Portal vein arterialization in liver transplantation: an option to restore arterial flow: a case report.

We report a 66-year-old woman who underwent emergency orthotopic liver transplantation due to acute liver failure. The donor's liver graft displayed extensive arteriosclerosis, involving the celiac trunk and hepatic artery. Arterial revascularization of the graft could not be achieved, requiring an arterioportal shunt between the gastroduodenal artery and the portal vein of the recipient. During the early postoperative period, the patient's clinical condition and liver function tests improved rapidly; the patient was discharged on postoperative day 30. Two months later, she developed acute cholangitis. Ischemic-type stenosis of the intrahepatic biliary tree was present, so successful elective retransplantation was undertaken at the ninth postoperative month. In our experience, portal vein arterialization may be useful as a bridging therapy in extreme situations.

Repeated liver resection for recurrence of colorectal cancer metastases

BACKGROUND: Resection of liver metastases is accepted as treatment for diverse tumours, implying a survival improvement. Metastases often recur after first hepatectomy and, very few would be potentially resectable. MATERIALS AND METHODS: A retrospective study of 18 patients undergoing repeated hepatectomies (two or more liver resections in the same patient) due to metastases of colorectal cancer between 1988 and 2006 was performed. RESULTS: Thirteen men and five women, mean age 57.55 years, participated. In all patients, repeated liver resection was performed due to recurrence of the metastases. Complications rate after first hepatectomy was 11.1% and after the second 16.6%. Mortality rate was 11.1% after second hepatectomy, and there was no mortality after third hepatectomy. Three- and 5-year survival after colectomy was 88.9% and 77.8%, respectively; after first hepatectomy 3- and 5-year survival was 88.9% and 61.1%, respectively; after second hepatectomy, 3- and 5-year survival was 83.3% and 61.1% respectively; and 3-year survival after third hepatectomy was 67%. CONCLUSION: Repeated resections by expert surgeons for recurrent liver metastases can be safely performed, with low morbidity and mortality rates similar to first hepatectomies. Repeated resections of liver metastases of colorectal cancer improve global survival (AU)

[Hepatic hydatidosis. Radical vs. conservative surgery: 22 years of experience]. / Hidatidosis hepática. Cirugía radical vs. no radical: 22 años de experiencia.

OBJECTIVES: the incidence of hepatic hydatidosis has remarkably decreased in the last years due to the preventive measures adopted to stop the transmission of the parasite. However, surgery carries on being the treatment of choice, although the surgical procedure is still a matter of controversy. The aim of the study was to evaluate the results obtained with the treatment of this condition after two decades according to surgical procedure type. MATERIAL AND METHODS: from 1983 to 2005, 372 patients were operated on for hepatic hydatidic cyst in Hospital Ramón y Cajal. Radical surgery was performed for 162 (43.5%) and conservative surgery for 210 (56.5%). RESULTS: average postoperative hospital stay (8.65 vs. 14.9 days), morbidity (13.3 vs. 31.4%, p < 0.001), and mortality (0 vs. 3.8%, p < 0.01) were lower in the radical surgery group. Recurrence rate was 1.85% after radical surgery versus 11.9% in the conservative surgery group (p < 0.0001). CONCLUSION: radical surgery is associated with lower morbidity, mortality, postoperative hospital stay, and recurrence rates, and represents the treatment of choice for hepatic hydatidosis. However, its indication must depend on the patient characteristics, cyst anatomy, and surgical team experience.

Hidatidosis hepática. Cirugía radical vs. no radical: 22 años de experiencia / No disponible

Introducción: la incidencia de la hidatidosis hepática ha disminuidonotablemente en los últimos años gracias a las medidasde prevención adoptadas para interrumpir la transmisión del parásito.Con todo, la cirugía continúa siendo el tratamiento de elección,si bien su modalidad es todavía motivo de controversia.Objetivos: el objetivo de este trabajo es evaluar los resultadosobtenidos en el tratamiento de esta patología a lo largo de más dedos décadas, atendiendo a la modalidad quirúrgica empleada yafuese cirugía radical o no radical.Material y métodos: se analizaron un total de 372 pacientesintervenidos por quiste hepático hidatídico (QHH) entre 1983-2005 en el Hospital Ramón y Cajal. En162 se efectúa una cirugíaradical (43,5%) y en 210 una no radical (56,5%).Resultados: tanto la estancia media hospitalaria (8,65 días vs.14,9 días) como la morbilidad (13,3 vs. 31,4 %, p < 0,001) y lamortalidad (0 vs. 3,8%, p < 0,01) fueron menores en el grupo decirugía radical. La tasa de recidiva fue del 1,85% tras un abordajeradical frente al 11,9% en los abordajes no radicales (p < 0,0001).Conclusión: la cirugía radical se asocia con una menor morbimortalidad,menor estancia hospitalaria y menor recidiva, constituyendola técnica de elección en la hidatidosis hepática. Sin embargo,su aplicación debe atenerse a las características delpaciente, la anatomía del quiste y el grado de experiencia del equipoquirúrgico

