Profile of Liver Transplant Recipient in a Tertiary Hospital in Northern Spain.

Spain has the highest rates of liver transplantation (LT) per million inhabitants in the world, with the profiles of both donors and recipients in Asturias, a region in northern Spain, being different from the rest of the country. The main goal of this study was to carry out a preliminary analysis of the characteristics of LT recipients in Asturias, as well as of the basic characteristics of surgery and the postoperative period, and to discuss whether the results obtained in this study were comparable to what is described in the literature. This was a retrospective, descriptive, cross-sectional study, analyzing the LT carried out in a reference center of Asturias between 2002 and 2017. Relative and absolute frequency distributions for qualitative variables are provided, as are position and dispersion measures for quantitative variables. Using the multivariate Cox regression model, the prognostic factors associated with overall survival were determined. A total of 533 LTs were analyzed; 431 were men and 102 were women. The mean age was 55.1 years, concentrated between 40 and 69 years for both genders. LT was performed for chronic parenchymal liver disease (mostly of alcoholic etiology) and the recipients underwent surgery in an advanced stage of liver disease. Of these recipients, 8.1% (43 patients) were retransplantions, 65.1% in the first year due to primary graft dysfunction and complete hepatic artery thrombosis. Most patients had presented a grade II of Clavien-Dindo as the most frequent complication. Biliary complications were found in 12.3% of patients, with the main cause of death in the first 30 days being instability in the 24 h after LT. The median survival of the group was 13 years, with a 5-year survival probability of 79.3% and a 10-year survival probability of 61.9%. In view of the analyzed series, it can be concluded that the most frequent recipient profile was a male patient (mean age 55 years), with a significant alcohol habit, who was overweight, with chronic parenchymal liver disease of alcoholic or viral etiology, and who had reached the Child C stage before LT. This study could lay the foundations for future studies, to complete this analysis with the characteristics of LT surgery, its postoperative period, and the follow-up after discharge, to obtain a broader view of LT recipients in this region.

Ventral Portal Vein Over Gallbladder and Pancreas---An Exceptional Anatomical Variation Found in a Liver Transplant Patient: A Case Report.

BACKGROUND: Anatomic variations are well known in the liver hilum. A rare precholecystic, preduodenal, prepancreatic portal vein is described as found in a liver transplant candidate. Precholecystic location of portal vein is an exceptional finding and does not seem to have been previously described. It is associated with a preduodenal portal vein. Its position is challenging, as its surface can be mistaken with the gallbladder wall. We present the case of a patient candidate to liver transplantation. In the preoperative studies, a portal thrombosis was suspected, with recanalization by collaterals, but also a malformation was suggested. The patient had a primary biliary cirrhosis. Other findings included agenesis of inferior vena cava on the right side. During operation, the portal vein was found over the gallbladder and fixed to it, making it at first difficult to distinguish one from the other. CONCLUSIONS: A precholecystic portal vein is a rare finding that poses a challenge for the surgeon. It must be ruled out in the preoperative workout.

Perforación intestinal tras liposucción / Intestinal perforation after liposuction

No disponible

Liver transplantation for adenomatosis: European experience.

The aim of this study was to collect data from patients who underwent liver transplantation (LT) for adenomatosis; to analyze the symptoms, the characteristics of the disease, and the recipient outcomes; and to better define the role of LT in this rare indication. This retrospective multicenter study, based on data from the European Liver Transplant Registry, encompassed patients who underwent LT for adenomatosis between January 1, 1986, and July 15, 2013, in Europe. Patients with glycogen storage disease (GSD) type IA were not excluded. This study included 49 patients. Sixteen patients had GSD, and 7 had liver vascular abnormalities. The main indications for transplantation were either a suspicion of hepatocellular carcinoma (HCC; 15 patients) or a histologically proven HCC (16 patients), but only 17 had actual malignant transformation (MT) of adenomas. GSD status was similar for the 2 groups, except for age and the presence of HCC on explants (P = 0.030). Three patients with HCC on explant developed recurrence after transplantation. We obtained and studied the pathomolecular characteristics for 23 patients. In conclusion, LT should remain an extremely rare treatment for adenomatosis. Indications for transplantation primarily concern the MT of adenomas. The decision should rely on morphological data and histological evidence of MT. Additional indications should be discussed on a case-by-case basis. In this report, we propose a simplified approach to this decision-making process.

