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Introduction: The Law for the Regulation of Health Professions (LOPS) indicates that health professionals will carry out continuous training throughout their professional life, and will regularly prove their professional competence. The objective of the study was to carry out a national survey to find out the opinion of Spanish surgeons and thus be able to prepare a recertification project by the Spanish Association of Surgeons., Methods: Cross-sectional observational study carried out in June-July 2020, through a survey sent to the members of the Spanish Association of Surgeons., Results: The survey had a total of 1230 visits and an overall completion rate of 784 responses (67.3%). 69.6% were unaware of the LOPS forecasts and 83.4% were unaware of similar initiatives in other specialties and 95.5% agreed to demand adequate information. 71.4% believed it necessary but only 57% believed that it should be mandatory. 82.9% would agree that it should be regulated through an objective and predictable official procedure., Conclusions: The concept of re-accreditation is not well known in our specialty and in view of the results obtained, adequate and reliable information seems necessary. Therefore, it would be pertinent to propose by the A.E.C. a specific project to assess activities and skills., (Copyright © 2020 AEC. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: To determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing two guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC., Methods: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg/day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg/day for BMI of 35-40 and 60mg/day for BMI 40-60., Results: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g/dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months., Conclusions: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding., (Copyright © 2020 AEC. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: to determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing 2guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC., Methods: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg / day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg / day for BMI of 35-40 and 60mg/day for BMI 40-60., Results: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g / dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months., Conclusions: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding., (Copyright © 2020 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients., (© 2020 AEC. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: Physicians, especially surgeons, are significatively affected by burnout. Duty-hour violation, as well as discrimination, abuse and sexual harassment may contribute to burnout. A study about this topic has been published in residents from United States, demonstrating a high incidence of burnout. Our objective is to know which is the situation in Spain and to compare it with United States., Methods: Cross-sectional observational study carried out in January-February 2020, based on the responses to a validated survey administered to General Surgery residents in Spain., Results: There are 931 General Surgery Residents. 739 have entered in the survey and 452 (61.2%) eventually responded to it. In any occasion during the training period, 55.1% reported discrimination based on their gender, 8.8% reported racial discrimination, 73.9% reported verbal/psychological abuse, 7.1% reported physical abuse and 16.4% reported sexual harassment. Attending surgeons are the most frequent source of sexual harassment and physical and verbal abuse, whereas patients are the most frequent cause of gender discrimination. Burnout symptoms were reported by 47.6% of residents and 4.6% reported suicidal thoughts. 98% of residents reported duty-hour violations and 47% of them do not have the day off after to be on call. Both of these issues are burnout predictive factors., Conclusions: Mistreatment (discrimination, abuse and harassment) occurs among General Surgery residents during their training period in our country. Every kind of mistreatment is more frequent in Spain than in the United States, with the exception of racial discrimination. It is associated with exceeding weekly duty-hour. It is necessary to know these problems and to avoid them in order to improve work environment of General Surgery training period., (Copyright © 2020 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: De Garengeot's Hernia is a rare type of femoral hernia in which the appendix is located inside the herniated sac. Diagnosis of the condition is challenging and its treatment must be performed without delay., Presentation of Case: We present the case of a 75-year-old patient with a femoral hernia in which an appendix with signs of inflammation was found. An appendectomy followed by hernia repair was performed under an open preperitoneal approach according to Nyhus technique. The patient did not present any complications and was discharged on the second postoperative day., Discussion: This type of hernia is often unexpected and its preoperative diagnosis is difficult to perform. In most cases the clinical picture is indistinguishable from a common incarcerated hernia. Contrast-enhanced CT is the most useful complementary test, although it is not as accurate as desirable, so the diagnosis is frequently found intraoperatively. There is a wide variety of surgical options and there is no consensus on the most appropriate one. The preperitoneal approach enables the performance of an appendectomy and subsequent hernia reparation. The use of prosthesis should be considered if there are no signs of perforation or abscess., Conclusion: De Garengeot's hernia is a very rare entity. The diagnosis and subsequent surgical treatment must be early to prevent the disease progression. The preperitoneal approach should be considered as the first choice technique, as it allows the exploration of the herniated sac and the performance of surgical procedures on its content., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country., (Copyright © 2018 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Cystic pancreatic neoplasms are a heterogeneous group of pathology, and intraductal papillary mucinous neoplasia is becoming more common. The aim of this study is to review our series of cystic pancreatic neoplasms that underwent surgery and to evaluate the similarities with Fukuoka recommendations., Methods: Retrospective review of our experience analyzing clinical and radiological data, indication for surgery and pathology study of 11 patients operated on in our centre from july 2011 to july 2015, aiming to evaluate the degree of agreement with the current consensus., Results: In our series the majority of cases (7/11) had symptoms at diagnosis. Preoperative diagnosis was achieved in 10 patients using radiology and/or endoscopy. Indications for surgery were the presence of symptoms, radiological data suspicious of malignancy, and secondary branch neoplasia over 30mm. Pathological findings were malignancy in 6/11 cases (2 invasive neoplasia, 4 high grade dysplasia), moderate dysplasia in 2/11, low-grade dysplasia in 2/11 and no dysplasia in one patient., Conclusions: Surgical indication of intraductal mucinous pancreatic neoplasms depends on the associated symptoms, size, location, risk and suspicion of malignancy., (Copyright © 2016 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Management of rectovesical fistulas poses a significant challenge where a definitive surgical treatment is necessary in the majority of the patients. The application of transanal endoscopic surgery is an useful option, adding the adventages of a minimally invasive surgery. We report our first case of transanal endoscopic surgical treatment of RVF with a successful outcome.

