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Background: Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of benign disease and a few patients will develop end-stage liver disease (ESLD) requiring a liver transplant (LT). Objective: Analyse the experience using LT as a definitive treatment of BDI in Argentina. Patients and Methods: A national survey regarding the experience of LT for BDI. Results: Sixteen out 18 centres reported a total of 19 patients. The percentage of LT for BDI from the total number of LT per period was: 1990-94 = 3.1%, 1995-99 = 1.6%, 2000-04 = 0.7% and 2005-09 = 0.2% ( P < 0.001). The mean age was 45.7 ± 10.3 years (range 26-62) and 10 patients were female. The BDI occurred during cholecystectomy in 16 and 7 had vascular injuries. One patient presented with acute liver failure and the others with chronic ESLD. The median time between BDI and LT was 71 months (range 0.2-157). The mean follow-up was 8.3 years (10 months to 16.4 years). Survival at 1, 3, 5 and 10 years was 73%, 68%, 68% and 45%, respectively. Conclusions: The use of LT for the treatment of BDI declined over the review period. LT plays a role in selected cases in patients with acute liver failure and ESLD. [ABSTRACT FROM AUTHOR]

Abstract: Steatotic liver grafts represent the most common type of “extended criteria” organs that have been introduced during the last two decades due to the disparity between liver transplant candidates and the number available organs. A precise definition and reliable and reproducible method for steatosis quantification is currently lacking and the potential influence of the chemical composition of hepatic lipids has not been addressed. In our view, these shortcomings appear to contribute significantly to the inconsistent results of studies reporting on graft steatosis and the outcome of liver transplantation. In this review, various definitions, prevalence and methods of quantification of liver steatosis will be covered. Ischemia/reperfusion injury of the steatotic liver and its consequences on post-transplant outcome will be discussed. Selection criteria for organ allocation and a number of emerging protective strategies are suggested. [Copyright &y& Elsevier]

Background: In 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. Methods: Between 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. Results: From 234 out of 1623 (14.4%) requests, the overall approval rate was 60.2% including: 2 amyloidosis, 6 HPS, 111 T2 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. Conclusions: MELD 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. [ABSTRACT FROM AUTHOR]

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 fulfill 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. [ABSTRACT FROM AUTHOR]

The article deals with a 57-year-old man who was diagnosed with groove pancreatitis following pancreaticoduodenectomy.

Background: 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. Methods: 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 2478 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. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: Our goal was to analyze the results of resection of colorectal cancer and liver metastases in one procedure.Study Design: Between June 1982 and July 1998, 522 patients underwent liver resection for colorectal metastases. Liver resection was performed simultaneously with colorectal resection in 71 cases, representing the population in this study. Morbidity, mortality, overall survival, and disease-free survival times were analyzed. Median followup time was 29 months (range 6 to 162 months). Prognostic factors and their influence on outcomes were analyzed.Results: The median hospital stay was 8 days (range 5 to 23 days). Morbidity was 21% and included nine pleural effusions, seven wound abscesses, four instances of hepatic failure, three systemic infections, three intraabdominal abscesses, and one colonic anastomosis leakage. Operative mortality was 0%. Recurrence rate was 57.7% (41 or 71), and progression of disease was detected in 33.8%. Overall and disease-free survivals at 1, 3, and 5 years were 88%, 45%, and 38% and 67%, 17%, and 9%, respectively. Prognostic factors with notable influence on patient outcomes were nodal stage as per TNM classification, number of liver metastases, diameter (smaller or larger than 5 cm), liver resection specimen weight (lighter or heavier than 90 g), and liver resection margin (smaller or larger than 1 cm).Conclusions: Simultaneous resection of colorectal cancer and liver metastases can be performed with low morbidity and mortality rates, avoiding a second surgical procedure. [ABSTRACT FROM AUTHOR]

Background: 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.Aims: 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.Methods: 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.Results: 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)].Conclusions: 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The physiological regulation of the liver blood flow is a result of a reciprocal portal vein and hepatic artery flow relationship. This mechanism is defined as the hepatic arterial buffer response (HABR). This study was addressed to investigate whether HABR is maintained in denervated grafts in liver transplant recipients. Portal blood flow (PBF) and hepatic arterial resistance index (PI) were measured 6 months after transplantation using Doppler. In each patient we consecutively measured the vasodilator (Ensure Plus PO versus placebo) and vasoconstrictor (isosorbide dinitrate 5 mg SL versus placebo) stimuli. The meal ingestion caused a significant increase of both parameters, PBF (from 1495 ± 260 to 2069 ± 250 mL/min, P < 0.05) and PI (from 0.7 ± 0.2 to 0.8 ± 0.2, P < 0.05). By contrast, isosorbide dinitrate reduced PBF (from 1660 ± 270 to 1397 ± 250 mL/min, P < 0.05) and PI (from 0.7 ± 0.2 to 0.5 ± 0.2, P < 0.05). We show that PBF and PI are reciprocally modified with the administration of vasoconstrictor and vasodilator stimuli. These results suggest the persistence of the HABR in a denervated human model, suggesting that this mechanism is independent of the regulation from the autonomic nervous system. [ABSTRACT FROM AUTHOR]