Impact of tacrolimus and mycophenolate mofetil regimen vs. a conventional therapy with steroids on cardiovascular risk in liver transplant patients.

The aim of this study was to evaluate the impact of a steroid-free regimen with tacrolimus and mycophenolate mofetil (modified therapy) vs. a standard regimen of tacrolimus and steroids on the cardiovascular risk score of liver transplant recipients. Patients who received a liver transplant were randomized to a modified therapy (n = 58) or a standard regimen (n = 59). Both groups were balanced at baseline, except for a higher prevalence of diabetes mellitus (DM) (p < 0.01) and a higher serum creatinine concentration (p < 0.05) in the modified therapy group. After 12 months, the prevalence of new-onset DM, arterial hypertension, hypercholesterolemia, hypertriglyceridemia, and changes in cardiovascular risk factors was similar in both groups. The increase in serum creatinine (mg/dL) compared to baseline at one yr post-transplantation was numerically lower in the modified therapy group (0.22 ± 0.42) than in the standard regimen group (0.41 ± 0.67) (p = 0.068). Although estimated cardiovascular risk score did not vary significantly compared to baseline in either group, there was a slight reduction in the modified regimen (-0.27 ± 2.87) vs. a mild increase (0.17 ± 2.94) in the standard regimen (p = 0.566). In conclusion, a steroid-free regimen with tacrolimus and mycophenolate mofetil was associated with a trend toward better preservation of kidney function and reduction of cardiovascular risk score.

Inflammatory pseudotumor of spleen: a case report.

INTRODUCTION: Inflammatory pseudotumor of spleen is an extremely rare benign condition of uncertain etiology that presents with nonspecific symptoms or as an incidental finding in patients studied by other processes. Since the first description in 1984 by Cotelingam and Jaffe, only 114 cases have been reported. PRESENTATION OF CASE: We present a case of a fifty-six years old woman with a splenic injury in ultrasound and computed tomography. The patient undergoes laparoscopic splenectomy and the histologic study of the specimen revealed findings consistent with inflammatory pseudotumor of spleen. DISCUSSION: This rare entity whose pathogenesis is still unknown, can present with nonspecific symptoms. Radiologic studies may lead the diagnosis being useful CT and MRI. The definitive diagnosis is established with the histological findings, characterized by the presence of inflammatory cells with areas of necrosis and fibrosis. There are multiple differentials diagnoses: metastasis, lymphoma, splenic infarction, hemangiomas, vascular malformations, lymphangioma, plasmacytoma, reactive lymphoid hyperplasia, abscess and infectious granulomatous processes; therefore suspicion of malignant neoplasm must be considered, being indicated splenectomy to confirm the diagnosis. CONCLUSION: Inflammatory pseudotumor of spleen is a benign disease, in which diagnostic approach must bear in mind the possibility of a malignant lesion. For this reason, the surgical approach is appropriate to confirm the diagnosis and rule out malignancy with histology.

Intestinal and multivisceral autotransplantation for tumors of the root of the mesentery: Long-term follow-up.

OBJECTIVE: To present the indications, techniques, short- and long-term outcomes after visceral exenteration, ex vivo resection, and intestinal/multivisceral autotransplantation. PATIENTS AND METHODS: All patients who have undergone this procedure at our center were studied. Technique, postoperative complications, survival, tumor recurrence, and functional status were recorded. RESULTS: Ten patients, 4 children and 6 adults, have undergone these procedures since January 1999. Seven patients are alive at 13-138 months later, 6 with functioning autografts and one after rescue with an allotransplantation. CONCLUSION: Intestinal/multivisceral autotransplantation is a potentially valuable option for some otherwise unresectable neoplasms of the root of the mesentery.

Liver transplantation with preservation of the inferior vena cava: lessons learned through 2,000 cases.