Outbreaks of viral haemorrhagic fevers such as Ebola can lead to imported cases in Europe and America. The eventuality of surgery in the setting of Ebola Virus Disease (EVD) is low, but the Spanish Association of Surgeons elaborated a surgical protocol for EVD., Indication: Elective surgical procedures are not indicated. Emergency cases can be considered in: persons under investigation, possible cases and early confirmed cases. In some conditions usually treated by surgery a medical treatment can be tested., Hospitals and Teams: All cases must be treated in high technology hospitals. These hospitals must be equipped with adequate means for healthcare provider's protection. All members of the healthcare team should practice thorough simulation prior to caring for a possible Ebola patient., Surgical Protocol: This protocol is based on international guidelines on use of Personal Protective Equipment, protocols of other scientific societies, and specific recommendations for the operating room environment., (Copyright © 2015 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To assess the magnitude of the different causes of anxiety in patients and families, facing surgery., Methods: Cross-sectional multicenter national survey recruiting 1,260 participants between patients and companions, analyzing the impact of 14 areas selected based on scientific publications aimed at the general public, concerning patients and/or companions, focused on concern about surgery. Patient sex, age, type of surgery (minor/major) and expected inpatient or ambulatory surgery were analyzed. For the companions sex and age, and relationship to patient were analyzed. In both cases it was assessed based on a unidimensional scale of 0 to 10, with 0 being be minimal cause for concern and 10, maximum., Results: The most prominent have been the fear of the unknown, possible complications, the impact on quality of life, the accuracy of diagnosis and possible malignancy of the disease, as well as anesthesia and pain control. There are significant differences in the involvement of patients and companions; and are also differences by sex and age of the patient; type of surgery (minor/major) and expected hospital admission or not., Conclusions: The patient faces surgery with a number of fears that can be reduced with increased information., (Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Management of spleen trauma has changed over last decades, although there is no data on its treatment in Spain. The aim of this study is to determine the characteristics of spleen injuries in adults with severe abdominal injuries and how we manage them., Methods: A prospective study using the databases of six Spanish hospitals: Gregorio Marañón Hospital, Virgen de la Vega Hospital, Torrevieja Hospital, Getafe Hospital, Doce de Octubre Hospital and Corporació Sanitària Parc Taulí., Results: A total of 566 patients who had sustained spleen injuries were analyzed (448 males and 118 females), most of them were due to blunt trauma (94%), and the most frequent mechanism of injury was motor vehicle accident. The mean Injury Severity Score (ISS) was 25.2. The initial treatment was surgical in 56.6% of the patients (85.3% total splenectomy and 14.7% other conservative surgical procedures, of which 4.6% finally failed and required total splenectomy). The remaining 43.4% were initially managed conservatively, but 6.5% of them finally required surgical splenectomy, and in 8.8% angio-embolization was performed., Conclusion: In Spain, management of spleen trauma is mainly surgical (particularly splenectomy). Angio-embolization and conservative surgical procedures are now hardly used., (Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved.)

