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Background & Aims: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. Methods: An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. Results: A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14–24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p

BACKGROUND Intraoperative cholangiography (IOC) has been historically used to detect common bile duct (CBD) stones, delineate biliary anatomy, and avoid or promptly diagnose bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). We aimed to determine the usefulness of routine IOC during LC in an urban teaching hospital. METHODS A consecutive series of patients undergoing LC with routine IOC from 2016 to 2018 was prospectively analyzed. Primary outcomes of interest were: CBD stones, BDI, and anatomical variations of the biliary tract. Secondary outcomes of interest were: IOC success rate, IOC time, and readmission for residual lithiasis. A comparative analysis was performed between patients with and without preoperative suspicion of CBD stones. RESULTS A total of 1003 LC were analyzed; IOC was successful in 918 (91.5%) patients. Mean IOC time was 10 (4 to 30) minutes. Mean radiation received by the surgeon per procedure was 0.06 millisieverts (mSv). Normal IOC was found in 856 (93.2%) patients. CBD stones and aberrant biliary anatomy were present in 58 (6.3%) and 4 (0.4%) cases, respectively. Two patients (0.2%) underwent unnecessary CBD exploration because of false-positive IOC. Four patients (0.4%) with normal IOC were readmitted for residual CBD stones. Five (0.5%) minor BDI undetected by the IOC were diagnosed. Patients with preoperative suspicion of CBD stones had significantly higher rates of CBD stones detected on IOC as compared with those without suspicion (23.2% vs. 2.1%, P

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

The A.A.E.E.H has developed this guideline for the best care of patients with hepatocellular carcinoma (HCC) from Argentina. It was done from May 2018 to March 2020. Specific clinical research questions were systematically searched. The quality of evidence and level of recommendations were organized according to GRADE. HCC surveillance is strongly recommended with abdominal ultrasound (US) every six months in the population at risk for HCC (cirrhosis, hepatitis B or hepatitis C); it is suggested to add alpha-feto protein (AFP) levels in case of inexeperienced sonographers. Imaging diagnosis in patients at risk for HCC has high specificity and tumor biopsy is not mandatory. The Barcelona Clinic Liver Cancer algorithm is strongly recommended for HCC staging and treatment-decision processes. Liver resection is strongly recommended for patients without portal hypertension and preserved liver function. Composite models are suggested for liver transplant selection criteria. Therapies for HCC with robust clinical evidence include transarterial chemoembolization (TACE) and first to second line systemic treatment options (sorafenib, lenvatinib, regorafenib, cabozantinib and ramucirumab). Immunotherapy with nivolumab and pembrolizumab has failed to show statistical benefit but the novel combination of atezolizumab plus bevacizumab has recently shown survival benefit over sorafenib in frontline. Fil: Piñero, Federico. Universidad Austral. Hospital Universitario Austral; Argentina Fil: Tanno, Mario. Universidad Nacional de Rosario. Facultad de Ciencias Médicas. Hospital Nacional del Centenario; Argentina Fil: Aballay Soteras, Gabriel. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor "Dr. Cosme Argerich"; Argentina Fil: Tisi Baña, Matías. Universidad Austral. Hospital Universitario Austral; Argentina Fil: Dirchwolf, Melisa. Hospital Privado de Rosario; Argentina Fil: Fassio, Eduardo. Hospital Nacional Profesor Alejandro Posadas.; Argentina Fil: Ruf, Andrés. Hospital Privado de Rosario; Argentina Fil: Mengarelli, Silvia Estela. Gobierno de la Provincia de Entre Rios. Hospital San Roque.; Argentina Fil: Borzi, Silvia. Hospital Privado de Cordoba; Argentina Fil: Fernández, Nora. Hospital Británico de Buenos Aires; Argentina Fil: Ridruejo, Ezequiel. Universidad Austral. Hospital Universitario Austral; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET; Argentina Fil: Descalzi, Valeria. Fundación Favaloro; Argentina Fil: Anders, Margarita. Hospital Alemán; Argentina Fil: Mazzolini, Guillermo. Universidad Austral; Argentina Fil: Reggiardo, Virginia. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Doctor Cosme Argerich; Argentina Fil: Marciano, Sebastian. Hospital Italiano. Departamento de Medicina.; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Perazzo, Florencia. Hospital Británico de Buenos Aires; Argentina Fil: Spina, Juan Carlos. Hospital Italiano; Argentina Fil: McCormack, Lucas. Hospital Alemán; Argentina Fil: Maraschio, Martín Alejandro. Hospital Privado de Cordoba; Argentina Fil: Lagues, Cecilia. Universidad Austral; Argentina Fil: Gadano, Adrián Carlos. Hospital Italiano. Departamento de Medicina.; Argentina Fil: Villamil, Federico. Hospital Italiano. Departamento de Medicina.; Argentina. Hospital Británico de Buenos Aires; Argentina Fil: Silva, Marcelo. Universidad Austral. Hospital Universitario Austral; Argentina Fil: Cairo, Fernando. Hospital Británico de Buenos Aires; Argentina Fil: Ameigeiras, Beatriz. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; Argentina

