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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

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p

INTRODUCTION Simultaneous pancreas-kidney (SPK) transplant is a proven option of treatment for patients with type 1 diabetes mellitus and related end-stage renal disease, who are candidates for kidney transplantation. The results from the beginning of SPK transplant program in Comunidad Valenciana are presented. METHODS Descriptive, retrospective, and single-center study of the pancreas transplant performed at the Hospital Universitari i Politecnic La Fe, from September 2002 to December 2015. Clinical variables from donors and recipients, peri-operative variables, patient survival, and pancreatic graft survival were collected. RESULTS Eighty-one patients with type 1 diabetes mellitus (48 males and 33 females, mean age 37.4 ± 5.7 years, mean BMI 24.1 ± 3.4 kg/m2, mean duration of diabetes 25.5 ± 6.5 years) received SPK transplantation. The overall patient survival at one, 3, and 5 years were 91.3%, 91.3% and 89.5%, respectively. However, patient survival in the periods 2002-2008 and 2009-2015 were 88.2% and 93.6% at one year, 88.2% and 93.7% at 3 years, and 85.3% and 93.7% at 5 years, respectively (P = 1). The overall pancreatic graft survival at one, 3, and 5 years were 75.2%, 69.1% and 63.2%, respectively. On the other hand, pancreatic graft survival in the periods 2002-2008 and 2009-2015 were 67.5% and 80.6% at one year, 64.7% and 71.8% at 3 years, and 58.8% and 65.3% at 5 years, respectively (P = .0109). Post-transplant complications were: graft rejection 8.6%, venous graft thrombosis 7.4%, graft pancreatitis 4.9%. CONCLUSIONS In 13 years' experience of SPK transplantation, patient and pancreatic graft survival and the rate of complications after pancreas transplantation were similar to those of other larger series. The medical-surgical team experience improves pancreatic graft survival without influencing patient survival.

Resumen Introduccion El trasplante simultaneo de pancreas-rinon (SPK, por simultaneous pancreas kidney) es una opcion terapeutica valida en pacientes afectos de diabetes mellitus tipo 1 con enfermedad renal cronica terminal que son candidatos a trasplante renal. Se presentan los resultados desde el inicio del programa de trasplante SPK en la Comunidad Valenciana. Metodos Estudio descriptivo, retrospectivo y unicentrico de los trasplantes de pancreas realizados en el Hospital Universitari i Politecnic La Fe, desde septiembre de 2002 a diciembre de 2015. Se recogieron variables clinicas de los donantes y receptores, variables peri-operatorias y supervivencia del paciente y del injerto pancreatico. Resultados Ochenta y un pacientes con diabetes mellitus tipo 1 (48 hombres y 33 mujeres, de 37,4 ± 5,7 anos, IMC de 24,1 ± 3,4 kg/m2, con una duracion de su diabetes de 25,5 ± 6,5 anos) recibieron un trasplante SPK. La supervivencia global del paciente a uno, 3 y 5 anos fue del 91,3, el 91,3 y el 89,5%, respectivamente. Sin embargo, la supervivencia del paciente en los periodos 2002-2008 y 2009-2015 fue del 88,2 y el 93,6% al ano, del 88,2 y el 93,7% a los 3 anos, y del 85,3 y el 93,7% a los 5 anos, respectivamente (p = 1). La supervivencia global del injerto pancreatico a uno, 3 y 5 anos fue del 75,2, el 69,1 y el 63,2%, respectivamente. Por otra parte, la supervivencia del injerto pancreatico en los periodos 2002-2008 y 2009-2015 fue del 67,5 y el 80,6% al ano, del 64,7 y el 71,8% a los 3 anos, y del 58,8 y el 65,3% a los 5 anos, respectivamente (p = 0,0109). Las complicaciones postrasplante fueron: rechazo del injerto en un 8,6%, trombosis venosa del injerto en un 7,4% y pancreatitis del injerto en un 4,9%. Conclusiones En 13 anos de experiencia en trasplante SPK, la supervivencia del paciente y del injerto pancreatico y la tasa de complicaciones tras el trasplante de pancreas son similares a las de otras series de mayor tamano. La experiencia del equipo medico-quirurgico mejora la supervivencia del injerto pancreatico, sin influir en la supervivencia del paciente.

Background: Simultaneous pancreas-kidney transplantation (SPK) is still characterized by high rates of postoperative complications. This study aims to offer an in-depth characterization of short-, medium- and long-term complications following SPK to derive insights for postoperative management and follow-up.Methods: Consecutive SPK transplantations were analysed. Pancreatic graft (P-graft)- and kidney graft (K-graft)-related complications were analysed separately. The global postoperative course was assessed in three timeframes (early, medium-term, and late) using the comprehensive complication index (CCI). Predictors of complications and early graft loss were explored.Results: Complications occurred in 61.2% of patients, and the 90-day mortality was 3.9%. The overall burden of complications was significantly high during admission (CCI 22.4 ± 21.1) and decreased gradually afterwards. P-graft-related complications burdened the most in the early postoperative course (CCI 11.6 ± 13.8); postoperative ileus and perigraft fluid collection were the most frequent complications, and pseudoaneurysms, haemorrhages, and bowel leaks were the major concerns. K-related complications were milder but represented the largest proportion of the CCI in the late postoperative timeframe (CCI 7.6 ± 13.6). No predictors of P-graft- or K-graft-related complications were found. Conclusion: Pancreas graft-related complications represent the largest part of the clinical burden in the early postoperative timeframe but are negligible after 3 months. Kidney grafts have a relevant impact in the long term. The multidisciplinary approach to SPK recipients should be driven based on all graft-specific complications and tailored on a time-dependent basis.