Background. Significant amounts of red blood cells (RBCs) transfusions are associated with poor outcome after liver transplantation (LT). We report our series of LT without perioperative RBC (P-RBC) transfusions to evaluate its influence on early and long-term outcomes following LT. Methods. A consecutive series of LT between 2006 and 2011 was analyzed. P-RBC transfusion was defined as one or more RBC units administrated during or ≤48 hours after LT. We divided the cohort in "No-Transfusion" and "Yes-Transfusion." Preoperative status, graft quality, and intra- and postoperative variables were compared to assess P-RBC transfusion risk factors and postoperative outcome. Results. LT was performed in 127 patients ("No-Transfusion" = 39 versus "Yes-Transfusion" = 88).While median MELD was significantly higher in Yes-Transfusion (11 versus 21; P = 0.0001) group, platelet count, prothrombin time, and hemoglobin were significantly lower. On multivariate analysis, the unique independent risk factor associated with P-RBC transfusions was preoperative hemoglobin (P < 0.001). Incidence of postoperative bacterial infections (10 versus 27%; P = 0.03), median ICU (2 versus 3 days; P = 0.03), and hospital stay (7.5 versus 9 days; P = 0.01) were negatively influenced by P-RBC transfusions. However, 30-day mortality (10 versus 15%) and one- (86 versus 70%) and 3-year (77 versus 66%) survival were equivalent in both groups. Conclusions. Recipient MELD score was not a predictive factor for P-RBC transfusion. Patients requiring P-RBC transfusions had worse postoperative outcome. Therefore, maximum efforts must be focused on improving hemoglobin levels during waiting list time to prevent using P-RBC in LT recipients. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate a new three-dimensional gradient-echo (GRE) MR sequence performed with a parallel acquisition technique to shorten breath-hold times (parallel GRE MRI) in the detection of arterial variants and stenosis of the abdominal aorta and its visceral branches. A total of 102 patients underwent dynamic parallel GRE MRI, timed to the arterial phase by a test bolus (mean breath-hold time, 17 s). For both quantitative and qualitative analysis, the abdominal aorta and its visceral branches were divided into 13 arterial segments. In a subanalysis of 55/102 patients, the accuracy of parallel GRE MRI compared to MDCT in the detection arterial variants and stenosis was calculated for two independent readers. Mean SNRs and CNRs were 47.2 and 35.6, respectively. Image quality was rated good or excellent in 1,234/1,326 segments (93%). Hepatic and renal arterial variants were identified with an accuracy of 93 and 95%, respectively (reader 1) and 98 and 100%, respectively (reader 2). Both readers detected arterial stenosis with an accuracy of 98%. Interobserver agreement was good to excellent for the detection of hepatic (kappa=0.69) and renal (kappa=0.92) variants and for the diagnosis of stenosis (kappa=0.96). Dynamic three-dimensional parallel GRE MRI is feasible and allows a reliable and accurate diagnosis of arterial variants and stenosis of the abdominal aorta and its visceral branches in a short breath-hold-time. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare respiratory-triggered balanced steady-state free precession (bSSFP) with breath-hold contrast-enhanced dynamic two-dimensional (2D) gradient-echo (GRE) and time-of-flight (TOF) magnetic resonance imaging (MRI) for portal and hepatic vein visualization and assessment of portal and hepatic venous variants. Sixty patients with liver disease underwent nonenhanced bSSFP and contrast-enhanced GRE, bSSFP, and TOF imaging. Contrast-to-noise ratios (CNRs) for portal and hepatic veins were measured. Two readers rated the quality of portal and hepatic vein visualization on a 5-point Likert scale. The diagnostic performance of each MRI series in the detection of portal and hepatic venous variants was assessed in 40/60 patients who also underwent contrast-enhanced multidetector-row computed tomography (MDCT). CNRs for portal and hepatic veins were highest on contrast-enhanced bSSFP images. Image quality of portal and hepatic veins was rated higher for nonenhanced bSSFP than for contrast-enhanced GRE (p<0.03) and TOF (p<0.003) and higher for contrast-enhanced than for nonenhanced bSSFP (p<0.003). Compared with MDCT, portal and hepatic venous variants were identified with an accuracy of 99% on bSSFP images, with an excellent interobserver agreement (kappa=0.97). Compared with MDCT, presence of surgically important portal and hepatic venous anatomical variants can be predicted with high accuracy on bSSFP images. [ABSTRACT FROM AUTHOR]

Liver transplantation (LT) remains the only cure for hepatocellular carcinoma (HCC) in many cases. Over many years, most centers have applied the Milan criteria for selecting cirrhotic patients with HCC for LT. In a new era where several transplant groups are pushing the limits of transplanting HCC outside Milan criteria as an aggressive approach with promising results, we present interesting images of a patient that presented a unique and rare site of HCC metastasis after 36 months of liver transplantation. [ABSTRACT FROM AUTHOR]