Applicability and results of liver transplant combined with neoadjuvant chemo-radiotherapy in the treatment of unresectable hilar cholangiocarcinoma. / Aplicabilidad y resultados del trasplante hepático combinado con quimiorradioterapia neoadyuvante en el tratamiento del colangiocarcinoma perihiliar irresecable.

BACKGROUND: In 2007, a multicenter protocol was developed in Catalonia, Spain, combining neoadjuvant chemoradiotherapy and liver transplantation (LT) for those patients with unresectable hilar cholangiocarcinoma (hCCA). AIM: To analyse the effectiveness of the neoadjuvant chemoradiotherapy and LT for those patients enrolled in the protocol based on intention-to-treat. METHODS: Observational multicenter study which includes patients ≤ 68 years-old diagnosed with unresectable, solitary tumors ≤ 3 cm in radial diameter, without evidence of lymph node metastases. The protocol was based on a strategy of neoadjuvant therapy with high-dose radiation (45 Gy in total) plus intravenous fluorouracil (5-FU) given as a daily bolus for the first 3 days of radiation follow by oral capecitabine until transplantation. The patient was included in waiting list for LT if no evidence of disseminated disease was found. RESULTS: Between 2007 and 2018, 13 patients were enrolled in the transplant protocol. Of those, 61% (8/13) of the patients were transplanted. The average time spent on the waiting list was 122 days (range 5-192). Intent-to-treat survival was 69% and 39% at one and 5 years. Post-transplantation overall survival was 87% and 62% and 29% recurrence rate at 5 years. CONCLUSION: The suitability of the neoadjuvant chemoradiotherapy and LT protocol was 61% in our series with long-term overall survival and should be considered as an alternative to resection for patients with localized node-negative hCCA.

Differences on metabolic behavior between intra and extrahepatic cholangiocarcinomas at 18F-FDG-PET/CT: prognostic implication of metabolic parameters and tumor markers.

BACKGROUND AND PURPOSE: Cholangiocarcinoma is an infrequent neoplasm barely studied with 18F-FDG-PET/CT. We evaluated the metabolic behavior of cholangiocarcinoma in PET/CT according to its location (intra or extrahepatic) and analyzed the relationship between metabolic parameters of the primary tumor and tumor markers (CA19-9 and CEA), determining their prognostic significance. METHODS: Retrospective study of PET/CT of 60 patients with untreated cholangiocarcinoma, divided into two groups according to tumor location. FDG uptake was evaluated visually and semiquantitatively [SUVmax and tumor-to-liver ratio (TLR)], and differences between intra and extrahepatic cholangiocarcinomas were tested, both for FDG uptake in the primary tumor and for the presence of regional or distant disease (per-patient), as well as regarding tumor marker levels. A correlation between metabolic parameters and tumor markers was performed, and prognostic value of these factors was determined (univariate and multivariate analyses). RESULTS: Intrahepatic cholangiocarcinomas were significantly more FDG-avid than extrahepatic ones (p = 0.006 for SUVmax; p = 0.002 for TLR). There were differences neither between both groups considering the capacity of PET/CT to detect regional (p = 0.261) and distant involvement (p = 0.876), nor regarding the levels of tumor markers (p = 0.160 for CA19-9; p = 0.708 for CEA). Metabolic parameters and tumor markers showed a weak positive correlation (R2 0.22-0.27). At the multivariate analysis, advanced stage (p = 0.024), increased CEA (p = 0.022), and higher TLR (p = 0.003) were significantly related with shorter overall survival. CONCLUSIONS: Intra and extrahepatic cholangiocarcinomas behave differently on PET/CT, though no differences between both groups exist in its capacity to detect regional or distant disease. Metabolic parameters and levels of tumor markers seem to relate with tumor burden, impacting in prognosis.

The anterior hanging-approach improves postoperative course after right hepatectomy in patients with colorectal liver metastases. Results of a prospective study with propensity-score matching comparison.