To summarize the long-term complications after pancreas transplantation that affect graft function, a literature search was carried out on the long-term complications of pancreatic transplantation, namely, complications from postoperative 3rd mo onwards, in terms of loss of graft function, late infection and vascular complications as pseudoaneurysms. The most relevant reviews and studies were selected to obtain the current evidence on these topics. The definition of graft failure varies among different studies, so it is difficult to evaluate, a standardized definition is of utmost importance to know the magnitude of the problem in all worldwide series. Chronic rejection is the main cause of long-term graft failure, occurring in 10% of patients. From the 3rd mo of transplantation onwards, the main risk factor for late infections is immunosuppression, and patients have opportunistic infections like: Cytomegalovirus, hepatitis B and C viruses, Epstein-Barr virus and varicella-zoster virus; opportunistic bacteria, reactivation of latent infections as tuberculosis or fungal infections. Complete preoperative studies and serological tests should be made in all recipients to avoid these infections, adding perioperative prophylactic treatments when indicated. Pseudoaneurysm are uncommon, but one of the main causes of late bleeding, which can be fatal. The treatment should be performed with radiological endovascular approaches or open surgery in case of failure. Despite all therapeutic options for the complications mentioned above, transplantectomy is a necessary option in approximately 50% of relaparotomies, especially in life-threatening complications. Late complications in pancreatic transplantation threatens long-term graft function. An exhaustive follow-up as well as a correct immunosuppression protocol are necessary for prevention.

Indications and outcomes of extended pancreatectomies have been recently appraised by the International Study Group for Pancreatic Surgery. However, no definitive conclusions have been drawn, particularly in the setting of neoadjuvant treatments. We present here a case of 53-year-old man diagnosed with a bulky adenocarcinoma of the tail of the pancreas and infiltrating the adjacent organs and the thoracic wall. The patient was sent to neoadjuvant chemotherapy and he underwent 12 cycles of FOLFIRINOX. Since a significant radiological response was observed after chemotherapy, the patient was scheduled for extended distal pancreatectomy with en bloc resection of the thoracic wall, in order to achieve a radical resection. The surgery is herein described with all technical details. The patient was discharged after an uneventful early post-operative course and subsequently readmitted for a late grade B post-operative pancreatic fistula, which was ultimately treated successfully. Pathology showed complete response. When performed in centers with ample experience in pancreatic surgery, extended pancreatic resections represent a viable curative option with acceptable surgical outcomes. In this setting, challenging tailored resections should be considered to achieve negative margins, particularly following maximized effective downstaging strategies.

Metabolic syndrome (MS) and cardiovascular risk factors are common in liver transplant (LT) candidates and recipients. Cardiovascular events and de novo tumors are increasingly common causes of mortality in liver transplant recipients. The aim of this study were (i) assess the prevalence of MS in LT recipients and its growth over the years and (ii) determine if the presence of MS pre-LT is associated with a higher risk of post-LT cardiovascular events (CVE), de novo tumors or early and late survival.A retrospective study was performed that included LT recipients from January 2012 to December 2017. Baseline features (MS before LT and at 1year post-LT) and outcomes (CVE, de novo tumors and survival) were recorded.483 recipients were included, MS was present in 20% of pre-LT with an increasing prevalence over time, from 16% in 2012 to 34% in 2017 (p=0.025). One-year post-LT, an additional 12% had developed de novo MS. At a median of 56-months follow-up, 13% developed a CVE and 9% a de novo tumor. One and 5-yr survival rates were 91% and 83% in those with pre-LT MS and 93% and 85% in those without (p=0.94).The presence of MS before LT was independently associated with a higher risk of post-LT CVE (HR: 2.66 IC (95%): 1.6-4.4 p0.001), but not with de novo tumors (p=0.94) nor early and late survival (p=0.58 and p=0.87).Pre-LT MS is increasing among LT candidates and is associated with a higher risk of post-LT morbidity CVE yet without affecting mortality. .