Liver transplantation (LT) selection models for hepatocellular carcinoma (HCC) have not been proposed to predict waitlist dropout because of tumour progression. The aim of this study was to compare the alpha-foetoprotein (AFP) model and other pre-LT models in their prediction of HCC dropout.A multicentre cohort study was conducted in 20 Latin American transplant centres, including 994 listed patients for LT with HCC from 2012 to 2018. Longitudinal tumour characteristics, and patterns of progression were recorded at time of listing, after treatments and at last follow-up over the waitlist period. Competing risk regression models were performed, and model's discrimination was compared estimating Harrell's adapted c-statistics.HCC dropout rate was significantly higher in patients beyond (24% [95% CI 16-28]) compared to those within Milan criteria (8% [95% IC 5%-12%]; p .0001), with a SHR of 3.01 [95% CI 2.03-4.47]), adjusted for waiting list time and bridging therapies (c-index 0.63 [95% CI 0.57; 0.69). HCC dropout rates were higher in patients with AFP scores2 (adjusted SHR of 3.17 [CI 2.13-4.71]), c-index of 0.71 (95% CI 0.65-0.77; p = .09 vs Milan). Similar discrimination power for HCC dropout was observed between the AFP score and the Metroticket 2.0 model. In patients within Milan, an AFP score 2 points discriminated two populations with a higher risk of HCC dropout (SHR 1.68 [95% CI 1.08-2.61]).Pre-transplant selection models similarly predicted HCC dropout. However, the AFP model can discriminate a higher risk of dropout among patients within Milan criteria.

A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding.Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding. (CRD42021244288) RESULTS: Of the 2,478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post-LT, yet it did not increase the risk of bleeding.Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT. This article is protected by copyright. All rights reserved.

Liver transplant recipients are immunocompromised patients, and are often susceptible to bacterial, fungal and virus infections. We report the case of liver-only tuberculomas occurring eleven years following a deceased donor liver transplantation, that was initially interpreted as metastases of unknown origin. Interestingly, only a few such cases have been reported, usually within the first two years after transplantation, often when more aggressive immunosuppression is required. Although it is accepted that tuberculosis incidence among solid organ transplant recipients is higher when compared with the general population, its late onset after transplantation is very unusual.

Fatty liver disease is a frequent diagnosis. Rarely, it adopts a multifocal nodular pattern mimicking multiple liver metastases. Multifocal nodular fatty infiltration of the liver entails a challenging problem that must be included as a differential diagnosis when dealing with healthy patients with an incidental finding of multiple liver lesions, even in the absence of obesity or metabolic syndrome. A complete clinical examination and high-quality imaging, including magnetic resonance imaging, might help to confirm diagnosis and to avoid unnecessary liver biopsies.

This study aimed to compare liver transplantation (LT) outcomes and evaluate the potential rise in numbers of LT candidates with hepatocellular carcinoma (HCC) of different allocation policies in a high waitlist mortality region. Three policies were applied in two Latin American cohorts (1085 HCC transplanted patients and 917 listed patients for HCC): (i) Milan criteria with expansion according to UCSF downstaging (UCSF-DS), (ii) the AFP score, and (iii) restrictive policy or Double Eligibility Criteria (DEC; within Milan + AFP score ≤2). Increase in HCC patient numbers was evaluated in an Argentinian prospective validation set (INCUCAI; NCT03775863). Expansion criteria in policy A showed that UCSF-DS [28.4% (CI 12.8-56.2)] or "all-comers" [32.9% (CI 11.9-71.3)] had higher 5-year recurrence rates compared to Milan, with 10.9% increase in HCC patients for LT. The policy B showed lower recurrence rates for AFP scores ≤2 points, even expanding beyond Milan criteria, with a 3.3% increase. Patients within DEC had lower 5-year recurrence rates compared with those beyond DEC [13.3% (CI 10.1-17.3) vs 24.2% (CI 17.4-33.1; P = 0.0006], without significant HCC expansion. In conclusion, although the application of a stricter policy may optimize the selection process, this restrictive policy may lead to ethical concerns in organ allocation (NCT03775863).

Modern liver surgeon must be equipped with excellent theoretical and clinical skills to perform a perfect liver resection. A particular and growing relevance is devoted to parenchyma sparing liver surgery (PSS). Indeed, reducing the sacrifice of functioning parenchyma is one of the keys of a successful surgery, once oncological issues are properly addressed. Intraoperative ultrasound together with oncological and anatomical new insights have enhanced the possibility to offer PSS even in advanced disease usually afforded with major resections or staged procedures or even considered unresectable. These complex hepatectomies are mainly performed with open surgery, while major or staged procedures could be faced with minimal access liver surgery (MALS): that is generating a potential conflict between open PSS and MALS major hepatectomies. An overall evaluation of oncological radicality, safety, salvageability, and quality of life suggest to prioritize PSS, which is always minimal invasive liver surgery in a hepatic-centered perspective, while MALS is not.

