Improving early cholecystectomy rate in acute cholecystitis with an evidence-based local multidisciplinary protocol and a surgical audit: single-center experience through an Acute Care Surgery Division.

PURPOSE: To analyze if, after implementation of an evidence-based local multidisciplinary protocol for acute cholecystitis (AC), an intermediate surgical audit could improve early cholecystectomy (EC) rate and other therapeutic indicators. METHODS: Longitudinal cohort study at a tertiary center. The local protocol, promoted, created, and periodically revised by the Acute Care Surgery Unit (ACSu) was updated and approved on March 2019. A specific registry was prospectively fulfilled with demographics, comorbidity, type of presentation, diagnostic items, therapeutic decision, and clinical course, considering both non-operative management (NOM) or cholecystectomy, early and delayed (EC and DC). Phase 1: April 2019-April 2021. A critical analysis and a surgical audit with the participation of all the involved Departments were then performed, especially focusing on improving global EC rate, considered primary outcome. Phase 2: May 2021-May 2023. Software SPSS 23.0 was used to compare data between phases. RESULTS: Initial EC rate was significantly higher on Phase 2 (39.3%vs52.5%, p < 0.004), as a significantly inferior rate of patients were initially bailed out from EC to NOM because of comorbidity (14.4%vs8%, p < 0.02) and grade II with severe inflammatory signs (7%vs3%, p < 0.04). A higher percentage of patients was recovered for EC after an initial decision of NOM on Phase 2, but without reaching statistical significance (21.8%vs29.2%, n.s.). Global EC rate significantly increased between phases (52.5%vs66.3%, p < 0.002) without increasing morbidity and mortality. A significant minor percentage of elective cholecystectomies after AC episodes had to be performed on Phase 2 (14%vs6.7%, p < 0.009). Complex EC and those indicated after readmission or NOM failure were usually performed by the ACSu staff. CONCLUSION: To adequately follow up the implementation of a local protocol for AC healthcare, registering and periodically analyzing data allow to perform intermediate surgical audits, useful to improve therapeutic indicators, especially EC rate. AC constitutes an ideal model to work with an ACSu.

Análisis integral de la colecistectomía en una unidad de cirugía ambulatoria y corta estancia. Experiencia de los últimos 7 años / Integral analysis of cholecystectomy in an outpatient surgery and short-stay unit. Experience of the last 7 years

Introducción: La colecistectomía laparoscópica ambulatoria (CLA) se considera en la actualidad un trazador representativo de la calidad de un servicio de cirugía general. La gran diversidad de unidades de cirugía ambulatoria dificulta la comparativa de los diferentes indicadores de calidad. Objetivo: Conocer los resultados del manejo de la CLA en un centro integrado y como afecta a sus indicadores de calidad. Pacientes y método: Estudio observacional prospectivo entre 2015 y 2021 de las colecistectomías programadas en unidad integrada. Resultados: Se intervinieron 887 pacientes, el 76,5 % (n = 679) programados en régimen ambulatorio. La pernocta no planificada (PNP) media fue del 25,2 % (n = 171), siendo el índice de sustitución del 57,8 %. Las principales causas de PNP fueron: intolerancia digestiva (48,5 %), cirugía compleja (29,2 %) y el dolor (12,8 %). Los tiempos quirúrgicos fueron superiores en los pacientes en régimen de ingreso (p < 0,001) y en aquellos que causaron PNP (p < 0,001). Un tiempo quirúrgico superior a los 45 minutos fue causa de PNP de forma significativa (p = 0,007). La tasa global de infección de sitio quirúrgico fue del 3,1 %,siendo la infección profunda del 0,59 %. Ningún paciente reingresó en las primeras 24 horas, siendo la asistencia a urgencias a 30 días del 8,2 % (n = 73),reingresando el 1,91 % (n = 17) de los pacientes, con una tasa de reintervención del 0,35 % (n = 3). La tasa de fístula biliar fue del 0,67 %. Conclusión: La CLA es una técnica segura y expansiva, aunque la obtención de parámetros de calidad estandarizados es complejo por la diversidad de unidades.(AU)