A definition of pancreatic fistula specifically addressing pancreas transplantation (PT) is lacking. This study sought to characterize pancreatic fistula in this setting and to define its clinical relevance on the postoperative course and long-term graft survival (GS).Consecutive simultaneous pancreas and kidney transplantations were analysed. The global postoperative course was assessed through the comprehensive complication index (CCI). PF was defined according to the original International Study Group for Pancreatic Surgery (ISGPS) definition. Predictors of poor postoperative course and GS were explored.Seventy-eight patients were analysed. Surgical morbidity was 48.7%, with severe complications occurring in 39.7%. Ninety-day mortality was 2.6%. PF occurred in 56.6% of patients, although its average clinical burden was low and did not correlate with either early or long-term outcomes. Peri-graft fluid collections, postoperative day (POD) 1 drain fluid amylase (DFA) ≥ 2200 U/L, and POD 5 DFA/serum amylase ratio ≥7.0 independently correlated with poor postoperative course. Perigraft fluid collections were associated with reduced GS.Conventionally defined pancreatic fistula is frequent following PT, although its clinical impact is negligible. To define clinically relevant PF, novel cut-offs for DFA might be pondered in a future series, while perigraft fluid collections should be strongly considered.

Introduction: The access of surgeons to liver transplant teams in Spain is heterogeneous. This study aims to portray the current human resources of Spanish transplant teams, distribution of transplant duties among team members, how transplant team members acquire their skills, their leaders' view of their future, as well the motivations of Spanish General Surgery residents to choose transplantation as their future career choice. Methods: Two different surveys were created, one for head surgeons and one for residents, about the number of team members and their training, recruitment, organization of tasks and motivation to work in transplantation. The questionnaires were e-mailed to both the transplant program directors and the surgical residents. Results: There are on average 8 surgeons in each transplant unit. More than four surgeons perform the hepatectomy in 54.2% of the groups, while the graft implantation is performed by more than 4 surgeons at just 25% of the centers. Forty-two percent of the transplant chiefs advocated a fellowship training system, and 87.5% believe that generational turnover is guaranteed. Out of 525 residents, 101 responded. Regarding training, 12.8% had no interest in transplantation. Concerning their work preferences, 37.6% were not interested in transplantation because it is excessively demanding, and 52.5% would not like to be part of a liver transplant team in the future. Conclusions: The generational turnover seems to be guaranteed according to liver transplant program directors. The new generations of surgeons generally opt for other areas of surgery other than transplantation. Studies with a greater number of responses are necessary to validate these results (C) 2019 AEC. Published by Elsevier Espana, S.L.U. All rights reserved.

Resumen Introduccion El acceso de los cirujanos a los equipos de trasplante hepatico en Espana se realiza de manera heterogenea. El objetivo de este estudio ha sido cuantificar los recursos humanos de los equipos de trasplante espanoles, la distribucion de las diferentes tareas del trasplante entre los miembros del equipo, el mecanismo mediante el cual se adquieren las habilidades, la vision de sus lideres sobre su continuidad, asi como las motivaciones de los residentes de cirugia general espanoles para elegir el trasplante como su futura carrera profesional. Metodos Se elaboraron dos encuestas diferentes, para los jefes de equipo y para residentes, sobre numero de personas, capacitacion, reclutamiento, organizacion de tareas y motivacion para trabajar en trasplantes. Los cuestionarios se enviaron por correo electronico tanto a los directores de programa de trasplante como a los residentes de cirugia. Resultados Hay en promedio 8 cirujanos en cada unidad de trasplante. Mas de 4 cirujanos realizan la hepatectomia en el 54,2% de los grupos, mientras que el implante lo realiza mas de 4 cirujanos en solo el 25% de los centros. El 42% de los jefes de trasplante hepatico aboga por un sistema tipo fellowship y el 87,5% cree que el recambio generacional esta garantizado. De los 525 residentes, 101 respondieron. Respecto a la formacion, un 12,8% no tiene interes en el trasplante. En cuanto a sus preferencias laborales, el 37,6% no esta interesado en el trasplante por ser excesivamente exigente, y el 52,5% no desea ser parte de un equipo de trasplante de higado en el futuro. Conclusiones El recambio generacional parece estar garantizado segun los directores de programa de trasplante de higado. Las nuevas generaciones de cirujanos generalmente optan por otras areas de cirugia diferentes al trasplante. Son necesarios estudios con mayor numero de respuestas para validar estos resultados.

Resumen Introduccion Los buenos resultados obtenidos con la implementacion de los programas de colecistectomia laparoscopica ambulatoria han llevado a la ampliacion de los criterios iniciales de inclusion. Como objetivo principal planteamos evaluar los resultados y el grado de satisfaccion de los pacientes incluidos en un programa de colecistectomia laparoscopica sin ingreso, con criterios expandidos. Metodos Estudio observacional de una cohorte de 260 pacientes intervenidos de colecistectomia laparoscopica ambulatoria entre abril del 2013 y marzo del 2016 en un hospital de tercer nivel. Clasificamos a los pacientes en 2 grupos en funcion del cumplimiento de los criterios iniciales de inclusion del programa ambulatorio. El grupo i (criterios restrictivos) incluye a 164 pacientes, mientras que, en el grupo ii , se incluyen 96 pacientes (criterios expandidos: no cumplian alguno de los criterios de seleccion). Comparamos el tiempo quirurgico, la tasa de ingresos no deseados, tasa de conversion, reintervenciones, mortalidad y el indice de satisfaccion. Resultados El porcentaje global de exito de la colecistectomia laparoscopica ambulatoria fue del 92,8%. La causa mas frecuente de ingresos no esperados fue por causas medicas. No se objetivaron diferencias estadisticamente significativas entre los 2 grupos en la duracion del procedimiento quirurgico, en la tasa de conversion a cirugia abierta, ni en el numero de complicaciones mayores posquirurgicas. Cumplimentaron la encuesta el 88,5% de los pacientes, no encontrando diferencias entre los 2 grupos en el indice de satisfaccion de los pacientes. La calificacion global del proceso fue significativamente mejor en el grupo ii (p = 0,023). Conclusiones La colecistectomia laparoscopica ambulatoria es un procedimiento seguro y con una buena aceptacion por parte del grupo de pacientes con criterios expandidos que fueron incluidos en el programa de cirugia sin ingreso.