The lack of adequate financial coverage, education, and the organization has been the main limiting factor for the development of transplantation in Latin America. As occurred worldwide, the number of patients on liver waiting lists in Latin America grows disproportionately compared to the number of liver transplantations (LTs) performed. Although many law modifications have been made in the last year, most countries lack social awareness about the importance of donation and the irreversibility of brain death. The mechanisms and norms for organ procurement and infrastructure development, capable of supporting this high demand, are still in slow progress in most countries. Access to LT in the region is very heterogeneous. While some countries have no active LT programs so far, others are an international model of a public transplantation system (Brazil) or a national information system (Argentina). While some countries have only a few LT centers, others have too many LT centers performing an inadequate low number of LTs. Disparity to access transplantation remains the major challenge in the region. Cultural and educational efforts have to be accompanied by transparent public policies that will likely increase organ donation and activity in transplantation. The purpose of this article is to review the trends and current activity in LT within Latin America, based on prior publications and the information available in each country of the region.

Background and aims. Background and aims. Heter Background and aims. ogeneous data has been reported regarding liver transplantation (LT) for hepatocellular carcinoma (HCC) in Latin America. We aimed to describe treatment during waiting list, survival and recurrence of HCC after LT in a multicenter study from Latin America. Material and methods. Material and methods. Patients with Material and methods. HCC diagnosed prior to transplant (cHCC) and incidentally found in the explanted liver (iHCC) were included. Imaging-explanted features were compared in cHCC (non-discordant if pre and post-LT were within Milan, discordant if pre-LT was within and post-LT exceeding Milan). Results. Overall, Results.Results. 435 patients with cHCC and 92 with iHCC were included. At listing, 81% and 91% of cHCC patients were within Milan and San Francisco criteria (UCSF), respectively. Five-year survival and recurrence rates for cHCC within Milan, exceeding Milan/within UCSF and beyond UCSF were 71% and 16%; 66% and 26%; 46% and 55%, respectively. Locoregional treatment prior to LT was performed in 39% of cHCC within Milan, in 53% beyond Milan/within UCSF and in 83% exceeding UCSF (p < 0.0001). This treatment difference was not observed according to AFP values (d100, 44%; 101-1,000, 39%, and > 1,000 ng/mL 64%; p = 0.12). Discordant imaging-explanted data was observed in 29% of cHCC, showing lower survival HR 2.02 (CI 1.29; 3.15) and higher recurrence rates HR 2.34 when compared to AFP 1,000 ng/mL at listing was independently associated with a higher 5-year recurrence rate and a HR of 3.24 when compared to AFP

Introduction: Early preventive strict quarantine due to COVID-19 pandemic was implemented in Argentina since March 20th, 2020. Transplant societies and organ procurement organizations were challenged to face this complex scenario and sustain organ donation and transplantation activity. Objectives: We evaluated the impact of complete and preventive lockdown in organ procurement and transplantation before the COVID-19 peak onset. Materials and Methods: We analyzed prospectively collected data from the National Report Agency (INCUCAI). By constructing time series, we compared donation and transplant rates from the years 2010 to 2020, during a same monthly-period between March 3rd and July 20th. We evaluated the effect of preventive lockdown before the peak of COVID-19 curve. Donation rates per million population in these months were also registered for each year. Transplant accessibility was calculated, dividing the total number of transplants and the total number of listed patients. Results: The preventive lockdown was associated with a 34.5% relative reduction (95% CI 26.9-43.2) in organ procurement when compared to 2010-2019 and significantly reduced comparing 2019 [53.3% (CI 44.6-61.6)]. This scenario was even worse in Buenos Aires city and its surroundings, the region most affected by COVID-19. During this period, donation per million population rates decreased from 7.8 in 2019 to 3.3 in 2020. This reduction was even higher in the number of deceased and living donor transplants performed comparing 2019 vs. 2020, with a relative reduction of 62.0% (CI 30.8-89.1) and 68.8% (CI 65.7-71.7), respectively. Conclusions: During this short observation period of 120 days of preventive quarantine, not yet having reached the ''peak'' incidence of COVID-19, a marked reduction in procurement and transplantation rates were observed. Although waiting list mortality was not significantly modified, transplant access has been significantly reduced, showing a future negative trend on waitlist mortality.