BACKGROUND: We aim to demonstrate the utility and efficacy of the "piggyback technique" (PBT); liver transplant (LT) with caval preservation. STUDY DESIGN: Adult LTs were performed with intent to use the PBT except in cases of juxtacaval malignancy or technical difficulty. Hepatic venous outflow was established between the donor suprahepatic cava and the joined ostia of all recipient suprahepatic veins. Technical variants with the donor cava and recipient retrohepatic cava were used as needed. The experience was divided into 2 eras: E1 (1994-2002), E2 (2002-2010). RESULTS: We completed 945 of 1080 LTs in E1 (87.5%) and 851 of 920 LTs in E2 (92.5%) using the PBT. Thirty day mortality was 4.6% in E1, 3% in E2 (p = 0.02) with 2 intra-operative deaths in E1. One, 3, 5 year patient survival was 83.7, 75.6, 69.3% in E1 vs. 86, 78.4, 73.8% in E2 (p = 0.057). Graft survival was 77.7, 69, 62.3% in E1 vs. 84, 76.2, 71.2% in E2 (p < 0.0001). Median operative time and hospital length of stay improved in E2 (p < 0.0001, 0.0001). Outflow variants were used more frequently in E2 (11.3% vs. 6.1%). Nine patients (0.5%) developed outflow obstruction, 6 in E1, and 3 in E2. Twice, it was recognized and corrected intraoperatively. Seven patients presented with refractory ascites. Six were successfully treated (4 balloon dilatation, 2 surgical revision), one patient died after attempted dilatation. CONCLUSIONS: The PBT can be used as the preferred technique in adult LT. With experience, the technique was used more frequently, with more variants, with improved outcomes. Outflow obstruction was a rare complication.

Association between donor-specific antibodies and acute rejection and resolution in small bowel and multivisceral transplantation.

BACKGROUND: Donor-specific antibodies (DSA) are associated with acute kidney graft rejection, but their role in small bowel/multivisceral allograft remains unclear. We carried out a prospective study to understand the impact of DSA in the setting of intestinal allograft rejection. METHODS: Thirteen patients (15 grafts) were serially evaluated for DSA levels pre- and posttransplant. DSA was determined by Luminex and the results were interpreted as fluorescence intensity (FI), with FI more than 3000 considered positive. RESULTS: The clinical rejection episodes in allografts were significantly associated with the presence of DSA (P=0.041).We obtained 291 biopsy samples from graft ileum and date-matched DSA assay reports. Sixty-three (21.65%) of the biopsies showed acute rejection. The appearance of DSA were preformed (n=5, anti-human leukocyte antigen class II=3, anti-class I and II=2), de novo (n=4, 15.25±4.72 days after transplantation, anti-class II=1, and anti-class I and II=3) and never (n=6). Among the 63 biopsies, 30(47.6%) had significant correlations with positive DSA (kappa=0.30, P<0.001) and manifested severe rejection grade (P=0.009). CONCLUSIONS: In this cohort of small bowel/multivisceral transplantation patients, there was a high incidence of DSA. The presence of DSA should alert the clinical team of a higher risk of rejection, and reduction of the FI is clinically associated with resolution. Serial endoscopy guided biopsies combined with simultaneous DSA measurement in postintestinal transplantation follow-up is an effective means of screening for cellular and humoral-based forms of acute rejection.

A prospective randomized open study in liver transplant recipients: daclizumab, mycophenolate mofetil, and tacrolimus versus tacrolimus and steroids.

This open-label, randomized study compared the efficacy of a regimen of corticosteroids and tacrolimus (standard therapy group, n = 79) with a regimen of daclizumab induction therapy in combination with mycophenolate mofetil and tacrolimus (modified therapy group, n = 78) in primary liver transplant recipients. The primary endpoint was biopsy-proven acute rejection (BPAR) at 24 weeks. Secondary endpoints included time to rejection and patient and graft survival. The incidence of BPAR was significantly reduced in the modified therapy group compared to the standard therapy group (11.5% versus 26.6%, respectively, P = 0.017). The time to rejection was significantly shorter in the standard therapy group compared with the modified therapy group (P = 0.044). There was no significant difference between groups in patient or graft survival. Hepatitis C virus-positive patients exhibited no differences from hepatitis C virus-negative patients with respect to the incidence of BPAR. A steroid-sparing regimen of daclizumab, mycophenolate mofetil, and tacrolimus was effective and well tolerated in the prevention of BPAR in adult liver transplant recipients in comparison with a standard regimen of tacrolimus and steroids.

