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.

Multidisciplinary Approach in Hepatocellular Carcinoma in a Level II Hospital: The First Decade of Hospital Universitario Fundacion Alcorcon.

BACKGROUND/AIMS: Mean survival in hepatocellular carcinoma remains low. Many efforts have been done during the last years through screening, diagnosis and treatment to improve the results. The aim of this work is to present the experience of our hospital multidisciplinary group during the first decade of this century. METHODOLOGY: The patients with hepatocellullar carcinoma presented at the multidisciplinary meeting from 1999 to 2009 were prospectively studied. According to the tumor and functional status they were treated through the current available guidelines by transplant, partial hepatectomy, local/regional procedures, systemic or symptomatic treatment. RESULTS: One hundred and forty two patients were studied. Median tumor size was 3 cm. A single tumor was diagnosed in 64.8% of the patients. Eighteen patients had liver resection (6 transplantation and 12 with partial resection), 53 tumors were not treated due to advanced stage or liver dysfunction, and in the remaining patients radiofrequency, ethanol or embolization treatments were used, single or combined. CONCLUSIONS: a multidisciplinary approach of hepatocellular carcinoma in a second level hospital with trained professionals permits a diagnosis in early tumoral and functional stages in the majority of patients, and a variety of possible treatments with adequate survival outcomes.

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.

[Nutritional management of the patient after surgery of the biliary tract and pancreas]. / Manejo nutricional del paciente postcirugía de vías biliares y páncreas.

A big proportion of patients with biliary and pancreatic surgery present preoperative malnourishment aggravated by perioperative fasting and additional therapies. Surgery of the pancreas and the biliary tract may cause digestive impairments, mainly absorptive, especially with fat malabsorption. Many studies have shown the usefulness of nutritional support in gastrointestinal surgery. In the last years, there has been a remarkable effort in order to determine which are the best perioperative nutrition regimens in biliary and pancreatic surgery, particularly in the setting of duodenopancreatectomy. Generally, routinary parenteral nutrition (PNT) is not recommended, excepting in moderate-severe hyponutrition, the first choice therapy being enteral nutrition. Immunonutrition seems to improve the outcomes, and the best infusion might be cyclic. According to a survey carried out among the Hepatopancreatobiliary Surgery units in Spain, nowadays the most frequently used support regimen in biliary and pancreatic surgery is PNT, switching to oral feeding within 4-6 days. Enteral nutrition is seldom used.

Malrotación intestinal en adulto y apendicitis aguda / Intestinal malrotation in adults and acute appendicitis

No disponible

[Urachal sinus: an unusual cause of recurrent umbilical discharge in adults]. / Uracosinus: una causa poco frecuente de onfalitis recurrente en adultos.

Urachal sinus is a rare congenital anomaly due to incomplete closure the urachus in the umbilical region, it is very rare in adults. 47-year-old male who arrived at our Emergency Department with recurrent umbilical discharge. Not response medical treatment (oral antibiotic and drainage). Abdominal computerized tomography scan confirmed the urachal sinus with omphalitis. Surgical complete excision with omphalectomy was performed. Any complications in the postoperative was observed.

Uracosinus: una causa poco frecuente de onfalitis recurrente en adultos / Urachal sinus: an unusual cause of recurrent umbilical discharge in adults

El uracosinus es una anomalía congénita poco frecuente secundaria a la obliteración incompleta del uraco en su porción infraumbilical, que puede aparecer a cualquier edad. Presentamos un paciente de 47 años que acudió al servicio de urgencias por supuración umbilical persistente que no había respondido al tratamiento médico (antibioterapia y curas). El TAC confirmó la existencia de un sinus del uraco con cambios de onfalitis. La cirugía consistió en la resección en bloque del mismo con onfalectomía. El postoperatorio transcurrió sin incidencias

Urachal sinus is a rare congenital anomaly due to incomplete closure the urachus in the umbilical region, it is very rare in adults. 47-year-old male who arrived at our Emergency Department with recurrent umbilical discharge. Not response medical treatment (oral antibiotic and drainage). Abdominal computerized tomography scan confirmed the urachal sinus with omphalitis. Surgical complete excision with omphalectomy was performed. Any complications in the postoperative was observed

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.