Few studies have examined the postoperative long-term complications after partial pancreatoduodenectomy and there are mainly focused in the presence of biliary strictures. The occurrence of intra-pancreatic lithiasis secondary to the presence of late stenosis of the duct-to-mucosa pancreaticojejunostomy is an extremely rare condition. We observed that the late occurrence of a pancreaticojejunostomy stricture could be a potential cause for acute pancreatitis in long-term survivors following partial pancreatoduodenectomy. The importance of this report is to emphasize that the strategy of a redo of this difficult anastomosis is a very challenging abdominal operation but provides excellent early and long-term results

BACKGROUND & AIMS The French alpha-fetoprotein (AFP) model has recently shown superior results compared to Milan criteria (MC) for prediction of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) in European populations. The aim of this study was to explore the predictive capacity of the AFP model for HCC recurrence in a Latin-American cohort. METHODS Three hundred twenty-seven patients with HCC were included from a total of 2018 patients transplanted at 15 centres. Serum AFP and imaging data were both recorded at listing. Predictability was assessed by the Net Reclassification Improvement (NRI) method. RESULTS Overall, 82 and 79% of the patients were within MC and the AFP model respectively. NRI showed a superior predictability of the AFP model against MC. Patients with an AFP score >2 points had higher risk of recurrence at 5 years Hazard Ratio (HR) of 3.15 (P = 0.0001) and lower patient survival (HR = 1.51; P = 0.03). Among patients exceeding MC, a score ≤2 points identified a subgroup of patients with lower recurrence (5% vs 42%; P = 0.013) and higher survival rates (84% vs 45%; P = 0.038). In cases treated with bridging procedures, following restaging, a score >2 points identified a higher recurrence (HR 2.2, P = 0.12) and lower survival rate (HR 2.25, P = 0.03). A comparative analysis between HBV and non-HBV patients showed that the AFP model performed better in non-HBV patients. CONCLUSIONS The AFP model could be useful in Latin-American countries to better select patients for LT in subgroups presenting with extended criteria. However, particular attention should be focused on patients with HBV.

Biannual ultrasound (US) is recommended as the clinical screening tool for hepatocellular carcinoma (HCC). The effectiveness of surveillance according to the place where US is performed has not been previously reported. To compare the effectiveness of US performed in the center responsible for follow-up as opposed to US proceeding from centers other than that of follow-up. This is a multicenter cohort study from Argentina. The last US was categorized as done in the same center or done in a different center from the institution of the patient’s follow-up. Surveillance failure was defined as HCC diagnosis not meeting Barcelona Clinic Liver Cancer (BCLC) stages 0-A or when no nodules were observed at HCC diagnosis. From 533 patients with HCC, 62.4% were under routine surveillance with a surveillance failure of 38.8%. After adjusting for a propensity score matching, BCLC stage and lead-time survival bias, surveillance was associated with a significant survival benefit [HR of 0.51 (CI 0.38; 0.69)]. Among patients under routine surveillance (n = 345), last US was performed in the same center in 51.6% and in a different center in 48.4%. Similar rates of surveillance failure were observed between US done in the same or in a different center (32% vs. 26.3%; P = 0.25). Survival was not significantly different between both surveillance modalities [HR 0.79 (CI 0.53; 1.20)]. Routine surveillance for HCC in the daily practice improved survival either when performed in the same center or in a different center from that of patient’s follow-up.

Background and aim Adherence to the Barcelona Clinic Liver Cancer (BCLC) staging algorithm for the treatment of hepatocellular carcinoma is challenging in the daily practice. We aimed to analyze adherence to BCLC along with its effect on patient survival. Patients and methods A cohort study was conducted in 14 hospitals from Argentina including patients with newly diagnosed hepatocellular carcinoma (2009-2016). Adherence was considered when the first treatment was the one recommended by the BCLC. Results Overall, 708 patients were included. At diagnosis, BCLC stages were as follows: stage 0 4%, A 43%, B 22%, C 9% and D 22%. Overall, 53% of the patients were treated according to BCLC, 24% were undertreated, and 23% overtreated. Adherence to BCLC increased to 63% in subsequent treatments. Independent factors associated with adherence to BCLC were the presence of portal hypertension [odds ratio: 1.63; 95% confidence interval (CI): 1.11-2.39] and BCLC stage C (odds ratio: 0.32; 95% CI: 0.12-0.72). In a multivariable model adjusting for portal hypertension and BCLC stages, adherence to BCLC showed improved survival (hazard ratio: 0.67; 95% CI: 0.52-0.87). Conclusion Adherence to BCLC represents a challenge in the daily practice, with almost half of the patients being treated accordingly, showing that the decision-making process should be tailored to each individual patient. Fil: Piñero, Federico. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET.; Argentina Fil: Marciano, Sebastian. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET.; Argentina Fil: Fernández, Nora. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET.; Argentina Fil: Silva, Jorge. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET.; Argentina Fil: Zambelo, Yanina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET.; Argentina Fil: Cobos, Manuel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET.; Argentina Fil: Zerega, Alina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET.; Argentina Fil: Ridruejo, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET.; Argentina Fil: Miguez, Carlos. Fil: Ameigeiras, Beatriz. Fil: D'amico, Claudia Alejandra. Fil: Gaite, Luis. Fil: Coronel, Matías. Fil: Bermúdez, Carla. Fil: Rosales, Carlos. Fil: Romero, Gustavo. Fil: Mc Cormack, Lucas. Fil: Reggiardo, Virginia. Fil: Colombato, Luis. Fil: Gadano, Adrián Carlos. Fil: Rubinstein, Fernando Adrian. Fil: Silva, Marcelo.