Objectives: the incidence of hepatic hydatidosis has remarkablydecreased in the last years due to the preventive measuresadopted to stop the transmission of the parasite. However, surgerycarries on being the treatment of choice, although the surgical procedureis still a matter of controversy. The aim of the study was toevaluate the results obtained with the treatment of this conditionafter two decades according to surgical procedure type.Material and methods: from 1983 to 2005, 372 patientswere operated on for hepatic hydatidic cyst in Hospital Ramón yCajal. Radical surgery was performed for 162 (43.5%) and conservativesurgery for 210 (56.5%).Results: average postoperative hospital stay (8.65 vs. 14.9days), morbidity (13.3 vs. 31.4%, p < 0.001), and mortality (0 vs.3.8%, p < 0.01) were lower in the radical surgery group. Recurrencerate was 1.85% after radical surgery versus 11.9% in theconservative surgery group (p < 0.0001).Conclusion: radical surgery is associated with lower morbidity,mortality, postoperative hospital stay, and recurrence rates,and represents the treatment of choice for hepatic hydatidosis.However, its indication must depend on the patient characteristics,cyst anatomy, and surgical team experience

Massive low gastrointestinal bleeding due to a Dieulafoy rectal lesion.

Massive low gastrointestinal bleedings are often difficult diagnostically and in terms of management. Sometimes, it is not possible to identify the bleeding point after performing diverse diagnostic tests and the patient undergoes a blind subtotal colectomy. With rectal bleeding, this form of surgery is completely useless, as it will not solve the cause of the haemorrhage. The Dieulafoy lesion has been widely described in the stomach, but in the rectum is a very rare entity that can cause massive lower gastrointestinal bleeding. In the literature, there are only 25 described cases of rectal Dieulafoy lesion.

Benign rectovaginal fistulas: management and results of a personal series.

BACKGROUND: Treatment of benign rectovaginal fistula has a high failure rate and entails difficult decisions. The purpose of this retrospective study was to clarify the concepts which may improve its management. METHODS: Between 1983 and 2004, 46 consecutive women of median age 41 years were treated by the same surgeon. Etiology of simple fistulas was iatrogenic (n=6), obstetric (n=4) and septic (n=3). Complex fistulas were due to inflammatory bowel diseases (IBD) (n=18, 11 pouchvaginal) or were iatrogenic (n=9), actinic (n=5) or septic (n=1). Surgical techniques included endorectal or vaginal advancement flaps, fistulectomy and sphincteroplasty, vaginal/rectal closure and epiploplasty, restorative proctectomy and restorative proctocolectomy. In 20 patients, a diverting stoma was performed as a single procedure or concomitant to the curative attempt. RESULTS: Overall, 33 of the 39 fistulas (85%) treated for cure healed, including all simple fistulas and 20 complex fistulas (8 iatrogenic, 3 actinic, 2 ulcerative colitis without restorative proctocolectomy; 5 pouch vaginal; 1 septic; 1 Crohn's disease) (p=0.009). The first operation for the fistula was curative in 20 of 39 fistulas, including 10 of 13 simple and 10 of 26 complex fistulas (p=0.023). There was no significant age difference between cured and not-cured patients. CONCLUSIONS: Simple versus complex fistulas is the most determinant factor for healing. In IBD fistulas, ulcerative colitis shows better prognosis than Crohn's disease. For complex fistulas, a temporary diverting stoma seems necessary.

Value of third metastasectomy of colorectal adenocarcinoma

62 year-old woman with a tumour in sigmoid colon invading left ovary and metastases in both hepatic lobes. Posterior pelvic exanteration and metastasectomy of left hepatic lesions were performed in the first surgery, right hepatectomy in the second one and metastasectomy of 2 new metastases in the third one. A new metastases in remanent portal pediculum was considered non-operable. The patient died 29 months after first surgery (AU)

Angiogenic capacity of human omental stem cells.

OBJECTIVES: The goals of the present study are to obtain, expand and characterize a stem cell population from human omentum and to evaluate its in vivo angiogenic capacities. METHODS: Human omental CD34+ cells were obtained from samples of human omentum by density gradient centrifugation in Ficoll. Proliferative pattern, marker expression (by flow cytometry) and angiogenic growth factor synthesis by omental cell cultures were determined. In vivo angiogenic capacity of the cells was evaluated in rats. RESULTS: Omental stem cells showed a high rate of proliferation (Ki67 staining), expressed CD34 marker and synthesized bFGF and VEGF. When implanted in rats, omental cells promoted neovascularization. Human omental cells were localized in rat tissue, mainly forming the endothelium of neo-vessels. Implantation of omental cells also facilitated angiogenesis of rat origin. CONCLUSION: CD34+ cell population of human omentum could be responsible for the clinical benefit of omental transplantation by promoting angiogenesis and synthesizing angiogenic growth factors to facilitate revascularization of injured tissue.