Background: Hepatectomy in patients with large tumor load may result in postoperative liver failure and associated complications due to excessive liver parenchyma removal. Conventional two-stage hepatectomy (TSH) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique are possible solutions to this problem. Colorectal liver metastases (CRLM) is the most frequent indication, and there is a need to assess outcomes for both techniques to improve surgical and long-term oncological outcomes in these patients. Methods: A single-center retrospective study was designed to compare TSH with ALPPS in patients with initially unresectable bilateral liver tumors between January 2005 and January 2020. ALPPS was performed from January 2012 onwards as the technique of choice. Long-term overall survival (OS) and disease-free survival (DFS) were evaluated as primary outcome in CRLM patients. Postoperative morbidity, mortality and liver growth in all patients were also evaluated. Results: A total of 38 staged hepatectomies were performed: 17 TSH and 21 ALPPS. Complete resection rate was 76.5% ( n = 13) in the TSH group and 85.7% ( n = 18) in the ALPPS group ( P = 0.426). Overall major morbidity (Clavien-Dindo >= 3a) (stage 1 + stage 2) was 41.2% ( n = 7) in TSH and 33.3% ( n = 7) in ALPPS patients ( P = 0.389), and perioperative 90-day mortalities were 11.8% ( n = 2) vs. 19.0% ( n = 4) in each group, respectively ( P = 0.654). Intention-to-treat OS rates at 1 and 5 years in CRLM patients for TSH ( n = 15) were 80% and 33%, and for ALPPS ( n = 17) 76% and 35%, respectively. DFS rates at 1 and 5 years were 36% and 27% in the TSH group vs. 33% and 27% in the ALPPS group, respectively. Conclusions: ALPPS is an effective alternative to TSH in bilateral affecting liver tumors, allowing higher resection rate, but patients must be carefully selected. In CRLM patients similar long-term OS and DFS can be achieved with both techniques. (c) 2021 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.

BACKGROUND N-acetylcysteine infusions have been widely used to reduce ischemia/reperfusion damage to the liver; however, convincing evidence of their benefits is lacking. OBJECTIVE To perform the largest randomized controlled trial to compare the impact of N-acetylcysteine infusion during liver procurement on liver transplant outcomes. METHODS Single center, randomized trial with patients recruited from La Fe University Hospital, Spain, from February 2012 to January 2016. A total of 214 grafts were transplanted and randomized to the N-acetylcysteine group (n = 113) or to the standard protocol without N-acetylcysteine (n = 101). The primary endpoint was allograft dysfunction (Olthoff criteria). Secondary outcomes included metabolomic biomarkers of oxidative stress levels, interactions between cold ischemia time and alanine aminotransferase level and graft and patient survival (ID no. NCT01866644). RESULTS The incidence of primary dysfunction was 34% (31% in the N-acetylcysteine group and 37.4% in the control group [P = 0.38]). N-acetylcysteine administration reduced the alanine aminotransferase level when cold ischemia time was longer than 6 h (P = 0.0125). Oxidative metabolites (glutathione/oxidized glutathione and ophthalmic acid) were similar in both groups (P > 0.05). Graft and patient survival rates at 12 mo and 3 y were similar between groups (P = 0.54 and P = 0.69, respectively). CONCLUSIONS N-acetylcysteine administration during liver procurement does not improve early allograft dysfunction according to the Olthoff classification. However, when cold ischemia time is longer than 6 h, N-acetylcysteine improves postoperative ALT levels.

The portal venous aneurysm(PVA) is a very rare entity, which can be congenital or acquired (if portal hypertension, cirrhosis, pancreatitis, surgical history). Although the discussion is still ongoing, treatment would be indicated in symptomatic PVA, over 30mm or progressive growth. In order to provide an update on the subject due to the low incidence of this finding, we present the case of a 51-year-old woman who comes to the ER for painful obstructive jaundice; the ultrasound shows the presence of cholelitiasis and choledicolitiasis and identifies a nodular image in continuity with the right portal branch of 25x22x21 mm. This dilation is confirmed by MRI. After committee evaluation, follow-up was decided and to reserve the possibility of embolization if growth or symptomatology appeared.