Background: Trauma injuries are the main cause of death in the world. The aim of this study is to determine how trauma patients are treated in Spain at an organizational level., Material and Methods: A questionnaire was prepared consisting of 14 questions regarding aspects of the trauma care organization and trauma education. It was posted on the web site of the Spanish College of Surgeons and all members were encouraged to participate., Results: One hundred and ninety questionnaires from 110 different hospitals were received. More than two-thirds (67.3%) of the centers had protocols for treating trauma patients, with 81% of them based on ATLS guidelines. Almost three-quarters (72.6%) of the doctors had completed the ATLS course, and 38.9% the DSTC course. There was a specific education program in trauma in 24.5% of the centers, and 35.5% had a Trauma Committee. There was a rehabilitation program in 24.5% of the centers., Conclusion: Very few of the participating centers would fulfill the requirements of the American College of Surgeons accreditation for trauma centers. Trauma care in Spain has improved a lot in the recent years, but there is still a lot to do to reach the level of that in the United States of America., (Copyright © 2012 AEC. Published by Elsevier Espana. All rights reserved.)

The training of residents in abdominal wall surgery is a fundamental aspect of surgical training, representing globally 20% of its activity. In this paper, we analyze the current state of resident training in this kind of surgery in Spain, taking into account the broad spectrum it covers: general services, specific functional units, ambulatory surgery programs. To do this, based on the specifications of the specialty program, specific data were used from several different sources of direct information and a review of the results obtained by residents in hernia surgery. In general, our residents agree with their training and the recorded results are in line with objectives outlined in the program. However, it would be important to structure their teaching schedules, a rotation period in any specific unit and their involvement in outpatient surgery programs., (Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved.)

Introduction: The aim of the study is to try and find out the state of surgical training in Spain and to determine whether it meets the objectives of the Program., Material and Methods: The results of two surveys carried out on Residents and General Surgery Tutors by the Spanish Surgeons Association, based on the conclusions of the XXVII Congreso Nacional de Cirugía. The questions formulated referred to general aspects of the Service and specific ones related to access, teaching activity, surgery, research and personal perspectives. The responses were defined, adjusted and categorised as quantitative and qualitative variables. The statistics program G Stat 2.0 was used for processing and the descriptive presentation of the results., Results: The surveys were sent to 626 Residents and 142 Tutors, with a response rate of 19% and 29%, respectively. First year residents predominated (32%) compared to later years, with an R-5 response index of 7.2%. A total of 91% knew the speciality Program well, and 76% were satisfied with the training received., Conclusions: The results obtained as regards surgical activity agree with those established in the Program, both in the number of procedures and in their progression throughout the Residency, although it is not possible to ensure its uniformity. The functions and accreditation of the Tutors which are one of the main foundations of the training process are pending specific regulations.

Massive bleeding is a major cause of intraoperative death or death in the immediate postoperative period as a result of surgery. The present article describes the basic principles for the control of surgical bleeding as well as temporary and definitive maneuvers. Temporary control of bleeding can often be achieved with simple maneuvers, which may not be definitive, in which case damage control or planned reoperation are required. The surgeon's aim should always be to control the bleeding. If simple maneuvers fail, more complex procedures are required. The present article also describes these maneuvers to control bleeding (Pringle's maneuver, total vascular exclusion, atrial caval shunt, Mattox's maneuver, Cattel Braasch maneuver, Kocher's maneuver and aortic control maneuvers).

On 8 may 2007, the Official Bulletin (BOE) published the new Specialist Training Program. The Post-Graduate Training Section of the Spanish Surgeons Association (AEC), conscious of the importance of this situation, has carried out a reflective analysis of this Program and proposes a series of objectives. The new plan coordinates a training program that sets out three general objectives as regards, knowledge, skills and attitudes that the resident must assimilate and develop, it strictly defines the final product, without substantially changing the previous program and emphasises two fundamental aspects: training in minimally invasive surgery and research training, although the inclusion of previously unpublished new rotations and the continuation of the current assessment model. The logic in the definition of general surgery as "a major discipline paradigm" should lead to important structural changes. Aspects such as regulating work and training times, European Directives, lack of professional motivation and changes in the vocational spectrum of new residents, will make the optimisation of the results difficult a priori. The year 2017 will be the time to judge the results after five groups of surgeon graduates have been trained by this program.

Background: Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI., Methods: We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS., Results: The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h., Conclusions: Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.

Congenital fistulae between the tracheobronchial tree and oesophagus usually originate from the lower end of the trachea or right main bronchus. The case history is presented of a man in whom a fistula between the oesophagus and left main bronchus was not diagnosed until the age of 48.

