Modified Chevrel technique for abdominal closure in critically ill patients with abdominal hypertension and limited options for closure.

Abdominal compartment syndrome is a potentially life-threatening condition seen in critically ill patients, and most often caused by acute pancreatitis, postoperative abdominal vascular thrombosis or mesenteric ischemia. A decompressive laparotomy is sometimes required, often resulting in hernias, and subsequent definitive wall closure is challenging. AIM: This study aims to describe short term results after a modified Chevrel technique for midline laparotomies in patients witch abdominal hypertension. MATERIALS AND METHODS: We performed a modified Chevrel as an abdominal closure technique in 9 patients between January 2016 and January 2022. All patients presented varying degrees of abdominal hypertension. RESULTS: Nine patients were treated with new technique (6 male and 3 female), all of whom had conditions that precluded unfolding the contralateral side as a means for closure. The reasons for this were diverse, including presence of ileostomies, intraabdominal drainages, Kher tubes or an inverted T scar from previous transplant. The use of mesh was initially dismissed in 8 of the patients (88,9%) because they required subsequent abdominal surgeries or active infection. None of the patients developed a hernia, although two died 6 months after the procedure. Only one patient developed bulging. A decrease in intrabdominal pressure was achieved in all patients. CONCLUSION: The modified Chevrel technique can be used as a closure option for midline laparotomies in cases where the entire abdominal wall cannot be used.

Use of Nonvascularized Fascia in Liver Transplantation.

Abdominal wall transplant is developed in the context of intestinal and multivisceral transplant, in which it is often impossible to perform a primary wall closure. Despite the fact that abdominal wall closure is not as consequential in liver transplant, there are circumstances in which it might determine the success of the liver graft, especially in situations that compromise the abdominal cavity and facilitate an abdominal compartment syndrome. CASE 1: A 14-year-old girl suffering from cryptogenic cirrhosis with severe portal hypertension that causes ascites and severe malnutrition. Uneventful liver transplant, with a graft procured from a 14-year-old donor. At the time of wall closure it was decided to implant a nonvascularized fascia graft to supplement the right side of the transverse incision, with a 17 x 7 cm defect. This required reintervention after 4 months for biliary stricture. At that point, the wall graft was almost completely integrated into the native tissue. CASE 2: A 63-year-old man, transplanted for hepatitis C virus+ hepatocellular carcinoma+ nonocclusive portal thrombosis. Thirty-six hours after transplant the patient developed portal thrombosis. Thrombectomy and closure with biological mesh were performed. After 24 hours he was reoperated on for abdominal compartment syndrome and temporary closure with a Bogotá bag. Six days later he underwent omentectomy, intestinal decompression, and left components separation, identifying a 25 x 20 cm defect. For definitive closure, a nonvascularized fascia graft procured from a different donor was used, accomplishing a reduction in intra-abdominal pressure. Nonvascularized fascia transplantation is an interesting alternative in liver transplant recipients with abdominal wall closure difficulties.

The Impact of Culturing the Organ Preservation Fluid on Solid Organ Transplantation: A Prospective Multicenter Cohort Study.

BACKGROUND: We analyzed the prevalence, etiology, and risk factors of culture-positive preservation fluid and their impact on the management of solid organ transplant recipients. METHODS: From July 2015 to March 2017, 622 episodes of adult solid organ transplants at 7 university hospitals in Spain were prospectively included in the study. RESULTS: The prevalence of culture-positive preservation fluid was 62.5% (389/622). Nevertheless, in only 25.2% (98/389) of the cases were the isolates considered "high risk" for pathogenicity. After applying a multivariate regression analysis, advanced donor age was the main associated factor for having culture-positive preservation fluid for high-risk microorganisms. Preemptive antibiotic therapy was given to 19.8% (77/389) of the cases. The incidence rate of preservation fluid-related infection was 1.3% (5 recipients); none of these patients had received preemptive therapy. Solid organ transplant (SOT) recipients with high-risk culture-positive preservation fluid receiving preemptive antibiotic therapy presented both a lower cumulative incidence of infection and a lower rate of acute rejection and graft loss compared with those who did not have high-risk culture-positive preservation fluid. After adjusting for age, sex, type of transplant, and prior graft rejection, preemptive antibiotic therapy remained a significant protective factor for 90-day infection. CONCLUSIONS: The routine culture of preservation fluid may be considered a tool that provides information about the contamination of the transplanted organ. Preemptive therapy for SOT recipients with high-risk culture-positive preservation fluid may be useful to avoid preservation fluid-related infections and improve the outcomes of infection, graft loss, and graft rejection in transplant patients.