Introduction: Ambulatory laparoscopic cholecystectomy (ALC) is currently considered a representative tracer of the quality of a general surgery service. The great diversity of day surgery units makes it difficult to compare the different quality index. Objective: To know the results of the management of the CLA in an integrated center and how it affects its quality index. Patients and method: Prospective observational study between 2015 and 2021 of scheduled cholecystectomies in an integrated unit. Results: 887 patients were operated on, 76.5 % (n = 679) programmed on an outpatient basis. The average unplanned overnight stay (PNP) was 25.2 % (n = 171), with the replacement rate being 57.8 %. The main causes of PNP were: digestive intolerance (48.5 %), complex surgery (29.2 %) and pain (12.8 %). Surgical times were higher in patients on admission (p < 0.001) and in those who caused PNP (p < 0.001). Surgical time greater than 45 minutes was a significant cause of PNP (p = 0.007). The overall rate of surgical site infection was 3.1 %, with deep infection being 0.59 %. No patient was readmitted in the first 24 hours, with 30-day emergency care being 8.2 % (n = 73), readmission rate of 1.91 % (n = 17), with a reoperation rate of 0.35 % (n = 3). The biliary fistula rate was 0.67 %. Conclusion: CLA is a safe and expansive technique, although obtaining quality standard parameters is complex due to the diversity of units.(AU)

Tratamiento del síndrome de Budd-Chiari agudo intraoperatorio mediante colocación de prótesis de silicona / Treatment of acute intraoperative Budd-Chiari syndrome by placement of silicone prosthesis

La movilización hepática completa para resecciones mayores provoca, en ocasiones, basculación del hígado secundaria a la liberación de sus elementos suspensorios. Esto puede ocasionar una malposición hepática con obstrucción aguda al flujo venoso a nivel de las suprahepáticas (síndrome de Budd-Chiari). Para salvar esta complicación se han descrito técnicas como colocación de sondas de Foley, balón Sengstaken-Blakemore o implantación de endoprótesis vasculares en el postoperatorio. Aquí presentamos el caso de un paciente al que se le realizó una movilización completa para resección de un tumor renal derecho y resección de vena cava inferior por trombosis de ésta hasta entrada de las venas suprahepáticas. Durante el proceso se produjo un Budd-Chiari agudo por malposición del hígado que fue resuelto con la colocación de dos prótesis de silicona en la celda hepática (AU)

Complete liver mobilization for major resections sometimes causes liver tilting due to the release of the suspensory elements of the liver. Rarely this may take to a liver abnormal position with acute obstruction to venous flow at the suprahepatic level (Budd-Chiari syndrome). To avoid this complication, techniques such as post-operative stent implantation have been described. The case of a patient who underwent a complete mobilization of the liver for resection of the inferiour venous cava and a right renal tumor, was reported. After that, an acute Budd-Chiari Syndrome was observed caused of the liver malposition, which was solved with the placement of two silicone prostheses in the liver cell (AU)

Perioperative and oncologic outcomes of interval colectomy performed by acute care surgeons after stenting as a bridge to surgery for left-sided malignant colonic obstruction are non-inferior to the outcomes of colorectal surgeons in the elective setting: single center experience.