Since the inauguration of our liver transplant program two years ago, retrospectively we can distinguish two different periods as regards postoperative results. The patients studied were distributed in two groups by chronological order and date of introduction of an improved surgical and anesthetic strategy: retrohepatic dissection during the veno-venous bypass phase and meticulous hemostasis in the anhepatic phase: Group A: 11 transplants in 10 patients and Group B: 22 transplants in 21 patients. Preoperatively, both groups were homogeneous with respect to the clinical situation. During the operation, significantly larger transfusion volumes were given in group A (25.4 +/- 10.5 ml/kg/hr) than in group B (10.0 +/- 5.7 ml/kg/hr) (p less than 0.01). The anhepatic phase lasted 1'50" +/- 20" in group B (p less than 0.05). The postoperative outcome of group B was better than that of A as regards hemodynamic and respiratory parameters, functional impairment of the graft and mortality (p less than 0.05). We conclude that the realization of retrohepatic dissection and careful hemostasis during the anhepatic phase, which prolongs the duration of venovenous by-pass but does not increase intraoperative morbidity, reduces the need for blood transfusion, and yields better postoperative results.

A case of massive intra and extrahepatic lithiasis in a 52 year-old-man is presented. Diagnosis was confirmed by ultrasonography, CT and percutaneous cholangiography. The value of the different diagnostic procedures is analyzed. The need for elective surgical treatment is insisted on in order to remove the majority of the calculi, treatment of stenosis and adequate biliary drainage. Our case was treated with an hepatico-jejuno-duodenostomy (end to side) on an isolated jejunal loop with sphincteroplasty for drainage of the distal choledochus. In the postoperative period the patient was treated with Methyl-tert-butyl-ether for dissolution of the remaining calculi.

A series of 269 patients with 371 surgically treated hydatid cysts of the liver is reported. Cystopericystectomy was performed in 45.2% of cases, liver resection in 7%, subtotal cystectomy in 26.9%, cystojejunostomy in 1.8% and drainage in 9.7%. Overall mortality and morbility were 2.9% and 31% respectively, with a mean hospital stay of 29 days. The highest mortality (6%) and morbility (45%) were observed in patients undergoing subtotal cystectomy. In the group of patients treated by conservative surgery the overall mortality was 32.5%, while in the group treated by radical surgery it was 27% (p less than 0.05). These data suggest that in the treatment of hydatid disease radical resection is followed by the lowest complication and mortality rates.

The quality of the socio-affective adaptation of liver transplant patients is a fundamental assessment parameter in the context of postoperative recuperation. The patient's reinsertion into the socio-occupational environment, gradual recuperation of professional and recreational habits and psycho-affective reorganization represent, in our opinion, the most significant criteria for evaluation of the "modus vivendi" of the transplant patient. A total of 21 patients between 21 and 62 years were evaluated. They were divided into three groups for study and analysis. The remission of symptoms and normalization of organic activities, in addition to achievement of an adequate quality of life, constitute the basic rationale for any surgical intervention.

Over a period of 6.5 years, 29 patients with liver hemangiomas have been examined. In 8 patients, the most frequent symptom was pain; in 11, a tumor was found. The diagnosis was made by means of scintigraphy with 99mTc, followed by real-time sonography, computed tomography using a contrast medium, and selective arteriography. In 16 patients (15 women, 1 man), the tumor radius was more than 6 cm and in 9 of these, more than 10 cm. In 3 patients, a left lobectomy was carried out, and in 5 a right lobectomy; in an additional 5 patients, a extended right lobectomy (three segments excised) was done. In the rest, a medial lobectomy, a segmentectomy on the left side, or a segmentectomy on the right was performed. The only complications observed in the whole series were: pleural effusion (1 case), subphrenic abscess (1), and transitory biliary fistula (1). All hemangiomas with a radius of more than 10 cm should be removed operatively, as should smaller symptomatic hemangiomas and tumors that are not clearly benign.