Live liver donation: a prospective analysis of exclusion criteria for healthy and potential donors.

INTRODUCTION: Living donor liver transplantation represents a controversial option to increase the donor pool. DESIGN: Prospective and descriptive clinical study. OBJECTIVE: (1) To identify risk factors (exclusion criteria) for live donation; (2) to determine the rate of recipients that benefit from a living donor. METHODS: Between May 1995 (first adult-to-adult living donor liver transplantation in Spain) and November 2002, we evaluated 74 healthy volunteers and performed 12 living donor liver transplants (no donor mortality). RESULTS: All actual donors and volunteers are alive and healthy. After a mean time of 3.2+/-0.5 weeks, 72% of potential donors were considered unsuitable for live donation. Exclusion criteria were grouped in three categories: (primary) donor safety reasons (68%); (secondary): ABO mismatch (17%) and (tertiary): cadaveric graft transplantation (15%). Consequently, just 43.7% of the recipients presenting to us with a potential living donor, did finally benefit from these organs. The mortality rate was 8.3% for 43 recipients presenting with a living donor in comparison to 15% for those who did not (321 recipients between May 1995 and November 2001). CONCLUSIONS: ALDLT can benefit a significant number of recipients on the waiting list (43.7% of those presenting with a donor). The most frequent exclusion criteria concern donor safety, namely, unsuspected chronic liver diseases and unsuspected thrombophilic disorders.

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.

[Assessment of risk factors in the incidence of hepatic artery thrombosis in a consecutive series of 687 liver transplantations]. / Valutazione dei fattori di rischio nell'incidenza di trombosi dell'arteria epatica in una serie consecutiva di 687 trapianti di fegato.

AIM: The aim of this retrospective study was to characterize the risk factors of hepatic artery thrombosis (HAT) after orthotopic liver transplantation (OLT) in a consecutive series of 687 OLT, comparing the branch patch anastomosis (BPA) with the end-to-end anastomosis (EEA), in order to investigate, moreover, which technique may be statistically associated with a reduced incidence of HAT. METHODS: Between 1986-1999 we performed 687 OLT in 601 patients, of which 592 were adult and 95 pediatric. Preservation of all donor livers was accomplished with the University of Wisconsin solution since OLT No. 112, at the beginning of 1990. A multivariate analysis was performed in order to find independent variables influencing HAT. We compared, between the two study groups EEA (n = 340) vs BPA (n = 347), HAT incidences with the following variables: adult OLT; pediatric OLT; pre '90 period; post '90 period; donor age; ABO incompatibility; graft type; cold ischemia time; warm ischemia time; double anastomoses; retransplantation; whole blood, fresh frozen plasma and platelet transfusions. RESULTS: HAT was identified in 17/687 OLT (2.47%). HAT incidence was 2.0% in adults (12/592) and 5.2% in children (5/95) (p = 0.059). In the EEA group, HAT was diagnosed in 12/340 cases (3.53%), whereas in the BPA group 5/347 patients experienced HAT (1.44%) (p = 0.078). The need of back table reconstruction occurred in 2/17 HAT cases (11.7%). Possible causative factors included rejection in 5 patients, whereas were unknown in 7 cases. A clear mechanical cause for HAT was identified in one patient, in whom a mechanical intraabdominal compression caused poor inflow. In two cases an intimal dissection was found, while poor inflow occurred in two cases. After a univariate analysis of 44 variables, compared between the two study groups (EEA vs BPA) in patients who developed HAT after OLT (n = 17), only intraoperative PT (p = 0.0525), postoperative SGOT (48 h) (p = 0.0006) and postoperative SGPT (48 h) (p = 0.0222) correlated significantly with the occurrence of HAT. After a multivariate analysis, the variables found to be independent in increasing HAT incidence were: pre '90 period (HAT incidence was 4.5 times more frequent in the pre '90 period: p = 0.0093), ABO incompatibility (HAT incidence was 7.8 times more frequent in incompatible cases: p = 0.0363) and a shorter warm ischemia time (p = 0.0112). DISCUSSION: HAT after OLT is more common in the pediatric population, where it occurs in 10% to 26% of the cases, considerably higher than the 1.6% to 10.5% rate seen in the adult patients. In our series the risk of thrombosis was 2.6 times greater in children than in adults. Moreover, after a multivariate analysis, it was observed that the EEA was associated with an increased risk of thrombosis (2.4 times greater than in the BPA group). In this retrospective study we described a large number of variables, that may influence the development of HAT after OLT, identifying a group of risk factors that correlated statistically with this complication. The results of our report stressed the importance of medical factors compared with surgical factors in the incidence of HAT. CONCLUSIONS: Even if the type of arterial reconstruction was not found to be an independent risk factor in reducing HAT incidence after OLT, our current preferred method of arterial anastomosis is the branch patch technique, using the hepatic-gastroduodenal bifurcation, with a HAT rate of 1.44%.