Endometriosis apendicular. Nuestra experiencia en los últimos 11 años / Appendiceal endometriosis. A retrospective analysis of 11 years’ experience

Introducción y objetivos: La endometriosis es una enfermedad con una incidencia que puede llegar al 50% en mujeres en edad fértil. La endometriosis apendicular se presenta en el 1% de estas pacientes, con una clínica variable: su presentación más frecuente es la propia de una apendicitis. El objetivo del estudio es describir y analizar las características clínicas y anatomopatológicas de los casos de endometriosis apendicular de los últimos 10años en el Hospital 12 de Octubre. Pacientes y métodos: Presentamos el estudio retrospectivo de los casos de endometriosis apendicular de nuestro centro en los últimos 10 años. Resultados: Encontramos 22 casos de endometriosis apendicular de un total de 7.051 piezas. La mediana de edad de las pacientes fue de 38,5 años, con 3 pacientes fuera de edad fértil. El inicio fue un abdomen agudo en 16 pacientes; hasta en 10 casos se requirió la realización de 2pruebas de imagen. La endometriosis apendicular fue sospechada en tan solo 2 pacientes. El abordaje laparoscópico fue la técnica de preferencia en los casos crónicos o dudosos. En 6 de las piezas apareció una apendicitis concomitante. Conclusiones: La endometriosis apendicular presenta un difícil diagnóstico preoperatorio y debe ser tenida en cuenta en el diagnóstico diferencial de la apendicitis aguda y considerar que puede ocurrir fuera de la edad fértil

Introduction and objectives: Endometriosis is a disease with an incidence that may reach 50% in women of childbearing age. Appendiceal endometriosis occurs in 1% of these patients. Although symptoms vary, it typically manifests with the same symptoms as appendicitis. The aim of this study was to describe and analyse the clinical, anatomical and pathological characteristics of the appendiceal endometriosis cases treated over the last decade at 12 de Octubre Hospital. Patients and methods: We present a retrospective study of the cases of appendiceal endometriosis treated at our centre over the last 10 years. Results: We found 22 cases of appendiceal endometriosis from a total of 7051 cases. Median patient age was 38.5 years, with 3 patients not of childbearing age. Acute abdomen was the initial manifestation in 16 patients, requiring the performance of 2imaging tests in 10 cases. Appendiceal endometriosis was suspected in only 2 patients. The laparoscopic approach was the preferred technique in chronic or doubtful cases. Concomitant appendicitis was found in 6cases. Conclusions: Appendiceal endometriosis presents a preoperative diagnostic challenge and should be considered in the differential diagnosis of acute appendicitis, bearing in mind that it can arise in women not of childbearing age

Aortic Graft Mycotic Pseudoaneurysm as a Severe Complication After Multivisceral Transplantation: A Case Report.