Simultaneous pancreas-kidney (SPK) transplant is a proven option of treatment for patients with type 1 diabetes mellitus and related end-stage renal disease, who are candidates for kidney transplantation. The results from the beginning of SPK transplant program in Comunidad Valenciana are presented.Descriptive, retrospective, and single-center study of the pancreas transplant performed at the Hospital Universitari i Politècnic La Fe, from September 2002 to December 2015. Clinical variables from donors and recipients, peri-operative variables, patient survival, and pancreatic graft survival were collected.Eighty-one patients with type 1 diabetes mellitus (48 males and 33 females, mean age 37.4±5.7 years, mean BMI 24.1±3.4kg/mIn 13-year's experience of SPK transplantation, patient and pancreatic graft survival and the rate of complications after pancreas transplantation were similar to those of other larger series. The medical-surgical team experience improves pancreatic graft survival without influencing patient survival.

Background. Simultaneous pancreas-kidney (SPK) transplantation is a proven option of treatment for patients with type 1 diabetes mellitus (T1DM) and related end-stage renal disease. There is discrepancy between the results of different studies about the impact of prolonged normalization of glucose metabolism achieved by SPK on the course of diabetic complications including severe forms of diabetic neuropathy. The objective of the study was to evaluate the prevalence of cardiovascular autonomic neuropathy (CAN) in patients undergoing SPK transplantation and its evolution 10 years after transplantation. Methods. Prospective study of 81 patients transplanted in a single center from year 2002 to 2015. Autonomic function was assessed using cardiovascular autonomic reflex tests (CARTs). CARTs were made before SPK transplantation and during the follow-up. Evolution of tests after SPK transplantation was evaluated by contrasting hypotheses (paired tests). Multiple testing was adjusted with the Benjamini-Hochberg procedure with a false discovery rate of 10%. Results. 48 males and 33 females, mean age 37.4±5.7 years, mean BMI 24.0±3.4 kg/m2, and mean duration of diabetes 25.5±6.5 years, received SPK transplantation. Ten years after SPK transplantation, 56 patients re tained the pancreatic graft (42 of them with normofunctioning pancreas and 14 with low doses of insulin therapy). These 42 patients were selected for the autonomic study. Before transplant procedure, all CART results were abnormal. After SPK transplantation, paired test analysis showed an improvement of systolic blood pressure (SBP) response to orthostasis at the 5th year after SPK (p=0.03), as well as improvement of the Valsalva ratio at the 3rd (p<0.001) and 5th (p=0.001) year after SPK. After correcting for the false discovery rate, all the variables of autonomic study reached significance at different time points. Conclusions. Prevalence of CAN in patients who are candidates for SPK transplantation is high and is generally advanced. SPK transplantation improves CAN with improved Valsalva ratio as the most precocious test.

AIM Liver transplantation is the only curative strategy for final stage liver diseases. Despite the great advances achieved during the last 20 years, the recipient immune response after transplantation is not entirely controlled. This results in high rates of acute cell rejection and, approximately, 10% of early mortality. Therapeutic treatment could be improved by efficiently transfecting genes that encode natural immunosuppressant proteins, employing safe procedures that could be transferred to clinical setting. In this sense, interleukin 10 plays a central role in immune tolerance response by acting at different levels. METHODS hIL10 gene was hydrofected by retrograde hydrodynamic injection in pig liver with complete vascular exclusion mediated by an 'in vivo' surgical procedure. Levels of IL10 DNA, RNA and protein were determined within liver tissue 1 and 10 days after the injection and, more frequently, also the interleukin-10 protein in peripheral blood. RESULTS The procedure was safe for the animals and neither hemodynamic parameters nor liver function determinations showed relevant alterations. The hIL10 hydrofection in watertight liver mediated efficient gene transfer and this was transcribed and translated to protein, achieving up to 110 pg/ml of IL10 in peripheral blood. This value is close to that considered able to reduce the activity of TNFα by half (IL10 IC50 for TNFα = 124 pg/ml). CONCLUSIONS Results of this work suggest that IL10 liver hydrofection with vascular exclusion in vivo is a safe and transferable procedure that mediates plasma protein levels with potential clinical interest in immune modulation after transplantation.

Post-transplant lymphoproliferative disorders (PTLD) are a rare complication after both solid organ (SOT) and allogeneic hematopoietic stem cell transplantation (allo-HSCT). In this single center retrospective study, we compared clinical, biological, and histological features, and outcomes of PTLD after both types of transplant. We identified 82 PTLD (61 after SOT and 21 after allo-HSCT). The presence of B symptoms, Waldeyer ring, spleen, central nervous system, and liver involvement, and advanced Ann-Arbor stage were more frequent in allo-HSCT recipients. PTLD had an earlier onset in allo-HSCT than in SOT cohort (4 vs. 64 months, p .0001). PTLD was EBV-positive in 100% of allo-HSCT, in contrast to 47% of SOT (p = .0002). Four years after PTLD diagnosis, median overall survival was 32% (95% CI, 22-48) and 10% (95% CI, 2-49) in SOT and allo-HSCT recipients, respectively (p = .002). In conclusion, the clinical presentation and the outcome of PTLD varies greatly depending on the type of transplant.

