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

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

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

Aim Analyze the evolution of the laparoscopic approach in emergent inguinal hernia repair at our center. Material and Methods Retrospective review of patients with emergent inguinal hernia repair in our center from January 2011 to June 2020. Demographic, clinical and postoperative data were analyzed as well as the evolution of the laparoscopic approach. Results 385 patients with incarcerated/strangulated inguinal hernia were registered. 58.96% were men, with a median age of 71. Of those, 22 patients (5.71%) were treated by laparoscopic approach and 363 (94.29%) by open approach. The open approach had a longer median hospitalization (4.82 vs 1.66 days), higher rate of surgical wound infection (5.51% vs. 0%), higher reoperation rate (3.31% vs 0%) and higher incidence of respiratory complications (1.97% vs 0%). 1 patient (4.54%) with laparoscopic approach required intestinal resection vs 48 patients (13.22%) of the open group, with a dehiscence rate of 0% vs 4.76% respectively. Mortality rate was 0% for the laparoscopic group and 2.75% in the open group. In the last 18 months, 28.98% of urgent hernias repaired have been performed laparoscopically, while previously from 2011 to 2017 only 0.95%, due to the learning curve obtained in elective surgery where the laparoscopic approach has had a major development in the last 3 years. Conclusions Despite the evident patient selection bias because the approach choice by the surgeon in emergent inguinal hernia repair, laparoscopic approach is feasible and has lower morbidity-mortality compared to open approach in our center. In specialized centers this may be a treatment option for selected patient groups.

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

Soft tissue infections (STIs), which include infections of the skin, subcutaneous tissue, fascia, and muscle, encompass a wide variety of heterogeneous pathologies. Treatment of STIs is based on surgical debridement of the affected area. One such treatment, negative pressure wound therapy (NPWT), has improved the management of STIs.The purpose of this study is to assess the safety and utility of NPWT in conjunction with dermatotraction in the early stage management of necrotizing STIs.The authors report a retrospective series of 3 cases in which NPWT and dermatotraction (NPWT-D) were used in an attempt to manage necrotizing STI. The NPWT-D device combination was employed to approximate the edges of the wounds. The NPWT device was changed every 2 or 3 days, and dermatotraction tension was adjusted concurrently.The NPWT-D device changes ranged from 3 to 4 times for 2 of the 3 patients, as 1 patient passed away secondary to STIs and therefore did not receive complete treatment. The total treatment ranged from 8 to 10 days in the remaining 2 patients. In both cases, complete wound closure was achieved while avoiding skin grafts. After 5 days of therapy in the incomplete treatment case, the wound area was reduced by about half.Based on the experiences herein, NPWT-D may be a safe and useful alternative surgical treatment for the management of necrotizing STIs. In the present cases, NPWT-D improved and shortened the wound healing process, and it achieved a tertiary wound closure, thereby avoiding the need for skin grafts.

Aim The aim of the study was to evaluate urgent care practice with regard to anorectal abscesses (AA) in a tertiary-level referral hospital. Materials and methods this was retrospective and unicentric study. Patients who underwent surgery for AA between 2016 and 2017 were included in the study. Demographic variables were analyzed as well as the treatment performed, the need for hospitalization, use of antibiotics, and referral to the coloproctology outpatient department (COD). The recurrence risk factors were also evaluated. Results A total of 220 evaluations under anesthesia were performed, corresponding to 190 patients, 129 males (mean age 46 ± 14.9 years). The most frequent treatment in the emergency department (ED) was simple drainage (75.8%). Antibiotic therapy was prescribed in 62.9% of the cases. A total of 41.1% of the patients were referred to a specialized COD. The only risk factor associated with recurrence was the presence of an associated anal fistula. Conclusions Anorectal abscesses are very frequent in the ED. There is great clinical variability regarding the taking of cultures, prescription of antibiotics, and referral criteria to a specialized coloproctology outpatient department, without clear impact of any of them on the recurrence of the abscess.