BACKGROUND: Surgical complications in multivisceral transplantation (MVT) are frequent and always severe. Those related to technical issues are relevant as they have implications not only on the graft but also on patient survival. The aim of this study was to review our case-based data and experience with 5 MVT performed since December 2004. CASE REPORT: A 38 year-old woman presented with ultra-short bowel syndrome due to massive ischemia also affecting the celiac trunk. She also had moderate to severe hepatitis/steatosis with some degree of fibrosis on liver biopsy, due to long-term home parenteral nutrition (HPN). An MVT was carried out in September 2010 including the liver, stomach, pancreatoduodenal complex with the spleen, and small bowel. The postoperative course was complicated by a leak from the pyloromiotomy, requiring reoperation on postoperative day 13. She also had central line catheter infection and renal impairment, requiring renal replacement therapy, and was discharged on postoperative day 150. Fifteen days later she was hospitalized because of severe abdominal pain associated with an abdominal mass. Computed tomography showed an aortic donor graft pseudoaneurysm, so we decided to operate on the patient. A complete resection of the pseudoaneurysm using an interposed polytetrafluoroethylene graft was performed. Six months after the MVT, the patient died due to sepsis, despite a functional graft and complete digestive autonomy. CONCLUSIONS: Although this complication is rare, surgical complications in MVT are severe and may seriously impair graft and patient survival.

Infectious Complications Following Small Bowel Transplantation.

Microbiological spectrum and outcome of infectious complications following small bowel transplantation (SBT) have not been thoroughly characterized. We performed a retrospective analysis of all patients undergoing SBT from 2004 to 2013 in Spain. Sixty-nine patients underwent a total of 87 SBT procedures (65 pediatric, 22 adult). The median follow-up was 867 days. Overall, 81 transplant patients (93.1%) developed 263 episodes of infection (incidence rate: 2.81 episodes per 1000 transplant-days), with no significant differences between adult and pediatric populations. Most infections were bacterial (47.5%). Despite universal prophylaxis, 22 transplant patients (25.3%) developed cytomegalovirus disease, mainly in the form of enteritis. Specifically, 54 episodes of opportunistic infection (OI) occurred in 35 transplant patients. Infection was the major cause of mortality (17 of 24 deaths). Multivariate analysis identified retransplantation (hazard ratio [HR]: 2.21; 95% confidence interval [CI]: 1.02-4.80; p = 0.046) and posttransplant renal replacement therapy (RRT; HR: 4.19; 95% CI: 1.40-12.60; p = 0.011) as risk factors for OI. RRT was also a risk factor for invasive fungal disease (IFD; HR: 24.90; 95% CI: 5.35-115.91; p < 0.001). In conclusion, infection is the most frequent complication and the leading cause of death following SBT. Posttransplant RRT and retransplantation identify those recipients at high risk for developing OI and IFD.

Histologic evaluation of organ preservation injury and correlation with cold ischemia time in 13 intestinal grafts.

Lesions produced in the graft mucosa due to harvesting, storage, and implantation must be graduated to assess the subsequent protocolized biopsy specimens. The aim is to identify type and intensity of graft mucosal lesions observed immediately after implantation. Congestion, hemorrhage, microthrombi, neutrophilic infiltrates, shortening of villi, epithelial detachment, erosion, and crypt loss were separately evaluated by two pathologists in mucosal biopsy specimens from 13 grafts. Each change was assessed as normal, mild, moderate, or severe and by splintering the summation of points a global score was designed. Cold ischemia time was registered. Correlation between the pathologists' evaluations and between final preservation injury degree and cold ischemia time was determined using the "index of correlation rho (ρ)" (Spearman's test). The same changes were assessed in 19 biopsy specimens from day 2 to day 6 (3.6 ± 1.1) to determine their evolution. Congestion was found in 7 biopsy specimens, microthrombi in 2, hemorrhage in 4, neutrophils in 6, villous atrophy in 8, epithelial detachment in 9, erosions in 2 and/or crypt loss in 2. The maximum degree of preservation injury was expressed as intense congestion and hemorrhage associated with epithelial detachment and villous atrophy. The global preservation score was grade 3 in 2 cases, grade 2 in 5, grade 1 in 2, and grade 0 in 4. There was positive correlation (ρ = 0.915) in the evaluation between pathologists (P < .01), total agreement in 9 biopsy specimens, and partial agreement (only 1 point disagreement) in 4. Mean cold ischemia time was 327 ± 101 min. (135-480). There was positive correlation (ρ = 0.694) between preservation score and cold ischemia time (P < .01). In the follow-up biopsy procedures, histological injury decreased by at least one grade in every case. Additionally, karyorrhexis was observed in 3 grafts and very occasional apoptosis in 2 others. This scale achieves good reproducibility and allows graduate preservation injury in intestinal transplantation.