Resumen Es bien aceptado por la comunidad quirurgica que la colecistectomia laparoscopica (CL) es la tecnica de eleccion en el tratamiento de la colelitiasis sintomatica. Sin embargo, mas controvertida es la estandarizacion de su realizacion en regimen de cirugia mayor ambulatoria (CMA) por las diversas connotaciones que presenta. Este articulo tiene por objeto actualizar los factores influyentes en la realizacion de la CL en regimen de cirugia sin ingreso, analizando estos 25 anos desde su implantacion, incidiendo en la calidad y aceptacion del proceso por parte del paciente. Es fundamental la individualizacion del proceso: un estricto criterio de seleccion de pacientes y la realizacion por equipos con experiencia en CL, son factores que aseguran una alta garantia de exito

It is accepted by the surgical community that laparoscopic cholecystectomy (LC) is the technique of choice in the treatment of symptomatic cholelithiasis. However, more controversial is the standardization of system implementation in Ambulatory Surgery because of its different different connotations. This article aims to update the factors that influence the performance of LC in day surgery, analyzing the 25 years since its implementation, focusing on the quality and acceptance by the patient. Individualization is essential: patient selection criteria and the implementation by experienced teams in LC, are factors that ensure high guarantee of success.

Liver transplantation is a treatment that significantly improves the patients' quality of life. However, we should be more ambitious and seek an improvement in their fitness through training protocols allowing them to fully return to daily activities. English and Spanish-language articles on PubMed and the Cochrane Library were searched untill 2014. Articles were reviewed by 2 of the authors to determine if they were suitable for inclusion. It is shown a compilation of studies that included patients who have participated in aerobic, strength, or both combined training programs, without implying a risk for the graft function. There is a lack of studies with high scientific evidence that stablish a proper exercise program methodology, supervised by specialists in physical activity and sports.

Resumen El trasplante hepatico es un tratamiento que ha permitido mejorar de manera significativa la calidad de vida de los pacientes. Sin embargo, se debe ser mas ambiciosos y buscar una mejora de su condicion fisica a traves de protocolos de entrenamiento que permitan una reincorporacion total a las actividades de la vida diaria. Se buscaron articulos en los idiomas espanol e ingles, en las bases de datos PubMed y Cochrane, hasta el ano 2014. Todos los articulos fueron revisados por 2 autores para determinar si eran apropiados para su inclusion. Se muestra una recopilacion de estudios donde se consiguen mejoras en el estado fisico de pacientes que han participado en programas de entrenamiento aerobico, de fuerza, o en combinacion de ambos, sin que esto suponga un riesgo para el injerto. No obstante, existe una falta de trabajos de alta evidencia cientifica, que establezcan una correcta programacion del ejercicio, tutorizada por especialistas en la actividad fisica y el deporte.

[Background & Aims] Although there is increasing interest in its use, definitive evidence demonstrating a benefit for postmortem normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation is lacking. The aim of this study was to compare results of cDCD liver transplants performed with postmortem NRP vs. super-rapid recovery (SRR), the current standard for cDCD., [Methods] This was an observational cohort study including all cDCD liver transplants performed in Spain between June 2012 and December 2016, with follow-up ending in December 2017. Each donor hospital determined whether organ recovery was performed using NRP or SRR. The propensity scores technique based on the inverse probability of treatment weighting (IPTW) was used to balance covariates across study groups; logistic and Cox regression models were used for binary and time-to-event outcomes., [Results] During the study period, there were 95 cDCD liver transplants performed with postmortem NRP and 117 with SRR. The median donor age was 56 years (interquartile range 45–65 years). After IPTW analysis, baseline covariates were balanced, with all absolute standardised differences, [Conclusions] The use of postmortem NRP in cDCD liver transplantation appears to reduce postoperative biliary complications, ischaemic type biliary lesions and graft loss, and allows for the transplantation of livers even from cDCD donors of advanced age., [Lay summary] This is a propensity-matched nationwide observational cohort study performed using livers recovered from donors undergoing cardiac arrest provoked by the intentional withdrawal of life support (controlled donation after circulatory death, cDCD). Approximately half of the livers were recovered after a period of postmortem in situ normothermic regional perfusion, which restored warm oxygenated blood to the abdominal organs, whereas the remainder were recovered after rapid preservation with a cold solution. The study results suggest that the use of postmortem normothermic regional perfusion helps reduce rates of post-transplant biliary complications and graft loss and allows for the successful transplantation of livers from older cDCD donors.

