. Results There were 18 arterial complications (4.5%): 10 early (7 thromboses and 3 stenoses) and 8 late (5 thromboses and 3 stenoses). Ninety percent of the early complications were subjected to invasive management (4 emergency thrombectomies, one re-transplant and 3 angioplasties), while 25% of the late complications were treated with re-transplant and the remaining 75% were subjected to symptomatic treatment. Survival after 12 and 60 months was lower in Group II (57% and 42%) than in Group I (90% and 68%), although without reaching statistical significance. The overall biliary complications rate among the patients with arterial thrombosis was 50%. The rate was significantly lower in Group I than in Group II (10% versus 71%) (P Conclusions Invasive management of the arterial complications of liver transplantation is associated with longer short-term survival and significantly fewer biliary complications. In our experience, patients benefit from an early diagnosis and aggressive management of complications of this kind.