Histologic evaluation of post-implantation immediate C4d deposition in 13 intestinal grafts: correlation with cell-based crossmatching, cold ischemia time, and preservation injury.

C4d deposits are predictive of humoral rejection in kidney and heart transplantation. The aim of this study was to identify C4d deposit patterns in intestinal mucosa of the grafts on biopsy specimens obtained immediately after implantation and to detect if it could be a valuable tool to predict humoral or acute rejection. A second objective was to search for a statistically significant relationship between positive C4d deposition and other collected variables. Thirteen immediately post-transplantation mucosal graft biopsy specimens, formalin fixed, underwent immunohistochemical stain for C4d deposits. Diffuse intense staining of capillary endothelium was considered positive and absent, focal or weak stains as negative. Preservation injury grade and cold ischemia times were registered for each case. Donor-specific preformed antibodies were detected by complement dependent cytotoxicity serologic technique (crossmatching). Another 19 endoscopic follow-up biopsy specimens from days 2 to 6 were also evaluated. Statistical studies were made using the index of correlation ρ (Spearman's test). Diffuse intense C4d deposits were observed in 2 grafts, focal and weak in 5, and completely negative in 6. The mean cold ischemia time was 327 ± 101 minutes. Two cases showed diffuse positive deposits, 1 had a positive crossmatch and the cold ischemia time was 360 minutes whereas the other had not preformed antibodies and its cold ischemia time was 475 minutes. Humoral or acute rejection was not observed in follow-up mucosal biopsy specimens. There was no statistically significant relationship between the C4d deposition, cold ischemia time, crossmatching results, and preservation injury degree. In conclusion, C4d deposition was not a helpful tool for diagnosis of humoral rejection and prediction of acute rejection during the early post-transplantation period.

Renal failure associated with intestinal transplantation: our experience in Spain.

BACKGROUND: Renal failure (RF) is a frequent complication in non-renal solid organ transplants. In the present study, we analyze our experience with intestinal transplants (ITx). METHODS: Between 2004 and 2012, we performed 21 ITx in 19 adult patients. Alemtuzumab was used as an induction agent followed by tacrolimus. Renal function was assessed before ITx and during the perioperative period. RESULTS: The main cause for transplants was non-resectable desmoids tumors (33.3%), followed by vascular thrombosis (19%) and others. Medical complications were frequent, especially infectious diseases, which were the most common (51%). Surgical complications were also frequent, but most of them (>50%) were mild but leading to a great number of re-operations and prolonged stays in hospital. Acute rejection is very frequent (66.6%) but mild in more than 70% of the cases. Finally, RF was very frequent (68.4%; 13/19 patients) and accounted for 15.6% of all medical complications. Causes were multiple. One patient is awaiting a kidney transplant, but no other patients need renal replacement therapy at the moment. Ileostomy closure was performed in 5 of 12 patients alive, showing improved renal function in 3 of them. CONCLUSIONS: RF is a problem in ITx and is always multifactorial. Increases in hospital stay, higher morbidity and is a cause for hospital readmission. Almost all patients had an impaired renal function when discharged. Immunosuppressants and ileostomy closure as soon as possible might prevent RF.

Porcine acellular dermal matrix for delayed abdominal wall closure after pediatric liver transplantation.