Resumen Introduccion La proporcion de pacientes anosos esta creciendo rapidamente. Conocer los verdaderos resultados de la cirugia pancreatica en este grupo etario ayudaria para la toma de decisiones terapeuticas. El objetivo es evaluar los resultados quirurgicos de resecciones pancreaticas en pacientes mayores de 70 anos. Metodos Estudio retrospectivo que incluye a pacientes tratados mediante reseccion pancreatica en el periodo 2009-2014. Se dividio la muestra en 2 grupos. G1: pacientes menores de 70 anos y G2: pacientes mayores de 70 anos. Se compararon los resultados quirurgicos en ambos grupos. Resultados Se realizaron 73 resecciones pancreaticas; 51 (70%) pacientes pertenecieron al G1 y 22 (30%) al G2. No hubo diferencias significativas entre G1 y G2 en cuanto al tiempo operatorio ni a los dias de internacion. Tampoco se obtuvo diferencia significativa en incidencia de retardo del vaciamiento gastrico, fistula pancreatica ni fistula biliar. La mortalidad global de la serie fue del 4,1%: del 2% en G1 y del 13,6% en G2 (p: 0,04). Al realizar un subanalisis en G2, la mortalidad en este grupo ocurrio unicamente en pacientes con comorbilidades significativas con ASA ≥ 3 (p: 0,004). Ambos grupos con enfermedad maligna presentaron similar sobrevida global y libre de enfermedad. Conclusiones La edad no deberia ser un factor limitante para realizar resecciones pancreaticas. Los pacientes anosos presentan similares resultados quirurgicos, y su mortalidad perioperatoria aumentada se deberia a la presencia de comorbilidades importantes asociadas, y no a la edad como variable independiente.

Introduction The proportion of elderly patients is growing rapidly. Knowing the results of pancreatic surgery in this group of patients would help surgeons to make therapeutic decisions. The objective is to evaluate the surgical outcomes of pancreatic resections in patients over 70 years. Method: Retrospective study including patients undergoing pancreatic resection during the period 2009–2014. The sample was divided into 2 groups. G1: Patients under 70 years and G2: Patients older than 70 years. Surgical results between the 2 groups were evaluated. Results Seventy-three pancreatic resections were performed, 51 (70%) patients belonged to G1 and 22 (30%) to G2. There were no significant differences between G1 and G2 in terms of operative time and hospitalisation days. No significant difference was obtained in the incidence of delayed gastric emptying, pancreatic fistula or biliary fistula. The overall mortality in the series was 4.1% showing difference between both groups, with 2% in G1 and 13.6% in G2 (P=.04). When a sub-analysis in G2 was made, mortality in this group occurred only in patients with significant comorbidities with ASA≥3 (P=.004). Both groups with oncologic disease had similar overall survival and disease-free survival. Conclusions Age should not be a limiting factor for pancreatic resections. The elderly have similar results as younger patients and their increased perioperative mortality is due to the presence of important associated comorbidities rather than age as an independent risk factor.