PURPOSE: To establish the role of the anterior approach with liver hanging maneuver for right hepatectomy in patients with colorectal liver metastases (CRLM). SUMMARY BACKGROUND DATA: The indications for hepatectomy in patients with CRLM are expanding. The liver remnant must be protected to avoid morbidity. METHODS: We prospectively enrolled all patients with the diagnosis of CRLM requiring right hepatectomy from 2009 to 2012. In all cases right hepatectomy with an anterior-hanging maneuver approach was attempted. We compared the group of patients who underwent this procedure with a group of patients who had previously undergone a conventional right hepatectomy. To minimize selection bias, propensity score matching was performed, based on baseline patient characteristics. RESULTS: A right hepatectomy was planned in 57 cases. The anterior-hanging approach was feasible in 85% of cases. Overall morbidity was similar. In-hospital mortality due to hepatic insufficiency was 2.3% in anterior-hanging group compared to 9% in the conventional group (p = 0.30). The incidence of ascites was significantly greater in the conventional group (AH: 18% vs Conv: 54%; p = 0.002), and hospital stay was longer (AH: 10.9 ± 5.7 vs Conv: 14.4 ± 8.1 days; p = 0.05). Bilirubin levels were significantly lower in anterior-hanging group in day 1 and 3. There were no differences on recurrence nor survival. CONCLUSIONS: The anterior-hanging approach for right hepatectomy in patients with CRLM can be used safely with a high feasibility rate. Its use contributes to improve postoperative course.

Surgical treatment of biliary tract complications after liver transplantation.

OBJECTIVE: Biliary strictures are the most common biliary tract complication after liver transplantation. There are scarce data on the results of hepaticojejunostomy (HJ) in the management of biliary complications after orthotopic liver transplantation (OLT). Thus, the role of surgery in this setting remains to be established. The aim of this study was to evaluate the results of surgical treatment of patients with biliary complications at our institution. PATIENTS AND METHODS: We reviewed 1000 consecutive liver transplantations performed at our institution from 1984 to 2007. We used a prospectively recorded database to identify patients who underwent HJ to treat any biliary tract complication. RESULTS: Overall, 62 patients (6.2%) underwent HJ, 40 for an anastomotic and 7 for a non-anastomotic stricture as well as 15 for biliary leaks. Postoperative morbidity was 16%, and postoperative mortality 1.6%. There were 7 cases of anastomotic stenosis (11.3%). Four patients (5%) required retransplantation. CONCLUSIONS: HJ is a safe procedure to manage biliary complications after OLT. It may be the first treatment choice especially for cases with anastomotic strictures.

A prospective, multicenter study of once-daily extended-release tacrolimus in de novo liver transplant recipients.

To minimize noncompliance in organ transplantation, a new formulation was developed of once-daily extended-release (EXTD) tacrolimus. To analyze the efficacy and safety of this new drug formulation in de novo liver transplant recipients, a prospective, multicenter study was performed in six centers in Spain. The primary objective of the study was to evaluate the incidence of biopsy-proven acute rejection episodes (BPAR) according to the BANFF criteria during the first 3 months of immunosuppression with the EXTD formulation of tacrolimus. Fifty-two patients received a mean initial dose of 10.0 ± 3.8 mg that was gradually reduced to 7.1 ± 4.0 mg, achieving stable mean blood levels of 8.6 ± 3.7 ng/mL at 3 months. BPAR was reported in seven (13%) patients, but patient and graft survivals were 100%. After transplantation liver function improved and was stably maintained throughout the study. At 3 months, mean bilirubin levels were 2.1 ± 5.5 mg/dL and mean alanine aminotransferase and aspartate aminotransferase were 61.6 ± 75.2 U/L and 55.2 ± 76.9 U/L, respectively. Mean serum creatinine of 0.8 ± 0.3 mg/dL pretransplant increased to 1.1 ± 0.4 mg/dL after 3 months (P < .0001). There was no significant increase in the rate of hypertension from pretransplant levels: 30% at baseline versus 31% at 3 months. Mean glucose levels did not change significantly throughout the study. There were no cases of hepatitis C virus relapse. EXTD tacrolimus demonstrated excellent stability in blood trough levels with a good efficacy and safety profile in de novo liver transplant recipients that was similar to the well-described properties of standard-release twice-daily formulation of tacrolimus.

Antral mass due to cytomegalovirus infection requiring gastrectomy in a liver transplant recipient.

The incidence of cytomegalovirus (CMV) infection after liver transplantation (LT) has decreased in recent years. Advances in immunosuppression and CMV prophylaxis have improved the management of CMV disease. Organ involvement is infrequent and gastrointestinal CMV disease is quite rare. Few cases of an antral mass due to CMV infection have been described; those reported to date have mostly been in patients with acquired immunodeficiency syndrome. We describe a case of a CMV-seronegative liver transplant patient who received a seropositive liver graft. Owing to gastrointestinal complaints, CMV prophylaxis was stopped one month after LT. The patient developed an antral mass due to CMV infection and an anastomotic biliary stricture. Antigenemia became negative with ganciclovir, but this treatment did not eliminate the mass. Ganciclovir resistance was ruled out as well as other causes of antral mass, especially malignancy. The patient finally required gastrectomy and hepaticojejunostomy. We conclude that CMV disease is less common today but should be included in the diagnosis of gastrointestinal mass after transplantation.