Children are one of the groups with the highest mortality rate on the waiting list for LT. Primary closure of the abdominal wall is often impossible in the pediatric population, due to a size mismatch between a large graft and a small recipient. We present a retrospective cohort study of six pediatric patients, who underwent delayed abdominal wall closure with a biological mesh after LT, and in whom early closure was impossible. A non-cross-linked porcine-derived acellular dermal matrix (Strattice(™) Reconstructive Tissue Matrix; LifeCell Corp, Bridgewater, NJ, USA) was used in all of the cases of the series. After a mean follow-up of 26 months (21-32 months), all patients were asymptomatic, with a functional abdominal wall after physical examination. Non-cross-linked porcine-derived acellular dermal matrix (Strattice(™) ) is a good alternative for delayed abdominal wall closure after pediatric LT. Randomized controlled trials are necessary to determine the best moment and the best technique for abdominal wall closure.

Malignancy after liver transplantation: cumulative risk for development.

BACKGROUND: Solid organ recipients are at high risk to develop malignancies due to the complex interactions of several factors, constituting a major cause of late death after transplantation. PATIENTS AND METHODS: We retrospectively reviewed an historic cohort of adult liver recipients from cadaveric donors (multiorgan recipients excluded) performed from 1986-2002 with a minimum follow-up of 36 months. The Kaplan-Meier method was used to assess cumulative risk to develop malignancy and survival analyses. RESULTS: Among the 528 patients undergoing orthotopic liver transplantation (OLT) with a mean follow-up of 2400 days, 98 developed cancer among which 25% were skin malignancies. Sixty-seven patients developed at least 1 noncutaneous malignancy, an overall incidence of 12.7%. Eighteen percent suffered from posttransplant lymphoproliferative disease; 14%, lung cancer; 4%, Kaposi's sarcoma; 7%, genitourinary malignancies; and 17%, oropharyngeal or laryngeal cancer. The cumulative patient risks to develop noncutaneous malignancies at 5, 10, and 15 years posttransplantation were 9% (confidence interval [CI]: 0.06-0.11), 18% (CI: 0.14-0.23), and 25% (CI: 0.18-0.31), respectively. CONCLUSIONS: OLT recipients are at higher risk to develop malignancies after transplantation, reaching a cumulative risk of 25% at 15 years. Long-term surveillance measures and screening programs must be seriously conducted for selected groups.

Compative study of bladder versus enteric drainage in pancreas transplantation.

INTRODUCTION: There is some controversy concerning the choice of best technique for drainage of exocrine secretions in pancreas transplantation. We compared patients with bladder drainage (BD) versus those with enteric drainage (ED). PATIENTS AND METHODS: From March 1995 to September 2008, 118 patients (68 men and 50 women) of overall mean age of 37.8 +/- 7.8 years underwent pancreas transplantation. There were 109 simultaneous pancreas-kidney, and 9 pancreas after kidney procedures. Recipients were divided in a BD (n = 66 patients) and an ED group (n = 52). RESULTS: Donor characteristics were similar in both groups. Thirty-two patients (48.5%) of the BD group versus none in the ED group experienced urinary tract infections (UTI; P < .001), and 16 patients (24.2%) BD versus 15 (29.4%) ED developed intraabdominal infections (P = NS). The overall rate of relaparotomies was 33.9% (n = 40): 34.8% (n = 23) in the BD versus 32.7% (n = 17) in the ED group (P = NS). Thirty patients (25.4%) lost their pancreas grafts: 21 (31.8%) in the BD group versus 9 (17.3%) in the ED group (P = .055). The acute rejection rates were 12.7%; namely, 15.2% in the BD versus 9.8% in the ED (P = NS). Three-year patient and graft survivals were equivalent in both groups: 96.1% and 65.3% in the BD versus 89.0% and 74.0% in the ED group, respectively (P = NS). CONCLUSIONS: ED is a good alternative to BD for drainage of pancreatic graft exocrine secretions because both techniques have the same patient and graft survival, but BD is associated with a significantly higher rate of UTI and urologic complications.

Conversion from bladder to enteric drainage for complications after pancreas transplantation.

