PROVIDE-HF primary results: Patient-Reported Outcomes inVestigation following Initiation of Drug therapy with Entresto (sacubitril/valsartan) in heart failure.

BACKGROUND: In PARADIGM-HF, sacubitril/valsartan improved quality of life (QOL) versus enalapril in heart failure with reduced ejection fraction (HFrEF), yet limited data are available regarding QOL changes after sacubitril/valsartan initiation in routine practice. METHODS: PROVIDE-HF was a prospective study within a national research network (Patient-Centered Outcomes Research Network) of HFrEF outpatients recently initiated on sacubitril/valsartan versus controls with recent angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation/dose change. The primary end point was mean Kansas City Cardiomyopathy Questionnaire (KCCQ) change through 12 weeks. Other end points included responder analyses: ≥5-point and ≥20-point KCCQ increase. Adjusted QOL change was estimated after propensity score weighting. RESULTS: Overall, 270 patients had both baseline and 12-week KCCQ data (151 sacubitril/valsartan; 119 control). The groups had similar demographics and HF details: median EF 28% and N-terminal pro-brain natriuretic peptide 1083 pg/mL. Sacubitril/valsartan patients had larger improvements in KCCQ (mean difference +4.76; P = .027) and were more likely to have a ≥5-point and ≥20-point response (all P < .05). Adjusted comparisons demonstrated similar numerical improvements in the change in KCCQ (+4.55; 95% CI -0.89 to 9.99; P = .101) and likelihood of ≥5-point increase (odds ratio 1.55; 95% CI: 0.84-2.86; P = .16); ≥20-point increase remained statistically significant (odds ratio 3.79; 95% CI 1.47-9.73; P = .006). CONCLUSIONS: In this prospective HFrEF study of sacubitril/valsartan initiation compared with recent angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation/dose change, the between-group difference in the primary end point, mean KCCQ change at 12 weeks was not statistically significant following adjustment, but sacubitril/valsartan initiation was associated with early improvements in QOL and a higher likelihood of ≥20-point improvement in KCCQ at 12 weeks. These data add additional real-world evidence related to patient-reported outcomes following the initiation of sacubitril/valsartan in routine clinical practice.

Fellows perspective of HPB training in Latin America.

BACKGROUND: Currently, no standards for HPB training exist in Latin America. The aim of this work is to evaluate fellows' experience of HPB training and the areas of opportunity to improve. METHODS: A 35 points survey was developed and distributed among fellows from dedicated HPB training programs in Latin America. The survey was applied by direct phone call (37%) or web based (63%), to fellows graduated between 2010 and 2014, from 7 different programs. RESULTS: Thirty-nine fellows from Argentina, Brazil, Chile and México were considered with a response rate of 82% (32/39). Most fellows (90%) shared cases with more than one co-fellow. Scrubbing with chief residents ocurred to 60% of fellows; only 14% of fellows noted having a primary surgeon role in more than 70% of cases. Median number of major hepatectomies during training was 15 (1-100), Whipple procedures 6 (1-40), and major bile duct repair 20 (1-80). Limited funding was the main reason to avoid HPB programs outside the country of origin. CONCLUSION: HPB training in Latin America requires more operative volume and autonomy. Financial burden is the main limitation to pursue training overseas. A multinational fellowship that takes advantage of each center may overcome differences in volume and type of cases.

Split liver transplantation: Report of right and left graft outcomes from a multicenter Argentinean group.

Grafts from split livers (SLs) constitute an accepted approach to expand the donor pool. Over the last 5 years, most Argentinean centers have shown significant interest in increasing the use of this technique. The purpose of this article is to describe and analyze the outcomes of right-side grafts (RSGs) and left-side grafts (LSGs) from a multicenter study. The multicenter retrospective study included data from 111 recipients of SL grafts from between January 1, 2009 and December 31, 2013. Incidence of surgical complications, patient and graft survival, and factors that affected RSG and LSG survival were analyzed. Grafts types were 57 LSG and 54 RSG. Median follow-up times for LSG and RSG were 46 and 42 months, respectively. The 36-month patient and graft survivals for LSG were 83% and 79%, respectively, and for RSG were 78% and 69%, respectively. Retransplantation rates for LSG and RSG were 3.5% and 11%, respectively. Arterial complications were the most common cause of early retransplantation (less than 12 months). Cold ischemia time (CIT) longer than 10 hours and the use of high-risk donors (age ≥ 40 years or body mass index ≥ 30 kg/m2 or ≥ 5 days intensive care unit stay) were independent factors for diminished graft survival in RSG. None of the analyzed variables were associated with worse graft survival in LSG. Biliary complications were the most frequent complications in both groups (57% in LSG and 33% in RSG). Partial grafts obtained from liver splitting are an excellent option for patients in need of liver transplantation and have the potential to alleviate the organ shortage. Adequate donor selection and reducing CIT are crucial for optimizing results.