AIM To investigate any changing trends in the etiologies of hepatocellular carcinoma (HCC) in Argentina during the last years. METHODS A longitudinal cohort study was conducted by 14 regional hospitals starting in 2009 through 2016. All adult patients with newly diagnosed HCC either with pathology or imaging criteria were included. Patients were classified as presenting non-alcoholic fatty liver disease (NAFLD) either by histology or clinically, provided that all other etiologies of liver disease were ruled out, fatty liver was present on abdominal ultrasound and alcohol consumption was excluded. Complete follow-up was assessed in all included subjects since the date of HCC diagnosis until death or last medical visit. RESULTS A total of 708 consecutive adults with HCC were included. Six out of 14 hospitals were liver transplant centers (n = 484). The prevalence of diabetes mellitus was 27.7%. Overall, HCV was the main cause of liver disease related with HCC (37%) including cirrhotic and non-cirrhotic patients, followed by alcoholic liver disease 20.8%, NAFLD 11.4%, cryptogenic 9.6%, HBV 5.4% infection, cholestatic disease and autoimmune hepatitis 2.2%, and other causes 9.9%. A 6-fold increase in the percentage corresponding to NAFLDHCC was detected when the starting year, i.e., 2009 was compared to the last one, i.e., 2015 (4.3% vs 25.6%; P < 0.0001). Accordingly, a higher prevalence of diabetes mellitus was present in NAFLD-HCC group 61.7% when compared to other than NAFLD-HCC 23.3% (P < 0.0001). Lower median AFP values at HCC diagnosis were observed between NAFLD-HCC and non-NAFLD groups (6.6 ng/mL vs 26 ng/mL; P = 0.02). Neither NAFLD nor other HCC etiologies were associated with higher mortality. CONCLUSION The growing incidence of NAFLD-HCC documented in the United States and Europe is also observed in Argentina, a confirmation with important Public Health implications. Fil: Piñero, Federico. Hospital Universitario Austral; Argentina. Sanatorio de la Trinidad San Isidro; Argentina Fil: Pages, Josefina. Hospital Universitario Austral; Argentina Fil: Marciano, Sebastián. Hospital Italiano; Argentina Fil: Fernández, Nora. Hospital Británico de Buenos Aires; Argentina Fil: Silva, Jorge. Provincia de San Juan. Hospital Rawson; Argentina Fil: Anders, Margarita. Hospital Alemán; Argentina Fil: Zerega, Alina. Sanatorio Allende; Argentina Fil: Ridruejo, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET; Argentina Fil: Ameigeiras, Beatriz. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; Argentina Fil: D'amico, Claudia. Centro Especialidades Médicas Ambulatorias Mar del Plata; Argentina Fil: Gaite, Luis. Clínica de Nefrología de Santa Fe; Argentina Fil: Bermúdez, Carla. Hospital Italiano; Argentina Fil: Cobos, Manuel. Hospital Alemán; Argentina Fil: Rosales, Carlos. Provincia de San Juan. Hospital Rawson; Argentina Fil: Romero, Gustavo. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; Argentina Fil: McCormack, Lucas. Hospital Alemán; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Reggiardo, Virginia. Gobierno de Santa Fe. Hospital Provincial del Centenario; Argentina Fil: Colombato, Luis. Hospital Británico de Buenos Aires; Argentina Fil: Gadano, Adrián Carlos. Hospital Italiano; Argentina Fil: Silva, Marcelo. Hospital Universitario Austral; Argentina

Summary Background and aim Non-alcoholic fatty liver disease (NAFLD) is an increasing cause of hepatocellular carcinoma (HCC) and liver transplantation (LT). Our study focused on changing trends of liver related HCC etiologies during the last years in Latin America. Methods From a cohort of 2761 consecutive adult LT patients between 2005 and 2012 in 17 different centers, 435 with HCC were included. Different periods including years 2005–2006, 2007–2008, 2009–2010 and 2011–2012 were considered. Etiology of liver disease was confirmed in the explant. Results Participating LT centers per country included 2 from Brazil (n = 191), 5 transplant programs from Argentina (n = 98), 2 from Colombia (n = 65), 4 from Chile (n = 49), 2 from Mexico (n = 12), and 1 from Peru (n = 11) and Uruguay (n = 9). Chronic hepatitis C infection was the leading cause of HCC in the overall cohort (37%), followed by HBV (25%) and alcoholic liver disease (17%). NAFLD and cryptogenic cirrhosis accounted for 6% and 7%, respectively. While HCV decreased from 48% in 2005–06 to 26% in 2011–12, NAFLD increased from 1.8% to 12.8% during the same period, accounting for the third cause of HCC. This represented a 6-fold increase in NAFLD-HCC, whereas HCV had a 2-fold decrease. Patients with NAFLD were older, had lower pre-LT serum AFP values and similar 5-year survival and recurrence rates than non-NAFLD. Conclusion There might be a global changing figure regarding etiologies of HCC in Latin America. This epidemiological change on the incidence of HCC in the world, although it has been reported, should still be confirmed in prospective studies.

Resumen Introduccion El objetivo del presente trabajo ha sido investigar el impacto del Model for End-stage Liver Disease (MELD) en los costes del trasplante. Material y metodos Se incluyeron todos los pacientes que recibieron un trasplante hepatico por una enfermedad hepatica terminal entre 2006 y 2010. El periodo de estudio incluye desde el dia del trasplante hasta el alta hospitalaria. Los pacientes fueron categorizados en 2 grupos: 6 a 19 y 20 a 40. En forma arbitraria se definio como alto coste aquel que excedia el percentil 85. Se analizaron 77 pacientes. Resultados La media del puntaje MELD al momento del trasplante fue 19,2 ± 7,0 (media ± DE). La media de los costes por trasplante en el periodo mencionado fue de 33.461 USD por paciente (rango 21.795-104.629). El coste del trasplante en los pacientes que tenian un valor de MELD de 6-19 fue de 30.493 ± 8.825 USD y en aquellos con un MELD de 20-40, de 36.506 ± 15.833 USD, siendo esta diferencia estadisticamente significativa (p = 0,04). En un analisis escalonado por regresion logistica, tener un puntaje MELD 20 fue el unico predictor independiente de alto coste (OR 11,8; CI 1,6-87). En el modelo de regresion lineal, el tiempo de estancia hospitalaria fue el predictor mas relevante de coste (r 2 = 43%). Discusion Nuestros resultados demuestran que el MELD tiene un impacto directo en el coste del trasplante. Sugerimos que los sistemas de reembolso deberian compensar a los diferentes prestadores en relacion a la gravedad de la patologia de base, evaluada mediante el modelo MELD.