OBJECTIVE: Bladder drainage (BD) of exocrine secretions is associated with urological and pancreatitis complications. Herein we have analyzed our experience with conversion from BD to enteric drainage (ED). PATIENTS AND METHODS: From March 1995 to September 2008, 118 patients underwent pancreas transplantation. There were 68 men and 50 women of a overall mean age at transplantation of 37.8 years. There were 66 patients with bladder drainage (BD) and 52 with enteric drainage (ED). RESULTS: Eight of 66 BD pancreas recipients (12.1%) underwent ED conversion. The mean time from pancreas transplantation to ED conversion was 29.3 +/- 30.6 months (range, 1-91 months). The major indications for conversion were recurrent reflux pancreatitis and chronic urinary tract infections in 7 patients; metabolic acidosis in 8; urethritis with severe perineoscrotal swelling in 1; and duodenocystostomy leak in 1. A comparative analysis of converted ED and not converted BD showed only a significantly prolonged period in the intensive care unit for patients who needed ED conversion (89 vs 47 hours; P < .01). Only 1 patient showed a duodenoenteric leak and peritonitis after conversion that required removal of the pancreas graft. The remaining 7 patients did not develop any postoperative complications and are currently well, showing normal pancreas graft function at a mean follow-up of 51.7 months after ED conversion. Patient and graft survivals were 100% and 87.5%, respectively. After ED conversion all urological complications disappeared; patients discontinued the use of oral bicarbonate. CONCLUSION: ED conversion in pancreas transplant recipients with urological and reflux pancreatitis complications was a safe, effective procedure.

Second case of neurocysticercosis in a patient with liver transplantation (first case in Spain): a case report.

BACKGROUND: Neurocysticercosis (NCC) is a disorder caused by the Taenia solium larva. It is the most common parasitosis of the central nervous system (CNS). Its distribution is universal, but it is endemic in many developing countries and in the third world. In Spain most patients come from countries where the condition is endemic. However, sporadic cases occur among the population of rural regions. NCC in transplant recipients is uncommon. One renal transplant recipient developed NCC but responded to treatment with praziquantel. Recently, it has been reported to complicate a liver transplantation. CASE REPORT: The patient was a 49-year-old Ecuatorian man who received a cadaveric donor liver graft in June 2001 due to acute liver failure induced by toadstool and was under treatment with FK506. In January 2006, the patient presented with a generalized onset of a tonic-clonic seizure for 1 minute without sphincter incontinence, headache, fever, or previous brain trauma. Neurological evaluation did not show evidence of organic brain dysfunction. The neuroimaging findings (brain) computed tomography scan, magnetic resonance imaging were compatible with NCC: many cystic lesions intra- and extraparenchymatous with a scolex visible in three of them. Serology for cysticercosis in plasma was initially indeterminate but positive afterward. The patient was treated with anticonvulsivants (valproic acid) and albendazole. Systemic steroids were added in order to reduce the edema produced upon death of the cyst. Treatment lasted 3 weeks and it was completed without complications or neurological symptoms. Liver function was not affected. One year later the patient remained asymptomatic. CONCLUSION: NCC is a condition that must be included in the differential diagnosis of patients with CNS involvement and cystic lesions on neuroimaging investigations in transplant recipients, especially patients originating from or traveling to endemic areas. First-line therapy for active cysts includes antiparasitic drugs (albendazole or praziquantel) as well as steroids and anticonvulsivants. In our patient, this therapy was effective.

Incidence of de novo nonmelanoma skin tumors after liver transplantation for alcoholic and nonalcoholic liver diseases.