PURPOSE: To analyze if perioperative and oncologic outcomes with stenting as a bridge to surgery (SEMS-BS) and interval colectomy performed by acute care surgeons for left-sided occlusive colonic neoplasms (LSCON) are non-inferior to those obtained by colorectal surgeons for non-occlusive tumors of the same location in the full-elective context. METHODS: From January 2011 to January 2021, patients with LSCON at University Regional Hospital in Málaga (Spain) were directed to a SEMS-BS strategy with an interval colectomy performed by acute care surgeons and included in the study group (SEMS-BS). The control group was formed with patients from the Colorectal Division elective surgical activity dataset, matching by ASA, stage, location and year of surgery on a ratio 1:2. Stages IV or palliative stenting were excluded. Software SPSS 23.0 was used to analyze perioperative and oncologic (defined by overall -OS- and disease free -DFS-survival) outcomes. RESULTS: SEMS-BS and control group included 56 and 98 patients, respectively. In SEMS-BS group, rates of technical/clinical failure and perforation were 5.35% (3/56), 3.57% (2/56) and 3.57% (2/56). Surgery was performed with a median interval time of 11 days (9-16). No differences between groups were observed in perioperative outcomes (laparoscopic approach, primary anastomosis rate, morbidity or mortality). As well, no statistically significant differences were observed in OS and DFS between groups, both compared globally (OS:p < 0.94; DFS:p < 0.67, respectively) or by stages I-II (OS:p < 0.78; DFS:p < 0.17) and III (OS:p < 0.86; DFS:p < 0.70). CONCLUSION: Perioperative and oncologic outcomes of a strategy with SEMS-BS for LSCON are non-inferior to those obtained in the elective setting for non-occlusive neoplasms in the same location. Technical and oncologic safety of interval colectomy performed on a semi-scheduled situation by acute care surgeons is absolutely warranted.

Donation After Cardiac Death in Liver Transplantation: An Additional Source of Organs With Similar Results to Donation After Brain Death.

BACKGROUND: As new sources of organs are needed, liver transplantation using donors after cardiac death (DCD) is progressively increasing, but outcomes with this method are still questioned. This study was accomplished to verify that DCD outcomes are comparable to those seen in donation after brain death (DBD). METHODS: This was a prospective cohort study including 100 liver transplantation performed between 2014 and 2017, divided according to donor type in 75 DBD and 25 DCD. RESULTS: DCD donors were younger (mean age: DCD 56 years, DBD 59 years; P = .009). Mean Modified End-stage Liver Disease (MELD) score was lower for DCD (DCD 16, DBD 19; P < .001). No differences were found regarding ischemia times and development of postreperfusion syndrome or coagulopathy. Primary graft dysfunction was more frequent in DCD (60%, DCD 29.3%; P = .006). Rates of primary graft nonfunction (DCD 0%, DBD 1.3%; P = .562) and acute rejection (DCD 20%, DBD 16.4%; P = .685) were similar. Acute kidney injury occurred more often in DBD (DCD 32%, DBD 12%; P = .051). Length of stay was comparable. Rates of biliary complications (DCD 20%, DBD 26.7%; P = .505) were similar, unlike ischemic cholangiopathy (DCD 12%, DBD 1.3%; P = .018). Retransplantation rates were also similar (DCD 8%, DBD 4%; P = .427) as was survival rate after 3 years (DCD 84%, DBD 86.7%; P = .739). CONCLUSION: DCD represents an additional graft source with results that are encouraging and may be comparable to DBD with a careful donor and recipient selection.

Comparison of 3 Explant-Based Prognostic Models as Predictors of Hepatocellular Carcinoma Recurrence After Liver Transplantation: Analysis of Our Experience.

Tumor load is often underdiagnosed on radiological examination previous to liver transplantation (LT) for hepatocarcinoma (CHC). Thus, post-liver transplant explant analysis is required following transplantation to assess the risk of the recurrence of CHC. The objectives were to compare the characteristics of CHC on pre-LT radiological examination and explant histology and validate three models for the prediction of recurrence based on data from a cohort of patients treated in our hospital. METHODS: A retrospective study was undertaken of 105 LTs for CHC performed in our unit between January 2006 and January 2015. The minimum follow-up was five years. The preoperative radiological tumor stage was compared to the explant-based histologic stage. Three prognostic models were validated using our cohort of patients. RESULTS: Following Milan's criteria, the tumor load was underdiagnosed on pre-LT radiological examination in 20 patients, which accounted for 19% of the total sample. The 5-year overall recurrence was 6.6% for scores <4 and 33.3% for scores ≥4 according to Decaens' model; 7% for scores ≤7 and 25% for scores >7 in the Up-to-Seven model; and 3.6% for PCRS ≤0, 27.8% for PCRS1-2, and 100% for PCRS≥3 according to Chan's model. The predictive model for 5-year recurrence after LT with the greatest area under the curve was Chan's model (0.813 [95% CI: 0.650-0.977]) versus Decaens' model (0.674 [95% CI: 0.483-0.866]) and the Up-to-Seven model (0.481 [95% CI: 0.296-0.667]). CONCLUSIONS: A pre-LT radiological examination leads to the underdiagnosis of tumor load, and the risk for recurrence must be recalculated following LT. In light of the results obtained, Chan's model is more accurate in predicting 5-year recurrence of CHC post-LT based on 3 levels of risk. New prognostic models are needed to optimize the prediction of recurrence after liver transplantation for hepatocarcinoma.