Surgical treatment of liver metastases from colorectal carcinoma in elderly patients. When is it worthwhile?

BACKGROUND: The elderly are under-represented in series of patients operated on for colorectal liver metastases (LM). OBJECTIVE: To analyse the influence of age on surgery of colorectal LM, and the identification of factors that could be used as exclusion criteria. PATIENTS AND METHODS: Six hundred and forty-eight patients underwent liver resection between 1990 and 2006. Demographic data, primary tumour related variables, stage of the disease, morbidity, mortality, survival and recurrence were prospectively recorded. RESULTS: One hundred and sixty of 648 patients (25%) were 70 years old or older. Postoperative mortality was significantly higher in elderly patients (8% vs. 3%, p=0.008). Morbidity was also higher (41% vs. 34%, p=0.008). Survival rate at 1, 3 and 5 years was 88%, 62% and 45% respectively in patients younger than 70 years, and 82%, 48% and 36% in the elderly (p=0.007). Excluding the postoperative mortality, the figures were 90%, 64% and 46%. 90%, 53% and 38% (p=0.061). Disease-free survival rates at 1, 3 and 5 years excluding postoperative mortality were 68%, 32% and 25% in younger patients, compared to 68%, 34% and 30% (p=0.71) in the elderly. Major liver resections increased mortality in the elderly. In the multivariate analyses only a tumour size equal to or more than 10 cm significantly increased the postoperative mortality risk in elderly patients. CONCLUSIONS: The elderly have a higher mortality. In recent years that difference has been markedly reduced. Excluding the postoperative mortality, the overall survival and disease-free survival are similar between both groups. The criteria to indicate surgery must be the same in both groups.

Effect of subcentimeter nonpositive resection margin on hepatic recurrence in patients undergoing hepatectomy for colorectal liver metastases. Evidences from 663 liver resections.

OBJECTIVE: To elucidate if a nonpositive <1-cm resection margin has any effect on hepatic recurrence in patients undergoing liver resection for colorectal liver metastases. PATIENTS AND METHODS: Six hundred and nine patients underwent 663 liver resections. Patients with positive margin were excluded from the analysis. Two groups were studied: group A, <1-cm resection margin and group B, > or =1-cm resection margin. RESULTS: A total of 545 liver resections in 523 patients were carried out with nonpositive resection margins. With a median follow-up of 25 months, the 5-year cumulative hepatic recurrence reached 54% in group A (n = 206) and 41% in group B (n = 339). Factors associated with hepatic recurrence were synchronic metastases (P = 0.0015), bilobar (P < 0.001), two or more metastases (P < 0.001), margin <1 cm (P = 0.0123) and extrahepatic disease (P = 0.0037). A strong correlation between resection margin and number of metastases was confirmed (P < 0.001). At multivariate analysis only two factors were independent predictors of hepatic recurrence: multinodular disease in the liver specimen [> or =4 metastases hazard ratio (HR) = 3.45; 95% confidence interval (CI): 2.2-5.38; P < 0.001] and extrahepatic disease at hepatectomy (HR = 1.58; 95% CI: 1.58-3.32). CONCLUSION: Subcentimeter nonpositive resection margins do not directly influence hepatic recurrence in patients undergoing hepatectomy for colorectal liver metastases.

[Radiofrequency ablation of hepatic tumors]. / Ablación por radiofrecuencia de tumores hepáticos.

This article aims to review the state of the art in ablation techniques for hepatic lesions. In addition to discussing the indications, outcomes, and potential complications of the technique, we illustrate the spectrum of imaging findings after treatment. Recent years have seen the development of a wide variety of minimally invasive techniques to treat liver cancer. These include ethanol injection, and thermal ablation using radiofrequency, laser, microwaves, or cryosurgery. Percutaneous radiofrequency ablation is one of the most promising non-surgical treatments for hepatic neoplasms. The results of several studies show that radiofrequency ablation enables adequate local control of tumors with few complications, achieving acceptable survival rates. Radiofrequency ablation can be performed using any imaging technique, although it is most commonly performed under ultrasound guidance. CT and MRI show the degree of tumor necrosis better and are more frequently employed in follow up. This article reviews the indications and contraindications for the procedure, potential complications, long-term outcome, and imaging findings for percutaneous radiofrequency ablation of hepatic tumors.