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

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

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

Resumen La incontinencia fecal representa una de las principales causas de institucionalizacion en las ultimas decadas de la vida de una persona, asociando ademas gran repercusion psicosocial y economica. La literatura muestra escasa evidencia cuando se trata de analizar de forma especifica a este grupo de poblacion, debido a la falta de uniformidad en la consideracion de «paciente anciano» y en la dificultad de su deteccion y diagnostico. El objetivo de este articulo ha sido realizar una revision narrativa de los principales aspectos relacionados con la incontinencia fecal en el anciano y facilitar el manejo de estos pacientes. La asistencia para la defecacion, las modificaciones dieteticas y el control de la consistencia de las deposiciones o el tratamiento farmacologico son en muchos casos medidas suficientes. No obstante, otras terapias como el biofeedback, la neuromodulacion o el tratamiento quirurgico no deben descartarse y han de ser valoradas de forma selectiva en pacientes ancianos.

ResumenAntecedentesLa colitis pseudomembranosa, producida por el Clostridium difficile, presenta una incidencia creciente en los últimos años, motivada principalmente por el uso indiscriminado de antibióticos. Aunque su tratamiento de inicio es médico, el papel de la cirugía de urgencias ha ido ganando terreno debido a una mortalidad elevada y a la aparición de cepas cada vez más virulentas. En nuestro medio su prevalencia aún es escasa, por lo que en ocasiones nuestra experiencia en su manejo es limitada.ObjetivoAnalizar nuestra experiencia quirúrgica en el tratamiento de esta dolencia y recordar el rol de la cirugía, así como alguno de sus aspectos técnicos.Casos clínicosPresentamos 2 casos clínicos de pacientes que han presentado un cuadro de colitis pseudomembranosa de presentación fulminante, sin respuesta al tratamiento médico inicial, por lo que se requiere una actuación quirúrgica urgente, con buena respuesta.ConclusionesEs importante siempre tener en mente la posibilidad quirúrgica en el tratamiento de la colitis pseudomembranosa, sobre todo cuando se presenta de manera fulminante, existen complicaciones asociadas o falla de respuesta al tratamiento médico.AbstractBackgroundPseudomembranous colitis, caused by Clostridium difficile, has an increased incidence in recent years, driven mainly by the indiscriminate use of antibiotics. Although initial treatment is medical, the role of emergency surgery has gained ground due to high mortality and the emergence of increasingly virulent strains. In our country the prevalence is still low so sometimes our experience in handling is limited.AimTo analyze our surgical experience in treatment of this disease and to remember the role of surgery as well as some technical aspects of it.Clinical casesWe present 2 cases of patients who have suffered a fulminant pseudomembranous colitis unresponsive to initial medical treatment at requiring urgent surgical intervention with a good response to it.ConclusionsIt is important to keep in mind surgical option in treatment of pseudomembranous colitis, especially when it presented as fulminant colitis, associated complications or failure to respond to medical treatment.

[Introduction]: Colonic lipomas are extremely uncommon benign non-epithelial tumours, with an incidence ranging between 0.035 and 4.4%. Although lipomas are most frequently asymptomatic, when colonic lipomas exceed 2-cm width, they may present symptoms such as constipation, abdominal pain or rectal bleeding. Most colonic lipomas typically occur in middle-aged women and are located in the ascending colon and the caecum, while occurrence in other parts of the colon and rectum is infrequent. We present a rare case of bowel obstruction secondary to colonic intussusception caused by a giant lipoma., [Case report]: A 55-year-old man presented with a longstanding history of intermittent abdominal pain and constipation. Physical examination was unremarkable. Colonoscopy revealed a smooth surface, submucosal mass which occupied the entire colonic lumen (diameter 50 mm) and there was also ulceration of adjacent mucosa. Abdominal CT-scan showed a colonic mass located at the splenic flexure, which caused colo-colic intussusception (Figs. 1, 2 and 3). The biopsy was inconclusive. The patient underwent laparoscopic segmentary colectomy and postoperative course was uncomplicated. Histological analysis revealed a 5-cm ulcerated lipoma (Figs. 4 and 5) affecting 60% of bowel circumference. The molecular study, using fluorescent in situ hybridization (FISH) showed no MDM2 gene amplification. At 6-month follow-up, the patient reported normal bowel habit., [Conclusion]: Although most colonic lipomas are asymptomatic, large ones may require surgical treatment since they are associated with complications. The complete removal of the lipoma will condition the prognosis. In these cases, laparoscopic approach is a safe alternative that offers the benefits of early postoperative recovery.