Background and Aims T-tube placement during choledochocholedochostomy (CCS) associated with liver transplantation (LT) remains controversial. This study was designed to validate the results of an earlier prospective randomized controlled trial (RCT) on use versus nonuse of the T-tube during CCS associated with LT. Methods Prospective cohort study. The primary outcome was the overall incidence of biliary complications (BCs). Results In total, 405 patients were included, and the median overall monitoring period was 29 months (interquartile range: 13–47 months). Selective use of the T-tube reduced BCs (23% vs 13%; P = .003), of which 75% were type IIIa or less in the Clavien-Dindo classification. The overall BC rate did not differ between patients with versus without T-tube placement. Conclusions We confirmed that selective use of a rubber T-tube during CCS associated with LT, following the principles established in our prospective RCT, reduced the rate of BC by 10% without detriment, even after enrolling patients at an a priori greater risk of BCs than were the RCT patients.

[EN] In this paper, a method to in vivo estimate the relative stifness between a hepatic lesion and the liver parenchyma is presented. Tis method is based on the fnite element simulation of the deformation that the liver undergoes during the breathing process. Boundary conditions are obtained through a registration algorithm known as Coherent Point Drif (CPD), which compares the liver form in two phases of the breathing process. Finally, the relative stifness of the tumour with respect to the liver parenchyma is calculated by means of a Genetic Algorithm, which does a blind search of this parameter. Te relative stifness together with the clinical information of the patient can be used to establish the type of hepatic lesion. Te developed methodology was frst applied to a test case, i.e., to a control case where the parameters were known, in order to verify its validity. Afer that, the method was applied to two real cases and low errors were obtained., This work has been funded by the Spanish Ministry of Economy and Competitiveness (MINECO) through research projects DPI2013-40859-R and TIN2014-52033-R, both also supported by European FEDER funds.

HVOO following liver transplantation is rarely treated surgically because it tends to debut subacutely. However, acute HVOO is a surgical emergency that compromises the viability of the graft. We report a case of HVOO diagnosed intra-operatively during surgical revision for a suspected arterial thrombosis in a 10-month-old male recipient of a second graft (segments II-III) for familial intrahepatic cholestasis. HVOO was related to a stenosis at the first transplant hepato-caval anastomosis, left in place to obtain longer venous cuffs for retransplantation. An anterior cavoplasty was necessary to resolve the issue. The new anastomosis was created under total vascular exclusion after gaining control of the supradiaphragmatic vena cava, because the inferior vena cava was unsuitable for further surgery. This approach (normally used as a means to avoid sternotomy in patients with hepatic or renal tumours associated with venous thrombosis) allows adequate vascular control and, in selected cases, offers a surgical alternative for treating HVOO.

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a novel surgical technique that provides fast and effective growth of liver remnant volume, allowing surgical resection of hepatic lesions initially considered unresectable. Short and long-term results and the convenience of carrying out this technique are issues that still remain under debate while waiting for the final outcomes of the multicenter registries with larger number of cases. The aim of this paper is to describe, from a critical point of view, the outcomes of the cases performed at our center (n = 8). On the other hand, it is possible to leave only one hepatic segment as a liver remnant and we illustrate this new surgical procedure (ALPPS monosegment) performed in one patient.

This paper presents a novel non-invasive methodology to obtain the patient-specific relative stiffness between a hepatic lesion and the liver parenchyma in vivo. This relative stiffness can be used as a biomarker about the type of lesion. This biomarker together with the rest of pathological information can be used to plan a biopsy, an image-guide intervention or a radiation therapy. This relative stiffness is estimated by means of the finite element simulation of the breathing process, which is embedded in an optimization routine based on genetic algorithms. This routine was aimed at finding the patient-specific relative stiffness between a hepatic lesion and the liver parenchyma for the proposed model. The feasibility of the proposed methodology was proved first with a synthetic case, where the relative stiffness factor between liver and a tumour were known and the algorithm performed a blind search of it. After that, the methodology was applied to real cases. The results show the good performance of the proposed methodology since the deformation of the tumors were detected with a mean error low.

Background: The aim of this work is to evaluate the efficacy of hydrodynamic venous IL10 gene delivery to "ex vivo" human colon segments and to determine its potential interest in Crohn's disease treatment. Methods: Twenty human colon segments were obtained from surgical resections. Hydrodynamic transfection through the main vein of the pedicle with 50 mL of hIL10 plasmid (20 mu g/mL) solution was performed on 13 of them. Tissue sections were cultured and DNA, RNA, and protein copies were determined after 1, 2, and 4 days. Data obtained were compared with 6 nontransfected specimens. Finally, 1 specimen was injected with gold nanoparticles, and their distribution was examined under electron microscope. Results: IL10 DNA levels were higher in treated tissues than in controls (P < 0.001), decreasing along time. The amount of hIL10 RNA was significantly increased in treated tissues when compared with controls (P = 0.001). The indexes of protein IL10 translation in treated groups were much higher (P < 0.001) than the basal production. The protein expression was higher in transfected tissue (10-50-fold, with respect to control tissue); this difference being established during the first hours and maintained during, at least, 4 days. With electron microscopy, we hardly observed large (15 nm) gold nanoparticles within the tissue, always in the submucosa. However, multiple small (4 nm) nanoparticles were observed within the cytoplasm of enterocytes in mucosa. Conclusions: Hydrodynamic procedure efficiently delivers the IL10 gene to the human colon, achieving levels of tissue protein expression high enough to mediate pharmacological effects with interest in controlling immune response in patients with Crohn's disease.