Quiste hepático ciliado embrionario multilocular. Aportación de un nuevo caso y revisión de la literatura / A new multilocular ciliated hepatic foregut cyst. Case report and review of the literature

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Total anorectal reconstruction: a novel technique.

The aim of this report is to describe a novel technical approach to total anorectal reconstruction after a Miles operation for rectal cancer. Recreation of an internal neosphincter with colonic muscle, the implant of an artificial bowel sphincter (ABS), and the association of a coloplasty constitute a complete substitution of the lost structures and functions. Although the patient developed a late complication which required removal of the ABS, the functional result of the technique can be considered as excellent, to be demonstrated by the incontinence score and quality of life with and without the colostomy.

Donor age as a risk factor for patient survival in the liver transplant.

OBJECTIVES: Our aims were to establish whether there is a relationship between donor age and patient and graft survival among liver transplant recipients and to determine the age at which this relationship emerges. PATIENTS AND METHODS: We reviewed 254 consecutive liver transplants performed at the Hospital Ramón y Cajal, Madrid in 206 patients over a 79-month period. Survival rates were determined using Kaplan-Meier curves analyzed by the log-rank method. RESULTS: The mean donors age was 42.08+/-17.89 years (range 8-79 years). The minimum and mean patient follow-up times were 6 months and 29.48+/-23.37 months. Mean patient and graft survival rates, along with their standard errors and 95% confidence intervals were 62.47+/-2.42(57.72-67.21) and 57.30+/-2.40(52.59-62.01) months, respectively. Mean survival was lower (P=.047) among patients who received a graft from a donor of 30 or more years (58.24+/-3.05[52.28-64.21] months) versus from a younger donor (66.19+/-3.55[59.23-73.15] months). Graft survival was also significantly different (P=.037) for donors older versus younger than 25 years (53.04+/-2.83[47.50-58.58] and 64.72+/-4.11[56.67-72.77] months, respectively). CONCLUSIONS: Patients undergoing liver transplant show lower survival when the donor is older than 30 and the survival of the implanted graft is also lower when the donor is over 25.

Impact of donor, recipient, and graft features on the development of primary dysfunction in liver transplants.

OBJECTIVES: To establish the utility of eight anatomic/pathologic suboptimal and 9 others graft features, versus in 20 donor versus 14 recipient characteristics to predict primary transplant dysfunction. PATIENTS AND METHODS: We reviewed 248 consecutive liver transplants performed at the Hospital Ramón y Cajal, Madrid, in 206 patients over a 79-month period. At least one biopsy specimen was obtained from 169 grafts (68.1%). Recipients were classified as showing primary function or dysfunction, the latter group being subdivided into primary failure and inadequate initial function. The primary function and inadequate initial function groups were defined in terms of transaminases less or more than 2000 IU and prothrombin activity over or under 50%, respectively during posttransplant days 2 to 7. RESULTS: The following graft-related rates were recorded: arteriopathy 6.5%, steatosis 29.4% (macrovesicular 26.4%, microvesicular 4.7%, or both 1.7%), hepatocyte vacuolization 14.2%, sinusoidal ectasia 12.4%, hepatocellular necrosis 44.7%, and neutrophilic infiltration 24.4%. The only significant factors in the multivariate analysis were cause of donor death other than cranioencephalic trauma (P=.032) and moderate steatosis (30%-60% affected hepatocytes); (P=.012). CONCLUSIONS: The only factors that seem to influence the development of primary liver dysfunction were a moderate degree of graft steatosis and a cause of brain death other than cranioencephalic trauma.

Survival and complication rates in liver transplant patients showing primary dysfunction versus normofunction.