[Aim] To assess clinical healing in patients with perianal Crohn’s disease with local intrafistular injection of autologous platelet-rich plasma., [Method] The pilot study was conducted at a single centre between January 2013 and December 2015. Autologous platelet-rich plasma was prepared in platelet-rich and platelet-poor fractions for local intrafistular injection in patients with proven, established perianal Crohn’s disease. Patients were permitted biological therapies, and the Perianal Crohn’s Disease Activity Index was recorded. Patients were followed for 48 weeks for clinical signs of healing (complete, partial or non-healing), monitoring fistula drainage, closure and epithelialization., [Results] The study included 29 patients (19 males; mean age 38 ± 12.8 years) with four exclusions in the operating room because surgery was not indicated and four lost to follow-up. Five adverse events were recorded, with two requiring the drainage of abscess collections. Of the 21 patients assessable at 24 weeks, there was complete healing, partial healing and non-healing in 7 (33.3%), 8 (38.1%) and 6 (28.6%) patients, respectively. By 48 weeks, there was complete healing, partial healing and non-healing in 6 (40%), 6 (40%) and 3 (20%) patients, respectively, with a reduction in the number of visible external fistula openings at both time points (P = 0.021). By the end of the study, there was a higher trend of healing if biological therapies were continued (85.7% with biologics vs. 75% without, P = 0.527), but there were no statistically significant differences and no differences in the Perianal Crohn’s Disease Activity Index., [Conclusion]Autologous platelet-rich plasma is safe in patients with perianal Crohn’s disease, with an acceptable healing rate over a medium-term follow-up, particularly if biological therapies are used concomitantly.

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

Parathyroid gland mediastinal ectopia is an unusual but challenging condition in surgical management of hyperparathyroidism. Posterior mediastinum parathyroid ectopia is rare, and glands need to be removed either with a broad open cervical or thoracic approach. In recent years, several minimally invasive approaches to mediastinal parathyroid glands have been described, but for posterior mediastinum adenomas, proposed techniques are transthoracic. The aim of this paper is to describe, to our best knowledge for the first time, a standardized pure endoscopic cervical technique to approach posterior mediastinal parathyroid adenomas which we have used in three patients. The technique was applied in three patients which excellent surgical, postoperative, and cosmetic results. Endoscopic prevertebral approach is a feasible, sure and inexpensive standardized pure endoscopic cervical approach to posterior mediastinal parathyroid adenomas, which may result in a less aggressive surgical option when compared with thoracic approaches.

espanolLos cuidados sanitarios en los festejos taurinos presentan una idiosincrasia propia debido al agente causante y al mecanismode produccion de las lesiones. Los principios basicos del ATLS (Advance Trauma Life Supports) proporcionanun marco de referencia para la evaluacion y tratamiento de estas que pueden poner en riesgo la vida del paciente. Suaplicacion en ambientes alterados y con recursos limitados nos obliga a adaptarlos a unas circunstancias especificas. Esimportante una actitud critica identificando los puntos criticos o areas de mejora para asegurar sus capacidades y sus limitaciones.Nuestro objetivo es realizar una revision de las caracteristicas de estos pacientes para demostrar su aplicabilidady validez. La prioridad es salvar la vida del paciente, una vez puesto fuera del area de peligro (exposicion al toro) siendodificil en ocasiones una inmovilizacion y un control cervical correcto. Dispone de la ventaja de que el personal medicopresencia el trauma lo que le permite tener una idea preconcebida de las posibles lesiones. El torero profesional es realmenteun atleta, habitualmente joven, sano y con una adecuada preparacion fisica, lo que conlleva que no presente signosprecoces de shock y su presion arterial sea usualmente baja. Creemos, basandonos en nuestra experiencia, que el sistemaATLS es aplicable a la Cirugia Taurina siendo necesario considerar algunas caracteristicas propias. EnglishHealth care in bullfights has its own idiosyncrasy due to causative agent and mechanism of injury. Basic principles ofATLS (Advance Trauma Life Supports) provide a frame of reference for evaluation and treatment. Its application inaltered environments and with limited resources forces us to adapt them to specific circumstances. A critical attitude isimportant by identifying critical points or areas for improvement to ensure their capabilities and limitations. Our objectiveis to perform a review of characteristics of these patients to demonstrate their applicability and validity. The priorityis to save the life of patient, once placed outside the danger area (exposure to bull), being sometimes difficult a correctimmobilizing or cervical control. It has the advantage that medical staff witnesses the trauma which allows him to havea preconceived idea of possible injuries. The professional bullfighter is really an athlete, usually young, healthy and withadequate physical preparation, which means that he does not present early signs of shock and his blood pressure is usuallylow. We believe, based on our experience that the ATLS system is applicable to Taurine Surgery and it is necessary toconsider some of its own characteristics.