Solid organ transplant (SOT) recipients are especially at risk of developing infections by multidrug resistant (MDR) Gram-negative bacilli (GNB), as they are frequently exposed to antibiotics and the healthcare setting, and are regulary subject to invasive procedures. Nevertheless, no recommendations concerning prevention and treatment are available. A panel of experts revised the available evidence; this document summarizes their recommendations: (1) it is important to characterize the isolate´s phenotypic and genotypic resistance profile; (2) overall, donor colonization should not constitute a contraindication to transplantation, although active infected kidney and lung grafts should be avoided; (3) recipient colonization is associated with an increased risk of infection, but is not a contraindication to transplantation; (4) different surgical prophylaxis regimens are not recommended for patients colonized with carbapenem-resistant GNB; (5) timely detection of carriers, contact isolation precautions, hand hygiene compliance and antibiotic control policies are important preventive measures; (6) there is not sufficient data to recommend intestinal decolonization; (7) colonized lung transplant recipients could benefit from prophylactic inhaled antibiotics, specially for Pseudomonas aeruginosa; (8) colonized SOT recipients should receive an empirical treatment which includes active antibiotics, and directed therapy should be adjusted according to susceptibility study results and the severity of the infection. J.T.S. holds a research contract from the Fundación para la Formación e Investigación de los Profesionales de la Salud de Extremadura (FundeSalud), Instituto de Salud Carlos III. M.F.R. holds a clinical research contract “Juan Rodés” (JR14/00036) from the Spanish Ministry of Economy and Competitiveness, Instituto de Salud Carlos III.

Resumen Introduccion La coledocolitiasis es la causa mas comun de ictericia obstructiva y ocurre en un 5-10% de los pacientes que presentan colelitiasis. Objetivos Elaboracion un modelo predictivo preoperatorio de coledocolitiasis. Material y metodos Estudio prospectivo de 556 pacientes ingresados en nuestros servicios por patologia biliar. Analisis comparativo de variables preoperatorias clinicas, analiticas y ecograficas de los pacientes sin coledocolitiasis frente a las de los 65 pacientes con dicho hallazgo. Analisis multivariante de regresion logistica para obtener un modelo predictivo de coledocolitiasis, determinando sensibilidad, especificidad, valores predictivos positivo (VPP) y negativo (VPN). Resultados Los factores predictivos de coledocolitiasis fueron la existencia de historia biliar previa (antecedentes de colicos biliares, colecistitis, coledocolitiasis o pancreatitis aguda biliar) (p = 0,021; OR = 2.225; IC 95%: 1.130-4.381), las cifras de BT al ingreso superior a 4 mg/dl (p = 0,046; OR = 2.403; IC 95%: 1.106-5.685), el valor de la FA al ingreso superior a 150 mg/dl (p = 0.022; OR = 2.631; IC 95%: 1.386-6.231), cifras de la GGT superiores a 100 (p = 0,035; OR = 2,10; IC 95%: 1.345-5.850), y el hallazgo ecografico de dilatacion de la via biliar (p = 0,034; OR = 3.063; IC 95%: 1.086-8.649). Un score superior a 5 conlleva una especificidad y VPP de 100% para detectar coledocolitiasis, y un score inferior a 3, una sensibilidad y un VPN del 100% para descartarla. Conclusiones El score obtenido descarta o confirma preoperatoriamente la existencia de coledocolitiasis, y permite al paciente beneficiarse directamente de la colecistectomia laparoscopica (CL) o de la realizacion previa de colangiopancreatografia retrograda endoscopica (CPRE).

A retrospective cohort multicenter study was conducted to analyze the risk factors for tumor recurrence after liver transplantation (LT) in cirrhotic patients found to have an intrahepatic cholangiocarcinoma (iCCA) on pathology examination. We also aimed to ascertain whether there existed a subgroup of patients with single tumors 2cm (very early) in which results after LT can be acceptable. Twenty-nine patients comprised the study group, eight of whom had a very early iCCA (four of them incidentals). The risk of tumor recurrence was significantly associated with larger tumor size as well as larger tumor volume, microscopic vascular invasion and poor degree of differentiation. None of the patients in the very early iCCA subgroup presented tumor recurrence compared to 36.4% of those with single tumors >2cm or multinodular tumors, p=0.02. The 1-, 3- and 5-year actuarial survival of those in the very early iCCA subgroup was 100%, 73% and 73%, respectively. The present is the first multicenter attempt to ascertain the risk factors for tumor recurrence in cirrhotic patients found to have an iCCA on pathology examination. Cirrhotic patients with iCCA 2cm achieved excellent 5-year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs. This multicenter study analyzes the outcome of patients transplanted for hepatocellular carcinoma who were found to have an intrahepatic cholangiocarcinoma at pathology examination, and focuses on the excellent posttransplant outcome of patients with single intrahepatic cholangiocarcinomas 2 cm.