Liver transplantation as last-resort treatment for patients with bile duct injuries following cholecystectomy: a multicenter analysis.

BACKGROUND: Liver transplantation (LT) has been used as a last resort in patients with end-stage liver disease due to bile duct injuries (BDI) following cholecystectomy. Our study aimed to identify and evaluate factors that cause or contribute to an extended liver disease that requires LT as ultimate solution, after BDI during cholecystectomy. METHODS: Data from 8 high-volume LT centers relating to patients who underwent LT after suffering BDI during cholecystectomy were prospectively collected and retrospectively analyzed. RESULTS: Thirty-four patients (16 men, 18 women) with a median age of 45 (range 22-69) years were included in this study. Thirty of them (88.2%) underwent LT because of liver failure, most commonly as a result of secondary biliary cirrhosis. The median time interval between BDI and LT was 63 (range 0-336) months. There were 23 cases (67.6%) of postoperative morbidity, 6 cases (17.6%) of post-transplant 30-day mortality, and 10 deaths (29.4%) in total after LT. There was a higher probability that patients with concomitant vascular injury (hazard ratio 10.69, P=0.039) would be referred sooner for LT. Overall survival following LT at 1, 3, 5 and 10 years was 82.4%, 76.5%, 73.5% and 70.6%, respectively. CONCLUSION: LT for selected patients with otherwise unmanageable BDI following cholecystectomy yields acceptable long-term outcomes.

Asociación de partición hepática y ligadura portal para hepatectomía diferida (ALPPS) en pacientes con enfermedad hepática avanzada / Associatng liver partton with portal vein ligaton for staged hepatectomy (ALPPS) in patents with advanced liver disease

La resección hepática es el único tratamiento con intención curatva para pacientes con enfermedades hepáticas malignas, primarias o secundarias. La posibilidad de lograr una resección curatva está limitada por el remanente hepático futuro y la insuficiencia hepática poshepatectomía es la complicación más grave de estos procedimientos. La asociación de partición hepática y ligadura portal para hepa-tectomía diferida (ALPPS) ha sido introducida en los últmos años como una estrategia novedosa para evitar la insuficiencia hepática poshepatectomía y permitr la resección en pacientes con enfermedad localmente avanzada, considerados previamente irresecables debido a un remanente hepático insuf-ciente. Esta técnica basa sus principios en dejar el hemihígado tumoral privado de fujo portal dirigiendo este al hígado para hipertrofar, mientras que la prevención de fujo cruzado intraparenquimatoso mediante la transección hepática maximiza el aumento de volumen en el remanente hepático. Son candidatos a esta cirugía aquellos pacientes con lesiones marginalmente resecables o primariamente irresecables unilaterales o bilaterales debido a un remanente hepático futuro inadecuado ya sea en volumen y/o calidad. La mayor parte de la evidencia actual obtenida respecto de ALPPS muestra hasta el momento resultados prometedores a corto plazo; de igual forma estos son dificiles de interpretar desde el punto de vista oncológico debido al grupo heterogéneo de pacientes con diferentes patologías de base, el uso variable de quimioterapia y las variaciones técnicas aplicadas. Sin embargo, el ALPPS es una estrategia factble y segura en manos de cirujanos experimentados, que debería ser tenida en cuenta como opción de tratamiento multdisciplinario, en pacientes oncológicos correctamente seleccionados y que hayan sido evaluados previamente en comités de tumores mult-disciplinarios. De esta forma, es necesario contar con mayor experiencia y resultados a largo plazo para poder defnir con mayor claridad cuál es el papel de este nuevo método.