Results of 22 years of experience in radical surgical treatment of hepatic hydatid cysts.

BACKGROUND/AIMS: As there is still no effective parasiticide, treatment of hydatid cysts continues to be surgical. The possibility of treatment by PAIR. (puncture-aspiration-instillation-reaspiration) or laparoscopy has intensified the debate on the need for radical surgery. This study aims to show that radical surgical resection of the hepatic hydatid cyst is a safe and very effective technique, based on our results after 22 years of experience. METHODOLOGY: Between 1974 and 1996 in 2 large Madrid hospitals we operated on 459 patients with 630 hydatid cysts. As technical advances and experience may vary results, patients were divided into 2 groups according to the period when they had undergone surgery: group A between 1974 and 1984; and group B between 1985 and 1996. Results of radical surgical resection and changes over the course of evolution of this technique were analyzed. RESULTS: A progressive drop was observed in morbidity and mortality. There were no deaths related to technical complications amongst total cystopericystectomy cases. Between 1990 and 1996 mortality was 0%, 2% of patients presented biliary fistula and 4% infection of the residual cavity. Mean hospital stay was 15.2 days. Only 1 patient of the 459 presented recurrence. CONCLUSIONS: As regards morbidity and mortality, technical advances and accumulated experience permit safe treatment of hepatic hydatid cysts by radical resection, with an almost nil recurrence rate. This makes it the technique of choice over others such as partial resection, PAIR or laparoscopy.