Organ shortage is the first cause of death on liver transplant waiting lists. As a consequence, we recently decided to expand liver acceptance to those organs that could potentially transmit infectious diseases to their recipients. On January 2010, we initiated a prospective protocol using livers from Chagas-infected donors for transplanting uninfected recipients without using prophylactic therapy. During a 13-month period, 9 of 37 (24%) liver transplants were performed within this protocol. After transplant, each recipient was sequentially and strictly monitored for infection transmission using the Strout method and promptly treated with benznidazole if this occurs. During follow-up, two patients died without Chagas infection and only two (donor-derived T. cruzi transmission rate: 2/9; 22%) patients developed donor-derived Chagas transmission without clinical symptoms. The median follow-up time of the seven live patients was 15 months (range: 13-20). At present, all are symptoms-free with excellent allograft function and without evidence of Chagas disease. In conclusion, we consider that Chagas-infected donors are a promising source of liver grafts that could reduce the growing mortality on liver waiting lists in America. Relevant data from larger prospective studies are required to confirm these preliminary excellent results.

This is the first report presenting a human immunodeficiency virus (HIV)-positive patient with fulminant hepatic failure receiving a liver graft from a Chagas disease-seropositive deceased donor. We describe the history of a 38-year-old HIV-positive female patient who developed fulminant hepatic failure of an autoimmune etiology with rapid deterioration of her clinical status and secondary multiorgan failure and, therefore, needed emergency liver transplantation (LT) as a lifesaving procedure. Because of the scarcity of organs and the high mortality rate for emergency status patients on the LT waiting list, we decided to accept a Chagas disease-seropositive deceased donor liver graft for this immunocompromised Chagas disease-seronegative patient. The recipient had a rapid postoperative recovery and was discharged on postoperative day 9 without prophylactic treatment for Chagas disease. Fifteen months after LT, she was still alive and had never experienced seroconversion on periodic screening tests for Chagas detection. Although there is an inherent risk of acute Chagas disease developing in seronegative recipients, our report suggests that these infected organs can be safely used as a lifesaving strategy for HIV patients with a high need for LT.

Takotsubo cardiomyopathy (TTC) is a rare clinical syndrome defined as a profound but reversible left ventricular dysfunction in the absence of coronary artery disease. We describe the clinical features and management of TC manifesting in the postoperative period in a patient undergoing liver transplantation. Two days after surgery, the patient developed clinical features of acute myocardial infarction. Ecochardiography revealed hypokinesis of the left ventricle. Coronary angiography revealed normal arteries without any stenosis or obstruction. The patient required vasopressor and inotropic support. The placement of intra-aortic balloon pump had a beneficial effect on the management of heart failure. The patient had a complete recovery of cardiac function 40 days after surgery. TC is a possible occurrence after liver transplant. Awareness of this condition is essential as early diagnosis and prompt management can save the patient's life.

hpb_193 523..530 Background: There is a worldwide need to expand the donor liver pool. We report a consecutive series of elective candidates for liver transplantation (LT) who received 'livers that nobody wants' (LNWs) in Argentina. Methods: Between 2006 and 2009, outcomes for patients who received LNWs were analysed and compared with outcomes for a control group. To be defined as an LNW, an organ is required to fulfil two criteria. Firstly, each liver must be officially offered and refused more than 30 times; secondly, the liver must be refused by at least 50% of the LT programmes in our country before our programme can accept it. Principal endpoints were primary graft non-function (PNF), mortality, and graft and patient survival. Results: We transplanted 26 LNWs that had been discarded by a median of 12 centres. A total of 2666 reasons for refusal had been registered. These included poor donor status (n = 1980), followed by LT centre (n = 398) or recipient (n = 288) conditions. Incidences of PNF (3.8% vs. 4.0%), in-hospital mortality (3.8% vs. 8.0%), 1-year patient (84% vs. 84%) and graft (84% vs. 80%) survival were equal in the LNW and control groups. Conclusions: Transplantable livers are unnecessarily discarded by the transplant community. External and internal supervision of the activity of each LT programme is urgently needed to guarantee high standards of excellence.