The aim of this paper is to evaluate to the safety, feasibility and efficacy of a novel treatment for transsphincteric cryptoglandular fistula: injection of autologous plasma rich in growth factors (PRGF) into the fistula tract accompanied by sealing using a fibrin plug created from the activated platelet-poor fraction of the same plasma. This article is a prospective, phase II clinical trial. The procedure was externally audited. Thirty-six patients diagnosed with transsphincteric fistula-in-ano were included. All patients underwent follow-up examinations at 1 week and again at 3, 6 and 12 months after discharge. Main outcome measures safety (number of adverse events), feasibility and effectiveness of the treatment. A total of 36 patients received the study treatment, with the procedure found to be feasible in all patients. A total of seven adverse events (AE) related to the injected product or surgical procedure were identified in 4 of 36 patients. At the end of the follow-up period (12 months), 33.3% of patients (12/36) had achieved complete fistula healing and 11.1% of patients (4/36) had achieved partial healing. In total, this amounted to 44.4% of patients (16/36) being asymptomatic at final follow-up. In successfully healed patients, a gradual reduction in pain was observed, as measured using a Visual Analog Scale (VAS) (p = 0.0278). Compared to baseline, a significant improvement in Wexner score was seen in patients achieving total or partial healing of the fistula (p = 0.0195). The study treatment was safe and feasible, with apparently modest efficacy rates. Continence and pain improvement following treatment may be considered predictive factors for healing.

Background Pseudomembranous colitis, caused by Clostridium difficile , has seen an increased incidence in recent years, driven mainly by the indiscriminate use of antibiotics. Although initial treatment is medical, the role of emergency surgery has gained ground due to high mortality and the emergence of increasingly virulent strains. In our country the prevalence is still low so that sometimes our experience in handling is limited. Aim To analyze our surgical experience in treatment of this disease and to remember the role of surgery as well as some technical aspects of it. Clinical cases We present 2 cases of patients who have suffered a fulminant pseudomembranous colitis unresponsive to initial medical treatment and requiring urgent surgical intervention with a good response to it. Conclusions It is important to keep in mind the surgical option in treatment of pseudomembranous colitis, especially when it presents as fulminant colitis, there are associated complications or failure to respond to medical treatment.

Resumen Introduccion El tratamiento clasico del diverticulo de Zenker (DZ) ha sido la miotomia del cricofaringeo (MCF), discutiendose la necesidad o no de resecarlo (diverticulectomia versus diverticulopexia). Sin embargo, la evolucion de las tecnicas endoscopicas esta obligando a replantear las estrategias de tratamiento. Analizamos las complicaciones y los resultados clinicos de nuestra serie con la miotomia del cricofaringeo y diverticulectomia en pacientes con DZ. Metodo Estudio observacional retrospectivo y descriptivo de 33 pacientes a los que se realizo, entre enero de 1998 y diciembre de 2010, diverticulectomia y MCF en los hospitales universitarios Virgen del Rocio de Sevilla y Carlos Haya de Malaga. Se analiza la morbilidad y variables demograficas y operatorias que pueden asociarse con esta. Resultados Diecisiete pacientes fueron tratados en el hospital Carlos Haya de Malaga y dieciseis en el hospital Virgen del Rocio de Sevilla. Aunque no hubo mortalidad, la tasa de morbilidad de la serie fue del 27% (9 casos), siempre relacionada con fistula esofago-cutanea. Ninguna de las variables estudiadas se asocio significativamente con la aparicion de morbilidad. Tras un seguimiento medio de 44 meses (rango 6-192) ningun paciente ha presentado recidiva clinica ni radiologica del DZ. Conclusiones La diverticulectomia asociada a MCF es una buena tecnica para el tratamiento del DZ, con excelentes resultados clinicos y funcionales a medio y largo plazo, pese a que la morbilidad mayor en forma de fistula esofago-cutanea ha sido alta.