Successful treatment with bortezomib of a refractory humoral rejection of the intestine after multivisceral transplantation.

Graft rejection is a serious complication after intestinal and multivisceral transplantation. Classic anti-rejection strategies often focus on addressing the cellular component, however mounting evidence suggests that antibody mediated rejection may also play an important role in patient and graft survival. Bortezomib, a proteasome inhibitor used in the treatment of multiple myeloma, has been found to be useful in treating antibody mediated rejection in kidney transplant recipients. The following case illustrates how bortezomib was used to successfully reverse refractory rejection in a patient following multivisceral transplantation. While the rejection was able to be controlled, this patient's course was complicated by an aggressive viral infection after bortezomib therapy. Bortezomib may be a useful agent in the treatment of rejection after intestinal and multivisceral transplantation; however more data is needed to assess its impact on infectious complications in this complex group of patients.

Plasma procalcitonin measured by time-resolved amplified cryptate emission (TRACE) in liver transplant patients. A prognosis marker of early infectious and non-infectious postoperative complications.

BACKGROUND: Elevated procalcitonin (PCT) levels are observed after major surgery, such as orthotopic liver transplantation (OLTx). The aim of this observational study was to evaluate PCT kinetics during the first 5 following days after surgery to establish the prognostic value of PCT changes in the outcome of OLTx, and to predict medical, technical and infectious complications. PCT was also evaluated in the differential diagnosis of infection vs. rejection. METHODS: A total of 64 OLTx were performed in 58 patients; they were split into two groups: with and without complications. Out of these patients, 18 developed infection, and nine rejection. PCT was measured before and during surgery, 12 h after transplantation and daily for the 5 following days. PCT was also measured the day when infection or rejection was diagnosed, and on the previous day. PCT was determined by time-resolved amplified cryptate emission (TRACE) technology. RESULTS: PCT elevation began at 12 h after surgery, reaching a peak on the 1st day in both groups. Significantly higher PCT concentrations were found in the group of patients developing complications, on the 5 postoperative days. It was found that a 24 h PCT value higher than 1.92 microg/L increased by 9.1-time-fold the risk of complications. When infection was diagnosed, a second peak of PCT was observed, but no PCT elevation was shown in rejection. CONCLUSIONS: Daily monitored PCT provides valuable information about the early outcome of OLTx.

Criterios mínimos de trasplante hepático: Child, MELD, excepciones / No disponible

No disponible

Immunosuppression without steroids in liver transplantation is safe and reduces infection and metabolic complications: results from a prospective multicenter randomized study.

BACKGROUND/AIMS: The purpose of this study was to evaluate the efficacy of a steroid-free immunosuppression protocol. METHODS: From 2001 to 2004, 198 liver-transplant patients were randomized to receive immunosuppression with Basiliximab and cyclosporine, with (St Group) or without (NoSt Group) prednisone. The primary end points were acute rejection, and patient and graft survival. The secondary end points were infection, metabolic complications, and hepatitis C-virus recurrence. RESULTS: Overall rejection rate was 15%, with no differences (St: 13% vs NoSt: 18%; P=0.33). Infection rate was similar in both groups (St: 51% vs NoSt: 47%; P=0.56), but diabetic patients in the St Group had a significantly higher rate of bacterial infections (St: 54% vs NoSt: 14%; P=0.005). The six-month protocol biopsies showed hepatitis C recurrence in 90% of patients, without differences between groups. Hypertension was more frequent in the St Group (St: 44% vs NoSt: 25%; P=0.006). De novo diabetes rate was higher in the St Group (month 1: St: 29% vs NoSt: 18%; P=0.06), with higher glycatedHb (5.1+/-1.1 vs 4.4+/-0.8; P=0.002). Six-month survival rates were similar (St: 89% vs NoSt: 94%, P=0.62). CONCLUSIONS: Immunosuppression without steroids is safe and reduces infection and metabolic complications.