Acute cholecystitis as a complication following percutaneous ethanol injection of a hepatocellular carcinoma.

UNLABELLED: Percutaneous ethanol injection is a useful option in the treatment of hepatocellular carcinoma which are not amenable to resection or transplantation. We describe a case of cholecystitis and tumour infiltration of the gallbladder after percutaneous ethanol injection, a complication not previously described in literature. The patient was a 70-year-old woman with a history of asymptomatic HCV+ hepatopathy and a 6 cm hepatocellular carcinoma nodule in segment V which had been treated two months before by percutaneous ethanol injection in another center. She attended our center due to febrile syndrome. Imaging studies suggested cholecystitis with an abscess on the wall of the gallbladder, purulent material obtained by means of a CT-guided puncture. Surgery revealed purulent and neoplasic material inside the gallbladder, with tumor invasion of the posterior wall; a partial cholecystectomy was therefore performed and a drainage inserted. The patient showed no post-operative complications and was discharged after seven days. CONCLUSION: we believe that the percutaneous ethanol injection of hepatocellular carcinomas located close to the gallbladder may occasionally lead to complications in the form of cholecystitis with neoplasic infiltration of the gallbladder. A case of cholecystitis secondary to radiofrequency treatment of a similarly-located tumor has previously been described and, therefore, the use of percutaneous local destructive treatments for tumors close to the gallbladder would seem unadvisable.

[Domino or sequential liver transplantation. Is it a feasible technique?]. / El trasplante hepático dominó o secuencial, es una técnica factible?

BACKGROUND: In domino liver transplantation (LT), the explanted liver of a patient with familial amyloidotic polyneuropathy (FAP) is donated to another patient. PATIENTS AND METHOD: Between February 1999 and March 2001 we performed 131 LT with 121 cadaveric donors in our unit. Ten domino LTs were performed. RESULTS: Patients with FAP were younger (37 years) than recipients of the second LT (64 years). The evolution of patients undergoing transplantation for FAP was excellent and all are currently alive and without complications. Among recipients of the second LT, one patient died in the postoperative period. A further two patients died from tumoral recurrence and hepatitis C virus recurrence 18 months and 9 months after transplantation, respectively. The remaining patients have shown no symptoms of FAP during the follow-up. CONCLUSION: The results of this study show that domino LT is technically feasible. The technique increases the number of grafts without apparent risk either to the recipient with FAP or to the recipient of the latter's explanted liver.

[Hemodynamics of the cirrhotic patient during liver transplantation. Influence of the preservation of portal and vena cava flow]. / Hemodinamia del paciente cirrótico durante el trasplante hepático. Influencia de la preservación del flujo portal y de la vena cava.

OBJECTIVE: To describe the hemodynamic pattern of patients undergoing liver transplantation with preservation of portocaval flow. PATIENTS AND METHODS: A prospective study of 20 cirrhotic patients who had not previously undergone surgery for portal hypertension or had porto-systemic bypass, both of which have hemodynamic effects in the cirrhotic patient. The patients were transplanted with preservation of inferior vena cava flow and temporary portocaval shunt. RESULTS: The decrease in cardiac output during the anhepatic phase was only 10% and mean blood pressure (77.6 +/- 11 versus 76 +/- 10 mm Hg) and supply pressures (central venous pressure 9.1 +/- 5.5 versus 8.4 +/- 5.3 mm Hg; pulmonary capillary pressure 11.4 +/- 6.1 versus 11.3 +/- 7.4 mm Hg) remained stable. Likewise, no significant increase in systemic vascular resistance (614 +/- 223 versus 676 +/- 306 dyne-sec/cm5) or heart rate (90 +/- 14 versus 97 +/- 17 beats/min). The number of units of packed red cells was 2.7 +/- 2.5 and 35% of the patients required no transfusions. Diuresis was stable throughout the procedure (total diuresis 3.6 +/- 2.4 mL/Kg/h; anhepatic phase 1.3 +/- 1.5 mL/Kg/h). CONCLUSIONS: Creation of a portocaval shunt during the anhepatic phase of liver transplantation allows hemodynamic vital signs to be held stable, decreases the need for transfusion and maintains diuresis.

[Clinical study of 437 consecutive hepatectomies]. / Estudio clínico de 437 hepatectomías consecutivas.