Resumen Fundamento y objetivo La infeccion por Ascaris lumbricoides en nuestro medio es anecdotica y suele estar relacionada con viajes a areas de alta endemicidad como la india y Sudamerica. La afectacion biliopancreatica por este parasito es infrecuente y una de las complicaciones mas temidas. En la literatura cientifica hay escasas publicaciones acerca de la afectacion pancreatica en la ascariasis. Presentamos un caso clinico de ascariasis pancreatica diagnosticado tras duodenopancreatectomia cefalica por sospecha de adenocarcinoma pancreatico. Paciente Varon de 58 anos que consulta por un cuadro clinico de dolor abdominal de largo tiempo y diarrea. Se realiza tomografia computarizada, endoscopia, RM y ecoendoscopia con toma de citologia por PAAF con resultado anatomopatologico de adenocarcinoma de cabeza pancreatica moderadamente diferenciado. Resultados Se realiza duodenopancreatectomia cefalica. Post-operatorio favorable, destacando fistula pancreatica grado B de la ISGPF. El analisis de la pieza evidencio la presencia de un seudotumor pancreatico por Ascaris lumbricoides. Tras estos hallazgos se completo el tratamiento con albendazol oral. Conclusiones La afectacion pancreatica por ascariasis en nuestro medio es inusual pero es necesario incluirla en el diagnostico diferencial de tumores y procesos inflamatorios pancreaticos.

Introduction: The anatomical variants of the hepatic artery may have important implications for pancreatic cancer surgery. The aim of our study is to compare the outcome following a pancreatoduodenectomy (PD) in patients with or without a variant hepatic artery arising from superior mesenteric artery. Material and methods: We reviewed 151 patients with periampullary tumoral pathology. All patients underwent oncological PD between January 2005 and February 2012. Our series was divided into two groups: Group A: Patients with a hepatic artery arising from superior mesenteric artery; and Group B: Patients without a hepatic artery arising from superior mesenteric artery. We expressed the results as mean ± standard deviation for continuous variables and percentages for qualitative variables. Statistical tests were considered significant if p < 0.05. Results: We identified 11 patients with a hepatic artery arising from superior mesenteric artery (7.3%). The most frequent variant was an aberrant right hepatic artery (n = 7), following by the accessory right hepatic artery (n = 2) and the common hepatic artery trunk arising from the superior mesenteric artery (n = 2). In 73% of cases the diagnosis of the variant was intraoperative. R0 resection was performed in all patients with a hepatic artery arising from superior mesenteric artery. There were no significant differences in the tumor resection margins and the incidence of postoperative complications. Conclusion: Oncological PD is feasible by the presence of a hepatic artery arising from superior mesenteric artery. The complexity of having it does not seem to influence in tumor resection margins, complications and survival.

Biliary atresia (BA) is a neonatal progressive cholangiopathy of unknown etiology and one of the most common reasons for liver transplantation (LT) in children. Kasai portoenterostomy (KP) improves survival of the native liver, although LT remains the only ultimate treatment. In some cases KP makes it possible to defer the ultimate LT until adulthood. We report our experience regarding 5 cases of BA treated with LT during adulthood. KP was performed in all patients at an average age of 176 days (range, 60–280), which allowed an average survival of the native liver of 19.01 years (range, 14.06–22.32). Five-year survival rate was 100%. Ten-year survival rate did not reach 100% because of a death 9.55 years after LT due to chronic graft rejection, in a patient who was already prepared for a new LT. Our results corroborate that KP remains the first-line treatment of BA. Early performance of the KP provides children with the best chance of survival, allowing the delay of the LT to adulthood. LT during adulthood in these patients achieves good post-LT survival rate; we have not found any data regarding this group of patients in the literature.

The authors regret that the names of the last four authors were omitted from their published paper. The authors would like to apologise for any inconvenience caused.

The progressive increase in the number of liver transplantation candidates has brought with it a consequent increase in waiting list mortality, making it necessary to revise donor selection criteria and to analyze the factors that optimize outcomes. This retrospective observational study of 1802 liver transplantations performed in Andalusia between 2000 and 2010 analyzes the outcomes from donors aged 70 years or older (n = 211) in terms of survival rates of the graft and the recipient, the type of transplant, donor age, and DMELD (Donor-Model for End-Stage Liver Disease) score. The most frequent reasons for transplantation were alcoholic cirrhosis (45.5%), hepatitis C cirrhosis (20.4%), and liver cancer (11.8%). The overall survival rate at 5 years was 67%; with a significant decrease in survival rates for recipients with a DMELD greater than 1400 (44%). In the 70-year-old-plus donor group, the overall patient and graft survival rates were 57% and 52%, respectively. The re-transplantation rate increased proportionately with donor age: 5.9% between 70 and 74 years, 9.5% from 75 to 79 years, and 17.6% from 80 to 84 years. In the alcoholic cirrhosis recipient sub-group, the overall survival rate at 5 years was 69% (P.05) compared to 34% in hepatitis C patients (P.05). The widening of the donor age selection criteria is therefore a safe option, provided that a DMELD score less than 1400 is obtained. Although re-transplantation rates increase progressively with donor age, they remain less than 10%. It is necessary to carefully screen recipients of older organs, taking into account that the best results are obtained for patients who have alcoholic cirrhosis, are hepatitis C negative, and have a DMELD score that is less than 1,400.