AIMS: To determine rates of vascular and biliary duct complications, acute rejection, and graft and patient survival according to function status following liver transplantation. METHODS: We classified 248 consecutive liver transplants performed at the Hospital Ramón y Cajal, Madrid, over a 79-month period according to initial function as primary function (NP) versus dysfunction (PD). The latter group was subdivided into grafts showing primary failure (PF) or inadequate function (IPF). The classes NP and IPF were distinguished according to whether transaminase (GOT or GPT) levels and prothrombin activity were above or below 2000 IU and 50%, respectively. RESULTS: There were 23 (9.3%) patients with PD, of whom 12 (4.8%) showed PF. The incidence of vascular and biliary duct complications was similar in both groups, although acute rejection showed a significant difference (PD 3/23 versus NP 98/225; odds ratio =.18). In contrast, the mean survival rates of the grafts (NP 60.37 versus IPF 39.90 months) or patients (NP 63.02 versus PD 47.10 months) were not significantly different. Only 1- and 3-month graft survival rates significantly differed between the NP and IPF groups (NP 95% versus IPF 63%; P=.03 and NP 89% versus IPF 58%; P=.02, respectively). CONCLUSIONS: Recipients with PD or NP after liver transplant showed no differences in the incidence of vascular or biliary duct complications. These groups did vary, however, in terms of rates of acute rejection episodes. No differences in graft and patient survival rates were observed except a significantly lower graft survival at 1 and 3 months, among patients with inadequate primary function.

Influence of ischemia and surgery times on development of primary dysfunction liver transplant in patients.

OBJECTIVE: (1) To determine the incidences of primary failure and primary dysfunction of liver transplants performed at our center. (2) To evaluate the effects of mean cold and warm ischemia times as well as the length of five stages of surgery on the development of primary dysfunction. PATIENTS AND METHODS: We reviewed 248 liver transplants consecutively performed in 206 patients at the Hospital Ramón y Cajal, Madrid over 79 months. Six cases were excluded because the patients died within 24 hours of transplant, it was therefore not possible to establish the postoperative liver function. Recipients were classified according to their posttransplant liver function as showing normal primary function (NP) or primary dysfunction (PD), which included patients with primary failure (PF) and inadequate primary function (IPF). The NP and IPF groups were defined in terms of transaminase levels and prothrombin activity from posttransplant days 2 to 7. The following factors were analyzed: graft cold (CIT) and warm (WIT) ischemia times; graft arterial (AIT) and venous (VIT) ischemia times; and times of surgery (ST), arterial anastomosis (AAT), and anhepatic phase (APT). RESULTS: Twenty-three (9.3%) patients were classified as showing PD, 12 (4.8%) of whom suffered an episode of PF. The mean values (and standard deviations) of the times (in minutes) were ST = 308.19 +/- 109.78; CIT = 411.08 +/- 140.62; WIT = 46.51 +/- 37.70; AIT = 510.95 +/- 165.95; VIT = 458.68 +/- 151.98; AAT = 54.12 +/- 31.84; and APT = 58.53 +/- 90.07. No significant differences were detected in the mean times of patients showing NP or PD. Neither were any differences observed between the two patient groups according to the variables CIT longer than 10 hours and WIT longer than 60 minutes. CONCLUSIONS: Our times of surgery and cold ischemia are shorter than those reported by other transplant teams, mostly North American surgeons who quote figures of around 7 and 12 hours, respectively. These relatively low values may account for the lack of effect shown by the times of ischemia or surgery stages on the appearance of primary dysfunction in patients undergoing liver transplant.

Angiomiolipoma hepático / Hepatic angiomyolipoma

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The use of ischaemic vessels as prostheses or tissue engineering scaffolds after cryopreservation.

OBJECTIVE: to evaluate the condition of organ donor arteries subjected to prolonged cold-ischaemia followed by cryopreservation, for their possible use as vascular grafts. MATERIALS AND METHODS: fresh specimens of human iliac artery from organ donors were used as controls. These arteries were divided into two portions, one of which was cryopreserved in an automated freezer. A further group of arteries was immersed in Wisconsin solution and kept for 4 days at 4 degrees C (cold-ischaemia). After this period, the arteries were also cut into two, and one of these portions was cryopreserved. All the cryopreserved arterial segments were stored for a month and then subjected to automated gradual thawing. The thawed specimens were evaluated by light microscopy, scanning and transmission electron microscopy, immunohistochemical analysis (MMPs, elastin, CD31, von Willebrand factor) and the in situ detection of fragmented DNA (TUNEL method). RESULTS: the most marked changes induced by cryopreservation were partial vessel deendothelialisation and morphological changes in cells of the intima that were in the process of detachment. No significant changes were observed in the medial layer, other than discrete elastic fibre fragmentation. Following cold-ischaemia, the endothelium was the most affected layer, with large denuded areas and exposure of the fibroelastic layer. Increased MMP-2 expression was also noted after cold-ischaemia. When subjected to both cold-ischaemia and cryopreservation, a large proportion of endothelial cells showed positivity for the TUNEL technique, however, no significant difference was observed between the ischaemic and the ischaemic/cryopreserved specimens. CONCLUSIONS: prolonged cold-ischaemia causes some additional damage to the arterial wall compared to cryopreservation alone. However, the structural component of the ischaemic vessel remains in a condition that is suitable for subsequent cryopreservation and use as a vessel substitute or a scaffold for tissue engineering.