BACKGROUND: The aim of this prospective study was to analyze the risk of liver resection in unselected patients. PATIENTS AND METHOD: From 1990 to 2000, 437 consecutive hepatectomies were performed in our center. Most frequent indications were liver metastases (n = 288), hepatocellular carcinoma (n = 62), Klatskin tumor (n = 17), gallblader carcinoma (n = 139) and other malignant tumors (n = 6). The indication was a benign tumor in 51 patients. In 357 cases the liver parenchyma was normal, 51 patients had an underlying cirrhosis and 17 patients had an obstructive jaundice. RESULTS: Overall mortality was 3.6% (15 cases). Mortality in benign tumors was lacking. The prevalence of postoperative complications was 43.9%, which was mainly influenced by malignancy (46.9% vs 21.6%, p = 0.001) and type of tumor (Klastkin tumor, p # 0.001). Major liver resection (p < 0.001), blood transfusion (p < 0.001), age over 60 years (p = 0.001) and the type of hepatectomy (p < 0.001) also increased significantly the morbidity. The prevalence of biliary fistula was 11.2%, which was mainly related to the type of hepatectomy (major hepatectomy; p = 0.002) and a biliary-enteric anastomosis (p < 0.001). The prevalence of hepatic insufficiency was 3.6%, and chief risk factors for its development were underlying liver disease and major liver resection (p = 0.017). CONCLUSIONS: Mortality after hepatectomy in experienced centers is low. Morbidity is mainly related to the amount of parenchyma resected, type of hepatectomy, underlying liver disease and associated procedures. Liver resection should be performed preferentially in centers with high volume by specialized surgeons.

Changing strategies in diagnosis and management of hilar cholangiocarcinoma.

Hilar cholangiocarcinoma is one of the most difficult tumors to stage and treat. This study aims to evaluate (1) the best diagnostic imaging, (2) the usefulness of preoperative biliary drainage, (3) the resectability rate, and (4) the results of palliative treatments and surgical resection. Seventy-six patients with hilar cholangiocarcinoma with a mean age of 64 +/- 11 years were treated at our institution from 1989 to 1999. Patients were studied preoperatively using ultrasound, computed tomography (CT), and percutaneous cholangiography or magnetic resonance cholangiography. Forty-eight patients (63%) underwent palliative treatment. Twenty-eight patients underwent surgical curative therapy; 20 resections and 8 orthotopic liver transplantations (OLTs). Percutaneous transhepatic cholangiography was performed in 18 of 28 patients (64%), and magnetic resonance cholangiography in 5 patients; both methods were equally effective in establishing tumoral invasion of the biliary ducts. Five patients did not undergo either diagnostic modality. Excluding the patients who underwent OLT, no significant differences were found in surgical mortality (1 v 2 patients) or postoperative morbidity (100% v 66%) for patients with and without preoperative biliary drainage. The postoperative mortality rate was 11% (3 of 28 patients). The overall resectability rate was 37%. Mean survival in the surgical and palliative groups was 35 and 6 months, respectively (P <.0001). Patients who underwent OLT had a better 5-year survival rate than those treated by tumor resection (36% v 21%; P =.02). Combined chemotherapy and radiotherapy apparently did not provide a significant survival benefit. Helical CT and magnetic resonance cholangiography are useful techniques to delineate tumor extent and rule out vascular invasion and lymph node or liver metastases. No clear conclusions regarding preoperative drainage can be drawn from this study. A high resectability rate (37%) is feasible with major hepatectomy.

A prognostic index of the survival of patients with unresectable hepatocellular carcinoma after transcatheter arterial chemoembolization.