Domino liver transplantation (DLT) is a strategy used to increase the number of available grafts. In this procedure, the transplant recipient is a living donor of her own liver. It is mandatory that the graft should be fully functional and the genetic defect should recur with sufficient latency period in the new recipient. Corino-Andrade disease, or familial amyloidotic polyneuropathy (FAP), satisfies these conditions. We retrospectively reviewed our prospective database of DLT. From July 2004 to April 2013, we performed 12 DLTs. We assessed age, sex, real Model for End-Stage Liver Disease (MELD) score, waiting list time, cold and warm ischemia times, intraoperative transfusion requirements, hospital stay, early peritransplantation morbidity (post-reperfusion syndrome, intraoperative cardiac arrest, post-transplantation thrombotic events, and biliary morbidity), acute cellular rejection, retransplantation, mortality, patient and graft survivals. With the intention to study the effect of the learning curve in the global survival results (including both donors and recipients of livers with FAP), we divided our series into 2 periods: the early period (from 2004 to 2008) and the present period (from 2009 to 2013). The crude mortality was 40% vs 0% (P = .042) in the early and present periods, respectively. The cumulative patient survival was also significantly in favor of the present period (P = .049). The graft loss prevalence was 60% vs 7.1% (P = .019) in the early and present periods, respectively. The cumulative graft survival was also significantly in favor of the present period (P = .030; Fig 2). In conclusion, we consider DLT to be a complex procedure, whose initial results are conditioned by the learning curve.

Appendiceal tumors are found in about 1% of appendectomies performed and 0.5% of intestinal neoplasias. Appendiceal carcinoids are the predominant histology in this group and are usually casual after appendectomy for other reasons. The prognosis is excellent and survival is 95% at 5 years after surgery.Retrospective analysis of all patients with appendiceal carcinoid surgery in our hospital for 20 years (1990-2010) and survival at 5 years. We also discuss the need for additional treatment and testing for follow-up visits.42 patients underwent surgery for appendiceal carcinoid tumor. 38 of them were operated on urgently, mostly for suspected acute appendicitis, without having reached the carcinoid tumor diagnosed preoperatively in any of them. The predominant symptomatology at admission was abdominal pain. Surgical treatment was appendectomy in 34 patients (12 laparoscopic), 7 patients required colon resections over intraoperatively by colonic involvement; only one patient required reoperation to complete right hemicolectomy. 2 patients had disseminated disease at diagnosis (liver metastases). The 5-year survival is over 95%, with no recurrence.The appendiceal carcinoid tumor is difficult to diagnose preoperatively. Appendectomy surgical treatment is usually sufficient, although colonic resections may be needed for dissemination. The 5-year survival is over 95%.Antecedentes: los tumores apendiculares se encuentran en cerca de 1% de las apendicectomías y representan 0.5% de las neoplasias intestinales. El tipo de tumor más frecuente es el carcinoide apendicular, que casi siempre es un hallazgo durante la apendicectomía por otro motivo. Su pronóstico es excelente y la supervivencia es mayor de 95% a cinco años de la intervención. Objetivo: reportar una serie de casos y analizar la supervivencia media a cinco años posteriores a la identificación el tumor. Material y métodos: análisis retrospectivo (1990-2010) de pacientes con tumor carcinoide apendicular intervenidos en el servicio de Cirugía General y del Aparato Digestivo del Hospital Universitario Virgen del Rocío, Sevilla, España. Se analizaron: la supervivencia a cinco años, la necesidad de tratamiento complementario y las pruebas para seguimiento en la consulta. Resultados: se encontraron 42 pacientes intervenidos por tener un tumor carcinoide apendicular. En 38 pacientes la operación fue de urgencia, la mayoría por sospecha de apendicitis aguda, sin que en ninguno se hubiera establecido el diagnóstico de tumor carcinoide antes de la operación. El síntoma predominante al ingreso fue el dolor abdominal. El tratamiento quirúrgico fue: apendicectomía en 34 pacientes (12 por laparoscopia), en el intraoperatorio siete pacientes requirieron resecciones colónicas mayores debido a la afectación del colon; sólo uno requirió la reintervención para completar la hemicolectomía derecha. Al momento del diagnóstico dos pacientes tenían enfermedad diseminada (metástasis hepáticas). La supervivencia a cinco años fue superior a 95%, sin recidivas o tratamiento posterior de la enfermedad. Conclusiones: el tumor carcinoide apendicular difícilmente se diagnostica antes del procedimiento quirúrgico. La apendicectomía suele ser suficiente aunque en algunos pacientes las resecciones colónicas son necesarias por diseminación. La supervivencia a 5 años es superior a 95%.