A retrospective analysis of 1,856 patients treated by esophageal achalasia in 23 different surgical departments from seven countries is reported. The predominant symptom was dysphagia (100%), pain, vomiting and weight loss (76.1%). The most useful diagnostic methods were: barium meal (85%), manometry (100%), endoscopy (100%) and 99mTc (100%). Conservative treatment (5.45%) was useful in 5.8% only. Dilatation (16.9%) produced amelioration in 65.9%. Thoracotomy was used in 20.9% and middle line laparotomy in 79.2%. Heller esophagomyotomy was performed in 99.52% associated with anterior fundoplasty in 79.8% and postero-lateral (Mark IV) in 9.75%. Most of the patients were controlled through barium meal, esophagoscopy, esophageal manometry, pHmetry and 99mTc ingestion. Good results after Heller's myotomy with anterior fundoplication were 81.7% and poor 7.2%. Recurrence of achalasia was present in 184 patients. A new esophagomyotomy was performed on 58.6% and distal esophageal resection in 62 (35.3%). In total, 988 patients were reviewed once a year. Absence of gastroesophageal reflux was shown in 73.9% of the explored patients.

A study was made of 44 patients who underwent liver transplant, distributed into three groups: Group A: patients who had ample liver dissection before entering bypass. Group B: patients who entered bypass after dissection of the hepatic hilum and prior to any other dissection; bypass time was prolonged for meticulous hemostasia. Group C: patients with perfectly defined hemodynamic problems, not secondary to bleeding, during the anhepatic phase. Preoperatively the three groups were homogeneous as regards clinical situation. During the operation a significantly larger transfusion volume (p less than 0.01) was administered in group C during phase II (70.1 +/- 27.2 ml/kg/h), phase III (32.6 +/- 9.6 ml/kg/h) and throughout surgery (32.7 +/- 10.3 ml/kg/h) than in the other two groups. Group B received a smaller transfusion volume during phase II (14.6 +/- 8.1 ml/kg/h), phase III (12.7 +/- 5.5 ml/kg/h) and throughout surgery (11.6 +/- 4.9 ml/kg/h) than the other two groups (p less than 0.01). The transfusion needs of group A were 28.4 +/- 15.6 ml/kg/h in phase II, 26.8 +/- 17.1 ml/kg/h in phase III and 21.2 +/- 11.2 ml/kg/h throughout surgery. The duration of the anhepatic phase was significantly shorter (p less than 0.01) in group A (1 h 10' +/- 10) than in (1 h 50' +/- 10) and C (1 h 40' +/- 45'). In the postoperative period a higher mortality was associated with group C (37.5%) and a lower mortality with group B (3.33%), the mortality of group A being 16.6%. The differences were statistically significant with p less than 0.01.

Two cases are presented of liver transplantation in adult patients with fulminant liver failure using grafts from incompatible blood group donors due to the urgency of the situation. The patients evolved well as first but later both developed ischemia and necrosis of the bile tract secondary to severe rejection. It is concluded that the use of incompatible grafts can save the patient's life in acute irreversible liver failure, but in most cases retransplantation may be necessary as the definitive treatment of postoperative complications.

The initial results of biliary reconstruction in 72 liver transplants realized in 62 patients, 50 adults and 12 children, are presented. Three reconstruction techniques were used: end-to-end choledocho-choledochostomy on a Kehr tube in 44 transplants (61.1%); choledocho-jejunostomy on a Roux-en-Y loop in 24 transplants (33.3%); double derivation cholecysto-choledocho-jejunostomy in 2 transplants (2.7%). The number of early complications related to biliary reconstruction was 5 (7.14%): 3 fistulas in the choledocho-choledochostomy series (6.8%) and 2 fistulas among the choledocho-jejunostomies (8.3%). All complications required reoperation and mortality was nil. Thirty-two months after the onset of the program, no late complications of the biliary anastomosis have been registered.

A case of a hepatic echinococcal cyst of the right lobe (diam. 16 cm.) involving the anterior wall of the retrohepatic inferior vena cava is reported. During surgery, the vein was occasionally damaged and suture of the lesion was not possible. Therefore resection of the retrohepatic vena cava was performed and the segmental continuity was replaced with a dacron graft (1,6 X 5 cm.). The patient had an uneventful recovery. The controls at 6, 12 and 24 months showed excellent permeability of the prosthesis. This report represents the second long-term survival case of the literature. The indications for graft replacement of the inferior vena cava, are discussed.

Three patients are reported who had liver hydatidosis that was not resolved by conventional surgery and who eventually underwent liver transplantation. In view of the satisfactory results obtained, with 100% postoperative survival, possible indications for liver transplant in this type of patients are discussed, fundamentally for secondary sclerosing cholangitis, secondary biliary cirrhosis and acute Budd-Chiari syndrome.