Complicaciones de las resecciones hepáticas / Complications in liver resection

Aunque la morbimortalidad de las resecciones hepáticas ha disminuido, sigue siendo considerable. El porcentaje de complicaciones es del 15-50 por ciento y la mortalidad del 0-5 por ciento. Los principales factores relacionados con mayor morbimortalidad son la transfusión, el tamaño de la resección, la ictericia previa, la cirrosis, la esteatosis y ASA mayor de uno. La edad por sí sola no se debe considerar factor de riesgo. Entre las complicaciones derivadas de la propia cirugía las más importantes son el absceso intraabdominal (3-15 por ciento), la fístula biliar (3-7 por ciento), la hemorragia postoperatoria (0-4 por ciento) y la insuficiencia hepática (1-7 por ciento). Las dos primeras raramente condicionan la reintervención o muerte del enfermo. Los abscesos se tratan por punción percutánea guiada con ecografía o tomografía computarizada. La fístula biliar generalmente se resuelve con tratamiento conservador. En fístulas persistentes de alto débito la colocación de un catéter transparietohepático o la esfinterotomía endoscópica facilitan su resolución al disminuir la presión en la vía biliar. La transfusión de sangre, además de coagulopatía, hipotermia, distrés respiratorio, etc., causa inmunosupresión e incluso se ha asociado a recidivas más precoces del tumor resecado. La mayoría de resecciones hepáticas se pueden realizar con un control vascular selectivo mediante ligadura de la tríada portal correspondiente o la maniobra de Pringle, y ligadura de la vena suprahepática correspondiente, con volúmenes de transfusión bajos. Sin embargo, algunos equipos abogan por el empleo de la técnica de exclusión vascular total en tumores grandes o próximos al hilio, vena cava o suprahepáticas. En nuestra experiencia, se puede realizar con seguridad cualquier tipo de resección hepática sin necesidad de una exclusión vascular total.La autotransfusión o la hemodilución normovolémica pueden reducir el volumen de transfusión de sangre homóloga en un 60 por ciento. La insuficiencia hepática origina una mortalidad del 0,7-2,5 por ciento. En hígados sanos se pueden hacer con seguridad resecciones del 75 por ciento del volumen hepático. La esteatosis, la quimioterapia o embolización previa y, sobre todo, la cirrosis, comportan un mayor riesgo de insuficiencia hepática. La selección de candidatos a resección en estos grupos es fundamental, y se debe hacer basándose en tests de reserva funcional hepática (el test de retención de verde de indocianina ha demostrado buenos resultados) y volumentría con tomografía computarizada. La embolización portal para hipertrofiar el lóbulo contralateral puede permitir la resección de algunos casos de otro modo irresecables. Entre las complicaciones generales las más frecuentes son: derrame pleural (5-25 por ciento), neumonía (0,5-5 por ciento), infarto (0,5-1,5 por ciento) y sepsis (1-6 por ciento).Las principales causas de mortalidad son: fallo hepático (40-60 por ciento), hemorragia (1 20 por ciento), sepsis (20-45 por ciento), infarto (20 por ciento) y neumonía (20 por ciento) (AU)

[Role of anatomic variations and methods of hepatic artery reconstruction in the incidence of thrombosis following liver transplantation]. / Ruolo delle varianti anatomiche e delle metodiche di ricostruzione dell'arteria epatica nell'incidenza di trombosi dopo trapianto di fegato.

AIM: The aim of this study was to investigate the incidence of anatomic variations of hepatic artery (HA) in order to evaluate if anatomical anomalies may be associated with an increased incidence of hepatic artery thrombosis (HAT) after orthotopic liver transplantation (OLT). Moreover, we focused on arterial reconstructive technique associated with a low incidence of HAT. METHODS: We reported a consecutive series of 687 OLT in 601 patients (1986-1999). Hepatic arterial reconstruction was variable and dependent upon donor and recipient anatomy, even if arterial anastomosis was mainly of two types: the end-to-end anastomosis (EEA), used in 340/687 OLT (49.4%) and the branch patch anastomosis (BPA), performed in 347/687 OLT (50.5%). Interrupted sutures of 7/0 polypropylene always were used. RESULTS: The diagnosis of HAT was made in 17/687 patients (2.47%). Anomalous hepatic arteries were found in 5/17 cases (29.4%). In the EEA group HAT occurred in 12/340 patients (3.53%), whereas in the BPA group HAT was diagnosed in 5/347 cases (1.44%) (p = 0.078). DISCUSSION: Anatomic variations of HA, most frequently observed, were the left hepatic artery originating from the left gastric artery (9.7-18%) and the right hepatic artery originating from the superior mesenteric artery (7.5-18%). There was no increased incidence of HA complications in the presence of HA anomalies in the donor. Moreover, the existence of an anomaly in the recipient HA was not important if it had appropriate size anf flow. CONCLUSIONS: In our series, the branch patch technique, using the hepatic-gastroduodenal bifurcation, was our current preferred method of arterial anastomosis, with a HAT-rate of 1.44%.