Combined Flush With Histidine-Tryptophan-Ketoglutarate and University of Wisconsin Solutions in Liver Transplantation: Preliminary Results.

INTRODUCTION: Ischemia reperfusion injury (IRI) is the main cause of early allograft dysfunction (EAD) and subsequent primary allograft failure (PAF). OBJECTIVES: The purpose of this study is to compare IRI, EAD, and PAF in liver transplantation in a cohort of patients perfused with histidine-tryptophan-ketoglutarate (HTK) solution and University of Wisconsin (UW) solution versus HTK alone. METHODS: A randomized trial was performed to compare outcomes in liver recipients who underwent transplantation surgery in the University Regional Hospital of Malaga, Spain. Forty patients were randomized to two groups. Primary endpoints included IRI, EAD, PAF, re-intervention, acute cellular rejection, retransplantation, arterial complications, and biliary complications at postoperative day 90. RESULTS: Postoperative glutamic oxaloacetic transaminase (1869.15 ± 1559.75 UI/L vs. 953.15 ± 777.27 UI/L; P = .004) and glutamic pyruvic transaminase (1333.60 ± 1115.49 U/L vs. 721.70 ± 725.02 U/L; P = .023) were significantly higher in patients perfused with HTK alone. A clear tendency was observed in recipients perfused with HTK alone to present moderate to severe IRI (7 patients in the HTK + UW solution group vs. 15 patients in the HTK-alone solution group; P = .06), EAD (0 patients in the HTK + UW solution group vs. 0 patients in the HTK-alone solution group; P = .76), and PAF (3 patients in the HTK + UW solution group vs. 8 patients in the HTK-alone solution group; P = .15). CONCLUSIONS: Initial perfusion with HTK solution followed by UW solution in liver transplantation improves early liver function as compared to perfusion with HTK alone.

Up-to-7 Criteria for Hepatocellular Carcinoma Liver Transplantation: A Retrospective Analysis of Experiences.

INTRODUCTION: The expansion of criteria for hepatocellular carcinoma (HCC) liver transplantation should produce satisfactory outcomes in terms of survival and recurrence. OBJECTIVES: To investigate if the up-to-7 criteria are applicable to liver transplantation for HCC. METHODS: A review of all liver transplantations performed at our unit between January 2002 and December 2010 was conducted (645 patients). The 91 patients of the sample who had HCC were divided into 3 groups: in Milan criteria (MC; n = 74), in up-to-7 criteria (UTSC; n = 12), and outside of up-to-7 criteria (OUTSC; n = 5). A descriptive retrospective study was carried out to analyze the characteristics of liver tumors and recipients and to estimate recurrence and survival rates for this population of patients. RESULTS: The characteristics of transplant recipients of the 3 groups were comparable. Statistically significant differences were observed in the number of tumors (1 ± 0.65 for MC, 3 ± 1.05 for UTSC, 6 ± 4.10 for OUTSC; P < .001), largest tumor size (2.47 ± 1.12 cm for MC, 3.78 ± 0.04 cm for UTSC, 4.04 ± 1.73 cm for OUTSC; P < .001), and recurrence (5.4% for MC; 33.3% for UTSC; 20% for OUTSC; P = .008). Survival rates (MC, UTSC, and OUTSC) at 3 and 5 years were 71.6%, 66.7%, and 60%, and 58.1%, 58.3%, and 40%, respectively, whereas tumor-free survival rates were 70.3%, 58.3%, and 60%, and 58.1%, 50%, and 40%, respectively. CONCLUSIONS: Survival in patients with HCC transplanted under up-to-7 criteria is acceptable. However, the expansion of criteria involves an increase in the number of patients included in the waiting list and a higher probability of relapse.