Gastrointestinal stromal tumors (GIST) are an infrequent cause (

Laparoscopic surgery has become more widespread in the last years. Creating the pneumoperitoneum is the first surgical procedure but it is still responsible for many of the adverse events described in this field. Until now, liver puncture producing a delayed biloma has not been described. We present a case where a biloma was developed after liver puncture by the Veress needle, during a laparoscopic procedure, and detected on the 3rd day. It was detected by CT scan and treated by laparoscopy. Biloma due to Veress needle is a new entity in the context of adverse events related to Veress needle insertion, which needs a high suspicious index. We recommend to do Palmer's test and to check the insertion and to look for possible lesions below with the camera in order to minimize incidence of such injuries. Should this happen, laparoscopic or percutaneous drainage are both suitable alternatives to solve this complication., Highlights • Laparoscopic pneumoperitoneum is still a technique associated to complications. • Veress needle may injury biliary conducts during entry that can be unnoticed due to absence of bleeding. • Safety tests are recommended in order to reduce complications. • Should unnoticed biloma happens, laparoscopic approach is safe and effective.

Liver transplantation for the treatment of patients with advanced liver disease is organized according to a waiting list taking into account different criteria. The agreed distribution model in Andalusia assumes that sometimes an organ is extracted in a different province to that where the implantation is to be performed (shipping), which, therefore, increases the graft ischemic time. The aim of the present study was to determine whether transportation of the organ and being harvested by a team other than the implantation team have a negative effect on final patient survival.

Hepatitis C virus (HCV) clearance is an independent predictive factor for long-term survival in HIV-HCV liver transplantation patients. After 46 months of antiviral therapy it is achieved in up to 80% of cases. Little is known, however, about spontaneous viral clearance. We performed prospective study of HIV-HCV coinfected liver transplant patients.Between January 1, 2001, and December 31, 2011, we analyzed the parameters from among HIV-HCV coinfected liver transplant patients of donor and recipient ages, transplant cause, Model for End-Stage Liver Disease (MELD) score, donor and recipient serology, transplant date, viral load before and after transplantation, immunosuppressive therapy, HCV recurrence, HCV viral clearance (spontaneous and duration), retransplant cause, and viral load before and after retransplant, as well as survival.The seven transplanted HIV-HCV coinfected patients had most commonly HCV-related hepatocarcinoma (n = 5, 71.42%). Three subjects (42.85%) developed HCV recurrences. Two patients (28.57%) were retransplanted, both due to HCV recurrence with one of them developing a spontaneous clearance of HCV (14.28%). This patient showed a preoperative HIV viral load50 copies IU/mL, CD4+ count 486/μL, HCV-RNA 2564 IU copies/mL, Anti-HBc+, and MELD 30. The donor was an 81-year-old female who was Anti-HBc+. Immunosuppressive therapy consisted of cyclosporine, mycophenolate, and prednisone. One month after transplantation, the patient developed an acute cellular rejection episode with progression of liver disease secondary to the HCV recurrence (56.5 × 105 copies IU/mL). He started antiviral treatment (α-interferon and ribavirin), but due to side effects and interactions with the antiretrovirals, they were stopped after four doses. The viral load decreased spontaneously and progressively until it became negative at 146 days after transplantation; he was retransplanted and HCV-RNA has continued to be negative after 772 days.Spontaneous clearance of HCV among HIV-HCV coinfected liver transplant patients is possible. Despite no treatment, one patient still has no detectable HCV viral load after retransplantation.