BACKGROUND: Transcatheter arterial chemoembolization (TACE) has been used as a palliative treatment for patients with unresectable hepatocellular carcinoma (HCC), but its prognostic usefulness has not previously been clarified. METHODS: The authors reviewed all patients treated at their institution with TACE for unresectable HCC in order to analyze prognostic factors and to determine which patients might benefit from this treatment. One hundred forty-three patients were retrospectively studied. Pretreatment, treatment, and follow-up variables with possible prognostic significance were analyzed. A stepwise multivariate analysis was performed using the Cox regression model, and a prognostic index was obtained. RESULTS: According to univariate analysis, variables significantly associated with survival were alpha-fetoprotein (>400 U/L), tumor size (>50%), ascites, albumin (<30 g/L), Child-Pugh grade (Child C), Okuda stage (Okuda III), portal vein thrombosis, tumor greatest dimension larger than 5 cm, more than 3 nodules, bilobular involvement, and pattern of iodized oil uptake, tumor size reduction, and radiologic T classification on computed tomography scan performed 7 and 30 days after TACE. However, only ascites, alpha-fetoprotein (>400 U/L), tumor size (>50%), Child-Pugh grade (Child C), pattern of iodized oil uptake, and portal vein thrombosis were independent factors in multivariate analysis. Using the beta-coefficients of alpha-fetoprotein (>400 U/L), tumor size (>50%) and Child-Pugh score, a prognostic index was calculated, and according to this index patients were classified into 3 categories with different prognoses. Ascites was excluded from the analysis because it is included in Child-Pugh grade, and iodized oil uptake was excluded because it cannot be evaluated before treatment. CONCLUSIONS: This simple prognostic index can predict the survival of patients treated with TACE and can therefore be used to decide which patients with unresectable HCC should receive this therapy. TACE should not be administered to patients with one or more positive prognostic factors.

Results of treatment in severe acute pancreatitis.

AIM: To analyze our results in the management of severe acute pancreatitis (SAP), especially in patients who required surgery. METHODS: In a retrospective study, 90 patients admitted between January 1992 and January 1998 were diagnosed as having SAP on the basis of clinical and radiological criteria. Contrast-enhanced tomography (CT) was done in all patients. The surgical technique of choice was necrosectomy and postoperative local lavage. RESULTS: Seventy percent of the patients (63/90) had pancreatic necrosis. Tomography had a sensitivity of 73% in detecting necrosis. Forty-nine patients (54%) needed surgery: 31 had infected SAP and 18 had sterile pancreatitis. Overall mortality rate was 25.6% (23/90); mortality was 43.8% (14/32) in patients with infected pancreatitis and 15.5% (9/58) in those with sterile SAP (p < 0.05). The mortality rate was 44.4% higher (8/18) in patients with sterile SAP who were operated on. Patients with infected SAP who were operated on during the first week of admission had a higher mortality rate (81%) than those operated on after the first week (20%) (p < 0.05). CONCLUSIONS: Pancreatic necrosis and infection are the most important prognostic factors in the course of SAP. The sooner the patients are operated on, the worse the prognosis, especially if there is infection. Efforts should be aimed at avoiding the onset of infection and organ failure, and at delaying surgery.

Laparoscopic adrenalectomy. A review of 30 initial cases.

BACKGROUND: Laparoscopic adrenalectomy is a good option for removal of the adrenal gland that is becoming preferred over the conventional open technique. METHODS: We reviewed the initial 30 laparoscopic adrenalectomies (in 27 patients) that were performed at our institution from 1995 to 1998. We used the lateral decubitus transperitoneal approach in 26 cases and the retroperitoneal approach in only one case. The indications for adrenalectomy were Conn's adenoma in eight patients, pheochromocytoma in six, Cushing's syndrome in five, nonfunctional adenomas in seven, and metastasis in one case. RESULTS: Only two patients (7%) were converted to laparotomy. Operating time ranged from 75 to 240 min. Average adrenal gland size was 6.1 cm (range, 4-9 cm). There was no mortality, and morbidity occurred in only two patients (8%)-one case of self-limited gastrointestinal bleeding and one case of hypercapnia and subcutaneous emphysema (in the only patient operated by the retroperitonal approach). Mean hospital stay was 3 days (range, 1-6). CONCLUSIONS: Laparoscopic adrenalectomy is a safe and useful procedure for nearly all adrenal pathologies. Lateral decubitus transperitoneal approach is the procedure of choice in most cases.

Results of using the recipient's splenic artery for arterial reconstruction in liver transplantation in 23 patients.

BACKGROUND: Arterial reconstruction is essential in liver transplantation. In some patients there may be an inadequate flow as a result of stenosis, intimal dissection, or anomalies of the hepatic artery. METHODS: This study analyzes our experience with 23 patients in whom arterial anastomosis was performed using the splenic artery due to the inadequacy of the hepatic artery. During the same period an aortoiliac conduit was used in 12 liver transplantations due to the same problem. RESULTS: No splenic infarction, pancreatitis, or other related complications were found. Artery thrombosis developed in only two patients in the aortoiliac conduit group. One- and three-year patient actuarial survival were 78% vs. 80% and 72% vs. 80%, respectively, for the splenic artery group and the aortoiliac conduit group. CONCLUSIONS: Anastomosis with the splenic artery is an alternative in liver transplantation and is particularly suitable when splenomegaly is present.