Acute Liver Failure Caused by Primary Non-Hodgkin's Lymphoma of the Liver.

INTRODUCTION: Acute liver failure (ALF) is a rare syndrome involving maximum liver dysfunction. This disease is characterized by a less than 26-week history of coagulopathy (INR ≥1.5) and hepatic encephalopathy and generally occurs in patients without any previously known disease. METHODS: We report the case of a healthy 25-year-old subject who presented with fulminant liver failure caused by a primary non-Hodgkin's lymphoma of the liver that required emergency liver transplantation. Diagnosis was based on pathologic confirmation of T-cell/histiocyte-rich large B-cell lymphoma and submassive hepatocyte necrosis. One year after surgery, the patient remains in complete remission. CONCLUSIONS: Fulminant liver failure is a sudden-onset severe disease that can be caused by a primary non-Hodgkin's lymphoma of the liver, which accounts for <1% of extranodal lymphomas. The diagnosis of this rare disease demands high diagnostic suspicion, and progression can be prevented through liver transplantation.

Pancreas Preservation With Viaspan, Celsior, and Custodiol Solutions: An Initial Experience.

BACKGROUND: There is still controversy about which preservation solution in pancreas transplantation could be the best. The aim of this study was to analyze our initial experience with Custodiol solution (CuS) compared with Viaspan solution (VS) and Celsior solution (CS) in pancreas transplantation. METHODS: A retrospective study included 94 consecutive pancreatic transplants, from 2007 until 2015. We compared 3 groups, depending on preservation solution: Viaspan (n = 41), Celsior (n = 40), or Custodiol (n = 13). The primary end point was patient and pancreas survival at 1 year after pancreas transplantation. RESULTS: The recipient and donor characteristics were similar except in cold ischemia time; it was higher with Celsior. No differences were found in postoperative complications and pancreas graft function at 3 months, 6 months, and 1 year (glucose, HbA1c, C-peptide, creatinine). The pancreas and patient survival at 1 year was comparable (pancreas survival: VS, 80%; CS, 90%; CuS, 92%; log-rank, 0.875; and patient survival: VS, 92%; CS, 97%; CuS, 100%; log-rank, 0.9). CONCLUSIONS: In our institution, the Custodiol solution in pancreas transplantation presented similar outcomes in terms of postoperative complications, pancreas graft function, and 1-year survival.

Impact of Liver Graft Transport on Postoperative Results and Short-Term Liver Survival.

BACKGROUND: The Andalusian community has a specific management model of liver transplantation with a common waiting list, forcing transportation of 45% of hepatic grafts. These trips within the community have been made exclusively via expressway since 2012, sometimes surpassing 400 km in distance. The objective of this study was to analyze the effect of graft transportation on our community regarding postoperative results, primary dysfunction, and short-term graft survival. METHODS: This was a retrospective observational cohort study that included 110 patients recipients of liver transplants from 2009 to 2012. Group A (n = 53) were patients transplanted with grafts removed in Malaga, and group B (n = 57) were patients with transported grafts. RESULTS: In group B, significant increments in total and cold ischemia time (TIT and CIT) were found. We found a significant higher increase, mostly in 2012, in TIT and CIT in the greater transportation distance subgroup (>150 km). In postoperative variables analysis, differences were found in the bilirubin levels the 1st postoperative day, alkaline phosphatase levels the 1st and 3rd days, and factor V in the 1st day in favor of the nontransported grafts. In the multivariable analysis transport and distance travelled in km presented a relationship with the 1st day bilirubin levels and the primary dysfunction of the graft. CONCLUSIONS: Our results point to graft transportation having an influence on primary dysfunction and graft survival. This relationship can be multifaceted and influenced by currently unknown factors. This is a factor to consider regarding liver transplant management strategy decisions.

Results of Liver Transplantation With Donors Older than 75 Years: A Case-Control Study.