BackgroundIn 2005, the model of end-stage liver disease (MELD)-based allocation system was adopted to assess potential liver transplant (LT) recipients in Argentina. The aim of the present study was to revise the activity of the MELD Exception Experts Committee.MethodsBetween 2005 and 2009, 1623 patients were listed for LT. Regulation provides extra-MELD points for amyloidosis, hepatopulmonary syndrome (HPS) and T2 hepatocellular carcinoma (T2 HCC). Centres could also request priority for other situations. Using a prospective database, we identified patients in whom priority points were requested. Pathology reports of explanted livers were analysed for patients with T2 HCC.ResultsFrom 234 out of 1623 (14.4%) requests, the overall approval rate was 60.2% including: 2 amyloidosis, 6 HPS, 111T2 HCC and 22 non-regulated situations. Of the 111 patients with T2 HCC, 6 died (5.4%), 8 had tumour progression (7.2%), 94 were transplanted (84.2%) and 3 are still waiting. An explants correlation showed that presumed diagnosis of T2HCC was incorrect in 20/94 (22%) and was correct in only 41/94 (43%) cases being T1 HCC in 9 and T3 HCC in 23.ConclusionsMELD exceptions are frequently requested in Argentina. Unfortunately, most receiving priority points for T2 HCC benefited by medical error or imaging limitations. An intense review process is urgently needed to maintain equity and justice in the allocation system.

BackgroundIn July 2005, Argentina was the first country after the United States to adopt the MELD system. The purpose of the present study was to analyse the impact of this new system on the adult liver waiting list (WL).MethodsBetween 2005 and 2009, 1773 adult patients were listed for liver transplantation: 150 emergencies and 1623 electives. Elective patients were categorized using the MELD system. A prospective database was used to analyse mortality and probability to be transplanted (PTBT) on the WL.ResultsThe waiting time increased inversely with the MELD score and PTBT positively correlated with MELD score. With scores≥18 the PTBT remained over 50%. However, the largest MELD subgroup with fourfold probability of dying on the WL than PTBT (14.3% vs. 3%; P

Pancreatic panniculitis is an uncommon condition that can occur in association with pancreatic disease. Most of the cases reported to date were associated with acute or chronic pancreatitis and pancreas cancer. Recently, development has been described in kidney transplant patients and secondarily to allograft pancreatitis in a pancreas-kidney transplant recipient. Both findings suggest that immunological processes may be involved in the pathogenesis of this entity. We report for the first time a case of acute pancreatitis associated with pancreatic panniculitis in a patient who underwent a liver transplant 10 months before. A 69-year-old man with a history of epigastric pain of a few days of evolution was presented with painful subcutaneous nodules on both legs. Blood chemistry showed raised serum amylase and lipase levels. Ultrasonography and multislice CT scan were suggestive of an acute pancreatitis. A skin biopsy showed typical features of pancreatic panniculitis which included lobular panniculitis with lipocyte degeneration with ghost cells. The administration of octreotide resulted in both a rapid improvement of symptoms and a disappearance of skin lesions. Liver transplant specialists should be aware that the pancreatic panniculitis could be a manifestation ofpancreas disease in patients who have undergone l ver transplantation.

Background: Although there is a worldwide need to expand the pool of available liver grafts, cadaveric livers with severe steatosis (>60%) are discarded for orthotopic liver transplantation (OLT) by most centers. Methods: We analyzed patients receiving liver grafts with severe steatosis between January 2002 and September 2006. These patients were matched 1:2 with control patients without severe steatosis according to status the waiting list, recipient age, recipient body mass index (BMI), and model for end-stage liver disease (MELD) score. Primary end points were the incidence of primary graft nonfunction (PNF), and graft and patient survival. Secondary end points included primary graft dysfunction (PDF), the incidence of postoperative complications, and histologic assessment of steatosis in follow-up biopsies. We also conducted a survey on the use of grafts with severe steatosis among leading European liver transplant centers. Results: During the study period, 62 patients dropped out of the waiting list and 45 of them died due to progression of disease. Of 118 patients who received transplants 20 (17%) received a graft with severe steatosis during this period. The median degree of total liver steatosis was 90% (R = 65%-100%) for the steatotic group. The steatotic (n = 20) and matched control group (n = 40) were comparable in terms of recipient age, BMI, MELD score, and cold ischemia time. The steatotic group had a significantly higher rate of PDF and/or renal failure. Although the median intensive care unit (ICU) and hospital stay were not significantly different between both groups, the proportion of patients with long-term ICU (≥21 days) and hospital (≥40 days) stay was significantly higher for patients with a severely steatotic graft. Sixty-day mortality (5% vs. 5%) and 3-year patient survival rate (83% vs. 84%) were comparable between the control and severe steatosis group. Postoperative histologic assessment demonstrated that the median total amount of liver steatosis decreased significantly (median: 90% to 15%, P < 0.001). Our survey showed that all but one of the European centers currently reject liver grafts with severe steatosis for any recipient. Conclusion: Due to the urgent need of liver grafts, severely steatotic grafts should be no longer discarded for OLT. Maximal effort must be spent when dealing with these high-risk organs but the use of severely steatotic grafts may save the lives of many patients who would die on the waiting list.