Immunoprophylaxis with basiliximab, a chimeric anti-interleukin-2 receptor monoclonal antibody, in combination with azathioprine-containing triple therapy in liver transplant recipients.

Acute graft rejection remains a major problem among additional sequelae in liver transplant recipients. Basiliximab, a chimeric monoclonal antibody with high affinity for the CD25 chain of the interleukin-2 receptor, has significantly reduced the incidence of acute rejection episodes in renal transplant recipients. This single-arm, open-label, multicenter study investigated the efficacy and tolerability of basiliximab immunoprophylaxis in adult patients undergoing first elective liver transplantation. One hundred one patients (70 hepatitis C virus [HCV]-negative patients, 31 HCV-positive patients) were administered basiliximab, 20 mg, by intravenous bolus injection the day of transplantation (day 0) and day 4. In addition, all patients were administered triple immunosuppressive therapy with cyclosporine, steroids, and azathioprine. The efficacy of basiliximab was assessed by conventional parameters, and tolerability was assessed by the incidence of adverse events, infections, and laboratory test result abnormalities. At 6 months, the incidence of first acute biopsy-confirmed rejection episodes was 22.8%. Rejections were more frequent in the HCV-positive (29.0%) than HCV-negative subgroup (20.0%; P =.441). No rejection episode was graded histologically as severe, and no patient required antibody therapy for the management of acute rejection. Ten patients (9.9%) required treatment with tacrolimus for acute rejection episodes. Patient and graft survival rates at 12 months were 90.1% and 88.1%, respectively. Basiliximab caused no injection-site reactions, anaphylaxis, or cytokine release syndrome. Five malignancies were reported at 12 months: of these, three malignancies predated transplantation surgery. Compared with earlier studies, the addition of basiliximab immunoprophylaxis to triple immunosuppressive therapy provides increased efficacy in reducing the incidence of acute rejection episodes, with no clinically significant increase in adverse events.

La ruptura intrabiliar como complicación de la hidatidosis hepática / Hepatic cysts with communication to the biliary tree

Se presentan 91 casos de quistes hepáticos comunicados a la vía biliar, de 435 casos de hidatidosis hepática intervenidos. La hidatidosis es una enfermedad endémica de diversos países de la región Mediterránea, Sudamérica y el Pacífico, y el hígado es el principal órgano afectado. En su evolución la apertura hacia la vía biliar es la complicación más frecuente. Las operaciones radicales sobre el quiste proporcionan los mejores resultados con menor morbimortalidad. El tratamiento del sistema biliar debe asegurar la evacuación completa de los componentes del parásito y prevenir complicaciones especialmente relacionadas con la fuga biliar. La fístula biliar y el absceso subfrénico son las complicaciones postoperatorias más frecuentes. La esfinteroplastia y coledocotomía con cierre primario son un procedimiento de elección (AU)

La ruptura intrabiliar como complicación de la hidatidosis hepática / Hepatic cysts with communication to the biliary tree

Se presentan 91 casos de quistes hepáticos comunicados a la vía biliar, de 435 casos de hidatidosis hepática intervenidos. La hidatidosis es una enfermedad endémica de diversos países de la región Mediterránea, Sudamérica y el Pacífico, y el hígado es el principal órgano afectado. En su evolución la apertura hacia la vía biliar es la complicación más frecuente. Las operaciones radicales sobre el quiste proporcionan los mejores resultados con menor morbimortalidad. El tratamiento del sistema biliar debe asegurar la evacuación completa de los componentes del parásito y prevenir complicaciones especialmente relacionadas con la fuga biliar. La fístula biliar y el absceso subfrénico son las complicaciones postoperatorias más frecuentes. La esfinteroplastia y coledocotomía con cierre primario son un procedimiento de elección