BACKGROUND: The inclusion of elderly donors can increase the pool of organs available for transplantation. The objective of this study was to compare clinical outcomes and survival rates of patients who received livers from donors aged ≥75 years versus younger donors. METHODS: We considered all liver transplantations performed in our unit from January 2006 to January 2015. Thirty-two patients received a liver from a cadaveric donor aged ≥75 years (study group), and their outcomes were compared with those of patients who received a liver from a younger donor (control group) immediately before and after each transplantation in the study group. This is a descriptive, retrospective, case-control study carried out to analyze the characteristics of donors and recipients as well as the clinical course and survival of recipients of older and younger donors. RESULTS: Statistically significant differences were observed according to donors' age (53.3 ± 13.6 vs 79 ± 3.4 years; P < .001). In total, 6.2% of the recipients of a liver from a donor aged <75 years required retransplantation versus 15.6% of recipients of donors ≥75 years. Patient survivals at 1, 3, and 5 years, respectively, were 89%, 78.6%, and 74.5% for recipients of donors <75 years versus 83.4%, 79.4%, and 59.6% for the study group. CONCLUSIONS: Livers from older donors can be safely used for transplantation with acceptable survival rates. However, survival rates are lower for recipients of livers from older donors compared with younger donors, and survival only increased with retransplantation.

Safety and Efficacy of Early Everolimus When Calcineurin Inhibitors Are Not Recommended in Orthotopic Liver Transplantation.

Our aim was to study the safety and efficacy of immunosuppression with everolimus (EVL) within the 1st month after orthotopic liver transplantation (LT) when calcineurin inhibitors are not recommended. For this purpose, 28 recipients who had been treated with EVL within the 1st month after adult LT were eligible to enter in a retrospective multicenter study. Patients were followed up for 12 months after LT. EVL therapy was initiated at a median of 14 days (range, 4-24) after LT. The reason for early EVL was neurotoxicity in 14 cases, renal dysfunction in 12, and acute cellular rejection combined with renal impairment in 2. In 23 patients, immunosuppression was EVL + mycophenolate mofetil/mycophenolate sodium + steroids, and EVL + tacrolimus + steroids/mycophenolate sodium was used in 4 cases. Neurotoxicity disappeared in all patients. Renal function in patients with renal impairment improved from a median of 32 mL/min/1.73 m2 at the moment of implementation of EVL to 62 mL/min/1.73 m2 at 1 year. Four patients (14.3%) developed acute cellular rejection. We observed incisional hernia in 4 patients (14.3%), hematologic complications in 6 (21.4%), proteinuria in 2 (7.1%), edema and/or effusions in 8 (28.6%), and dyslipidemia in 12 (42.8%). No arterial complications were observed. EVL was withdrawn in 5 patients during the 1st year after LT. One-year patient survival was 92.7%. In conclusion, use of EVL within the 1st month after LT when calcineurin inhibitors are not recommended seems to be an effective therapeutic option with an acceptable safety profile.

Everolimus plus mycophenolate mofetil as initial immunosuppression in liver transplantation.

BACKGROUND: The purpose of this study was to assess the efficacy and safety of a de novo immunosuppressive regimen with everolimus (EVL) plus mycophenolate mofetil (MMF) without calcineurin inhibitors (CNI) for liver transplantation. The secondary purpose was to compare the renal function with a control group of patients treated with tacrolimus plus MMF. METHODS: Sixteen male and 4 female liver transplant patients received immunosuppression with EVL plus MMF without CNI, with induction with steroids and 16 with basiliximab also. In 10 cases it was indicated as induction immunosuppression without CNI as prevention against nephrotoxicity and neurotoxicity or recurrence of hepatocarcinoma in predisposed patients and in another 10 after withdrawing CNI during the immediate post-transplant period, before hospital discharge, as the result of toxicity, mainly nephrotoxicity and neurotoxicity or the presence of hepatocarcinoma with a high risk of recurrence. A control group comprising 31 patients taking tacrolimus plus MMF was included to compare the renal function. RESULTS: The mean follow-up time was 24 months. One patient had a recurrence of hepatocarcinoma at 8 months after transplant. The cases of nephrotoxicity and neurotoxicity resolved favorably. There were 7 rejections (35%); 2 evolved to chronic rejection with both needing retransplantation, 2 resolved with dose adjustment, and 3 required conversion to CNI. The side effects were hyperlipidemia (25%), wound dehiscence (10%), lymphedema (10%), cytomegalovirus infection (25%), myelotoxicity (25%) and proteinuria >1 g in 1 case (5%). No differences were found in renal function between the two groups. CONCLUSIONS: This regimen was proven to be efficient to prevent and treat nephrotoxicity and neurotoxicity with an acceptable tolerability profile. However, the high associated rejection rate indicates that great caution is required in its use during the immediate post-transplant period. It is advisable to associate the regimen with low doses of CNI and to have agile methods available to monitor EVL to enable rapid dose adjustment.