INTRODUCTION: Skin tumors are the most common malignancies after orthotopic liver transplantation (OLT). They have been related to sunlight exposure, tobacco consumption, and immunosuppression. The aim of this study was to compare the incidence of de novo skin tumors (nonmelanoma) in patients who underwent liver transplantation for alcoholic cirrhosis versus nonalcoholic diseases. PATIENTS AND METHODS: Between April 1986 and July 2004, we performed 1000 OLT in a population of 888 recipients. This study was performed in a sample of 701 adult recipients who survived >2 months after transplantation: 276 patients (39.4%) underwent OLT for alcoholic cirrhosis (AC-group), and 425 (60.6%) for nonalcoholic disease (N-AC). The overall incidence of de novo skin tumors was 3.5% (25 tumors): 5.4% (15 tumors) in the AC-group and 2.4% (10 tumors) in the N-AC group (P = .027). Two patients developed two tumors. There were 19 men and 4 women, mean age at OLT of 54.4 +/- 6.8 years (range, 40 to 66 years). The mean time from OLT to tumor diagnosis was 66.1 +/- 51.4 months (range, 3 to 165 months): 56.4 +/- 44.4 months in the AC-group versus 80.6 +/- 59.8 months in the N-AC group (P = NS). Histologically, 17 tumors (68%) were basal cell carcinomas and eight tumors (32%) were squamous cell carcinomas (P = .128). Fourteen patients (60.8%) were smokers: 11 patients (84.6%) in the AC-group versus 3 patients (30%) in the N-AC group (P = .012). All the patients underwent tumor resection, with only one patient dying, because of lymph node invasion of the neck. CONCLUSION: There was a higher incidence of de novo skin tumors among patients who smoked who underwent OLT for alcoholic cirrhosis.

Hepatic allograft arterialization by means of the gastroduodenal bifurcation (branch patch) as a prognostic factor.

INTRODUCTION: Because of the current shortage of cadaveric organs, it is important to determine preoperatively those variables that are readily available, inexpensive, and noninvasive that can predict a higher incidence of hepatic artery thrombosis (HAT). MATERIAL AND METHODS: From April 1986 to October 2001, 717 patients underwent 804 liver transplants. All the arterial reconstructions were performed with fine (7-0) monofilament sutures in an interrupted fashion. Two methods were used: group I, end-to-end arterial anastomosis, and group II, the gastroduodenal branch patch. RESULTS: After a mean follow-up of 72 (range 3-174) months, HAT was observed in 19 patients (overall incidence 2.4%). End-to-end anastomosis (group I) was performed in 39.50% (316) of cases, and HAT developed in 14 (4.4%) cases. Branch-patch anastomoses (group II) were carried out in 60.5% (488) of the patients; the presence of HAT was detected in five cases (1.03%) (P = 0.03, P < 0.05). A total of 21 variables were selected in the univariate analysis; however, after the multivariate analysis, all but two of the factors lost statistical significance, and these corresponded to the type of arterial reconstruction (gastroduodenal branch patch vs. end-to-end) and the ABO compatibility. CONCLUSIONS: Liver transplantation with compatible grafts using branch-patch anastomosis for the arterialization (both manipulative by the transplant team) reduces HAT-derived loss of grafts, with the consequent increase in graft availability and reduced mortality rate on the waiting list.

Liver transplantation for hepatocellular carcinoma: our experience from 1986.

UNLABELLED: Currently liver transplantation is the treatment of choice for early hepatocellular carcinoma and end-stage liver disease. We analyzed our experience to identify factors that could be used to select patients who will benefit from liver transplantation. PATIENTS AND METHODS: From April 1986 to December 2001, 71 (8.7%) of 816 LT performed in our institution, were for patients with hepatocellular carcinoma. In 25 patients the tumor was observed incidental by (35.2%). All patients had liver cirrhosis, most due to hepatitis C related (35) or alcoholic (14) diseases. Before liver transplantation, chemoembolization was performed in 18 patients (25.4%). RESULTS: Bilateral involvement was present in seven patients. Eight patients showed macroscopic vascular invasion, and eight others showed satellite nodules. Most patients were stage TNM II (29) and IVa (16). Overall 1-, 3-, and 5-year survival were 79.3%, 61%, and 50.3% with recurrence-free survivals of 74.6%, 57.5%, and 49%, respectively. With a mean follow-up of 42 months, 12 patients (19%) developed recurrence and 29 patients died (only 11 due to recurrence). Stage TNM IVa, macroscopic vascular invasion, and the presence of satellite nodules significantly affected overall survival and recurrence-free survival rates and histologic differentiation and bilateral involvement only recurrence-free survival. Patients with solitary tumors less than 5 cm or no more than three nodules smaller than 3 cm showed better recurrence-free survival and lower recurrence rates. DISCUSSION: In our experience, liver transplantation proffers good recurrence-free survival and low recurrence rates among patients with limited tumor extension. The most important prognostic factor was macroscopic vascular invasion.