Objective The objective of this study was to analyze survival, and mortality, rates as well as its causes during the month following liver transplantation with respect to the model for end-stage liver disease (MELD) model. Material and Methods We reviewed the mortality at 24 and 48 hours as well as 1 and 4 weeks of 380 transplanted patients over the past 7 years with regard to the MELD score. Results The mean patient age was 55 years. Among subjects with MELD score ≤ 15 (n = 142; 37.36%), there were 34 deaths (23.94%), including 7 (4.92%) who died during the first month. The mean cause of death during this period was hemorrhage (n = 3; 8.8%). Among those with MELD scores between 16 and 18 (n = 76; 20%), the mortality rate increased to 23.68% (n = 18), including 3 who died during the first month (3.94%) with 1 case due to hemorrhage. Among the cohort with MELD scores between 19 and 21 (n = 78; 20.52%), 25 (32.05%) died, including 9 during the first month (11.53%). The most frequent cause of death was septic shock (n = 5; 20%). The mortality rate among patients with a MELD score between 22 and 24 was 22% (n = 11), of which 8% (n = 4) died in the month. The mean cause of death during this period was multiple organ dysfunction (n = 2; 18.1%). The patient group with a MELD score >24 had a 32.3% mortality rate (n = 11); 4 patients died during the first month following transplantation (11.76%). The most frequent cause of death was hemorrhage (n = 2; 18.1%). Conclusions Survival during the first month did not seem to be related to the MELD score at the time of transplantation, nor did we observe a direct correlation between the MELD score and the overall risk of mortality.

Mesenchymal neoplasms of the gallbladder are rare and in particular leiomyomas of the gallbladder have been rarely reported, all of them in patients with immune system disorders. This is the first report in Spanish of a 23-year-old female patient with a gallbladder leiomyoma without associated immunodeficiency. The patient lacks a previous history of uterine leiomyoma or any other form of neoplasm. She refers several episodes of epygastralgia. A hydatic cyst led to an initial diagnosis and the gallbladder was removed by means of simple cholecystectomy. The abnormal macroscopic aspect of the sample prompted intraoperative biopsy which revealed a benign gallbladder angiomyoma. Subsequent immunohistochemical analysis of the resected sample yielded the diagnosis of intramural endocavitary leiomyoma negative for EBV and C-kit / CD-117. The patient has good general condition and remains asymptomatic 15 months after surgery.

Resumen Presentamos el caso clinico de una mujer de 33 anos diagnosticada de carcinoma suprarrenocortical en estadio avanzado. Describimos la forma de presentacion clinica, los metodos diagnosticos empleados y el tratamiento, especialmente en su aspecto quirurgico, que puede precisar en determinadas ocasiones conocimientos y habilidades en cirugia hepatica y vascular para intentar conseguir la reseccion completa del tumor y mejorar la supervivencia en estos pacientes, generalmente muy jovenes; asimismo, realizamos una actualizacion bibliografica diagnosticoterapeutica de esta neoplasia, rara en su frecuencia pero agresiva en su evolucion

Ascaris lumbricoides infection in Spain is anecdotal and is usually associated with travel to areas with high endemicity such as India and South America. Biliopancreatic disease caused by this parasite is both rare and one of the most feared complications. There are few publications in the literature about pancreatic involvement in ascariasis. We describe a case of pancreatic ascariasis diagnosed after a pancreaticoduodenectomy was performed for a suspected pancreatic adenocarcinoma.A 58-year-old man consulted for longstanding abdominal pain and diarrhea. Computed tomography and magnetic resonance scans, endoscopy, and endoscopic ultrasound-guided fine-needle cytology were performed. The pathological diagnosis was moderately differentiated adenocarcinoma of the pancreatic head.Cephalic pancreaticoduodenectomy was performed. The postoperative course was favorable. A pancreatic fistula type B (ISGPF classification) developed and was resolved with conservative treatment. Analysis of the surgical specimen revealed the presence of a pancreatic pseudotumor due to Ascaris lumbricoides. After these findings, treatment was completed with oral albendazole.Pancreatic ascariasis in our environment is unusual, but should be included in the differential diagnosis of tumors and inflammatory processes of the pancreas.

The syntheses of eight conformationally restricted analogues of N -acetylmuramyl- l -alanyl d -isoglutamine (MDP) based on the d -glucopyrano[2,3- d ]oxazolidine ring system are described.