Induction therapy in simultaneous pancreas-kidney transplantation: thymoglobulin versus basiliximab.

BACKGROUND: Induction therapy for simultaneous pancreas-kidney (SPK) transplantation. Both thymoglobulin (ATG) and basiliximab are the most-used types of induction antibodies therapies in clinical practice. The aim of our report was to analyze our experience comparing 2 induction therapies, for SPK transplantation in terms of pancreas and patient survival, as well as rejection rate. METHODS: We reviewed retrospectively a total of 97 SPK transplantations in our institution. The cases were divided according to induction therapy in 2 groups, basiliximab (n = 38) and ATG (n = 59). Rejection, patient and graft survival, and postoperative complications were analyzed. RESULTS: Survival in the ATG group was better without statistical difference at 1-, 3-, and 5-year follow-up (97%, 95%, and 95% versus 92%, 90%, and 87%, respectively). No difference was detected in pancreas graft survival after 1-, 3-, and 5-year follow-up (basiliximab 85%, 80%, and 77% versus ATG 84%, 84%, and 81%, respectively; log-rank, 0.847). Overall cellular rejection and early rejection were more common in the basiliximab group (30 versus 14%, and 21% versus 6%). In the multivariate analysis considering human leukocyte antigen (HLA) mismatches, the ATG group was a protective factor for cellular rejection. Major complications (Grade III-IV) and median length of the hospital stay were higher in the basiliximab group (55% versus 34%, P = .057, and 21 versus 16 days, P = .056). CONCLUSIONS: The pancreas graft survival was not affected by induction therapy. ATG induction therapy compared with basiliximab is associated with lower overall and early rejection rate. Over time this difference disappears.

Acetylcholinesterase inhibitory activity of Haplophyton cimicidum.

In Oaxaca, México, Haplophyton cimicidum is used in combination with other plants as part of a folk strategy against arthropod pests of crops and cattle. Methanolic and crude alkaloid (acid-base extraction) extracts of H. cimicidum leaves were analysed by thin-layer chromatography (TLC) and assayed in vitro for acetylcholinesterase (AChE) inhibitory activity using Spodoptera frugiperda homogenates as source of enzyme. Derivatised chromatographic plates indicated the presence of indoles and alkaloids in the extracts. The crude alkaloid extract exhibited a higher number of compounds than the methanolic extract as judged by the number of spots on TLC plates. The crude alkaloid extract had a weak inhibition potential of AChE with a lower IC50 (93 µg mL(-1)) than the methanolic extract (159 µg mL(-1)). Indole alkaloids may be responsible for the activity, though a subsequent analysis of the extract components is necessary to determine the active alkaloid(s).

"Very early" intrahepatic cholangiocarcinoma in cirrhotic patients: should liver transplantation be reconsidered in these patients?

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 ≤2 cm ("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 >2 cm 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 ≤2 cm achieved excellent 5-year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs.

Intrahepatic cholangiocarcinoma or mixed hepatocellular-cholangiocarcinoma in patients undergoing liver transplantation: a Spanish matched cohort multicenter study.