Simultaneous liver-kidney transplant for combined renal and hepatic end-stage disease.

INTRODUCTION: After the first combined liver-kidney transplantation (CLKT) reported by Margreiter in 1984, it became clear that renal failure was no longer an absolute contraindication. OBJECTIVE: Our goal was to assess our results with combined liver-kidney transplant. Among 875 liver transplants performed between May 1986 and October 2002, there were 17 cases (1.96%) of combined liver-kidney transplant. RESULTS: With a mean follow-up of 42.2+/-29 months (range, 1-90), six patients had died (mortality: 37.5%). There were four (25%) operative in-hospital deaths, and two late mortality cases (beyond the month 6 after hospital discharge). The causes were sepsis (four cases, three postoperative and one in later follow-up), refractory heart failure (one postoperative), and recurrent liver disease (HCV-induced severe recurrence) during follow-up one). Actuarial survival (calculated for those who survived the postoperative period) was 80%, 71%, and 60% at 12, 36, and 60 months. Actuarial mean survival time was 60 months (95%IC:47-78). Neither the sex, the UNOS status, the etiology of liver disease, the etiology of renal failure, the type of hepatectomy (piggy back vs others) or the type of immunosuppression (P=.83) were related to long-term survival according to the log-rank test. A control group of 48 patients was constructed with subjects who underwent liver transplantation immediately before or after the combined transplant. A total (two cases after the CLKT and one case prior to). There were no differences in survival. CONCLUSION: Combined liver-kidney transplant represents a proper therapeutic option for patients with simultaneously failing organs based on long- and short-term outcomes.

Advantages of the piggy back technique on intraoperative transfusion, fluid compsumption, and vasoactive drugs requirements in liver transplantation: a comparative study.

INTRODUCTION: The piggyback technique was first described in adult liver transplantation in 1989, although it has been used in conjunction with venous bypass, with cross-clamping the vena cava, or both. In this study, the inferior vena cava was not occluded at any time during the liver transplant. OBJECTIVE: We compared the use of intraoperative blood products, fluid requirements, and vasoactive drugs among patients managed with bypass, without bypass, and with the piggyback technique. MATERIAL AND METHODS: Between May 1986 and October 2002, 875 liver transplants included 50 patients divided into three groups (cases considered to be the preliminary series on each group): group A/piggyback (17 patients:34%), group B/ bypass (16 patients: 32%), and group C/no bypass (17 patients:34%). There were no differences in mean age, gender, UNOS or Child-Pugh score, and indications for liver transplantation. RESULTS: Mean follow up was 134.63+/-32.19 months. At the end of the study, 91.3% of the patients are alive with no operative mortality. There were no differences in postoperative complications, postreperfusion syndrome rate, and postoperative renal failure. However, the number of packed red blood cell units consumed intraoperatively (12+/-7.43 vs 18.03+/-11.46 vs 17.59 +/- 23.8; P =.043), the need for intraoperative crystaloids (3.1 L+/-1.6 vs 6.8+/-4.8 vs 9.1 L+/-3.6; P=.001) and the requirement for vasoactive drugs (18% vs 38% vs 24%; P=.043) was notably lower in group A vs group B vs group C. Operative time was longer in group A (121.54+/-37.77 vs 78.73+/-11.89 vs 87.07+/-14.33 minutes). CONCLUSIONS: The piggyback technique requires a longer operative time but offers the advantages of reducing the red blood cell requirements and preventing severe hemodynamic instability by virtue of reducing the need for vasoactive drugs and for a larger volume of intraoperative fluids.