OBJECTIVE: To evaluate the outcome of patients with hepatocellular-cholangiocarcinoma (HCC-CC) or intrahepatic cholangiocarcinoma (I-CC) on pathological examination after liver transplantation for HCC. BACKGROUND: Information on the outcome of cirrhotic patients undergoing a transplant for HCC and with a diagnosis of HCC-CC or I-CC by pathological study is limited. METHODS: Multicenter, retrospective, matched cohort 1:2 study. STUDY GROUP: 42 patients undergoing a transplant for HCC and with a diagnosis of HCC-CC or I-CC by pathological study; and control group: 84 patients with a diagnosis of HCC. I-CC subgroup: 27 patients compared with 54 controls; HCC-CC subgroup: 15 patients compared with 30 controls. Patients were also divided according to the preoperative tumor size and number: uninodular tumors 2 cm or smaller and multinodular or uninodular tumors 2 cm or larger. Median follow-up: 51 (range, 3-142) months. RESULTS: The 1-, 3-, and 5-year actuarial survival rate differed between the study and control groups (83%, 70%, and 60% vs 99%, 94%, and 89%, respectively; P < 0.001). Differences were found in 1-, 3-, and 5-year actuarial survival rates between the I-CC subgroup and their controls (78%, 66%, and 51% vs 100%, 98%, and 93%; P < 0.001), but no differences were observed between the HCC-CC subgroup and their controls (93%, 78%, and 78% vs 97%, 86%, and 86%; P = 0.9). Patients with uninodular tumors 2 cm or smaller in the study and control groups had similar 1-, 3-, and 5-year survival rate (92%, 83%, 62% vs 100%, 80%, 80%; P = 0.4). In contrast, patients in the study group with multinodular or uninodular tumors larger than 2 cm had worse 1-, 3-, and 5-year survival rates than their controls (80%, 66%, and 61% vs 99%, 96%, and 90%; P < 0.001). CONCLUSIONS: Patients with HCC-CC have similar survival to patients undergoing a transplant for HCC. Preoperative diagnosis of HCC-CC should not prompt the exclusion of these patients from transplant option.

Pancreas graft survival in simultaneous pancreas-kidney versus pancreas-after-kidney and pancreas alone transplantations: a single institution experience.

BACKGROUND: Pancreas transplantation offers excellent outcomes today in patients who have type-1 diabetes mellitus (DM) with difficult control in terms of increasing patient and pancreatic graft survival. Different factors in donors, recipients, and the perioperative period have been associated with long-term graft survival. The aim of this study was to compare pancreatic graft survival in simultaneous pancreas-kidney transplantation (SPK) and the other two modalities, pancreas-alone and pancreas-after-kidney transplantation (non-SPK), at our institution. METHODS: This retrospective cohort study included 63 pancreas transplantation patients from January 2007 to May 2012 at our institution. The patients were divided into two groups: SPK and non-SPK transplantations. We excluded those patients who had transplants with vascular graft loss. The primary endpoint was 1-year and overall graft survival with consideration of multiple relevant variables. Non-parametric tests were calculated with the statistical package SPSS 20 (SPSS INC, Chicago, IL). RESULTS: The 1-year and overall graft survival in this period was 87.3% and 82.5%, respectively. The median follow-up was 963 days. The causes of graft loss were vascular (64%) and immunologic (34%). Finally, we included 56 pancreas transplantations, 46 (82%) were SPK and 10 (18%) non-SPK. The donor and recipient characteristics were similar in both groups, except for the duration of DM (SPK 22 years vs. non-SPK 29 years) and recipient body mass index (SPK 23 vs. non-SPK 28); P = .042 and P = .003, respectively. The cold ischemia time was 563 minutes (standard deviation, 145). Bivariate analysis showed that long-term graft loss was only influenced by matching for gender (P = .023). Using the Kaplan-Meier method, the pancreas graft survival was better in SPK than in non-SPK transplants (log rank .038). CONCLUSIONS: Patients who receive pancreas-alone or pancreas-after-kidney grafts have shorter long-term graft survival. Multiple strategies should be applied to improve immunologic surveillance and obtain an early diagnosis of graft rejection.