Análise das condições bucais e microbiológicas salivar de pacientes infantis em programação para o transplante hepático e avaliação da qualidade de vida da saúde geral de seus doadores / Analysis of the oral conditions and salivary microbiology of pediatric patients in programming for liver transplantation and evaluation of the quality of life of their donors' general health

O transplante hepático (Tx) pediátrico é o tratamento definitivo e indicado para doenças hepáticas terminais. Nele, estão envolvidos dois cenários: o da criança receptora e do doador, que abrangem questões como a saúde geral e bucal, imunossupressão e qualidade de vida. A imunossupressão pode acarretar infecções oportunistas como os poliomavírus BK e JC que causam complicações clínicas no pós-transplante. Assim, esta pesquisa trata-se de um estudo longitudinal que se propôs avaliar três vertentes: i) as condições odontológicas das crianças no processo do transplante hepático; ii) avaliar a excreção oral e viremia dos poliomavírus BK e JC nas crianças antes e após o Tx; iii) avaliar o impacto da qualidade de vida (QV) dos doadores. Para analisar as vertentes relacionadas ao receptor, foram incluídas 84 crianças em programação para o transplante hepático no Hospital Municipal Infantil Menino Jesus em São Paulo, mas apenas 51 fizeram parte da amostra final. Foram utilizadas as categorias avaliativas do Bedside Oral Exam BOE para avaliar as condições bucais pré- e pós-transplante imediato. Juntamente com o exame clínico bucal, foram realizadas seis coletas, uma pré-transplante e cinco semanalmente no pós-transplante, de saliva e sangue para avaliar a presença dos poliomavírus. Em contrapartida, para avaliar a QV dos doadores, participaram desse estudo 25 adultos. Para essa avaliação foi utilizado o questionário SF-36 versão 2, que é autoaplicável e aborda oito domínios sobre a saúde física e emocional, sendo aplicado no pré-Tx (um dia anterior a cirurgia) e no pós-Tx (um mês após a cirurgia). As análises estatísticas utilizadas para cada objetivo foram: i) análise descritiva das condições bucais nos dois momentos e comparadas através do teste de Wilcoxon; ii) análise da variável dicotômica e o teste de McNemar para identificar a presença do BK e JC; iii) teste de Shapiro-Wilk, seguido pela comparação dos dados paramétricos pelo teste t pareado e dados não paramétricos pelo teste de Wilcoxon considerando significância estatística de p<0,05 para a avaliação da QV do doador. As análises foram realizadas através do software JAMOVI. Assim, os resultados encontrados para cada objetivo foram: i) no pré-transplante a característica mais frequente foi à alteração de cor nas mucosas (78.6% n=84) e no pós-transplante alteração nos lábios (27.4% n=51), na função deglutição (13.8% n=51) e na cor dos dentes (27.4% n=51); apesar disso as crianças apresentavam BOE escore 8, 9 ou 10 tanto no pré-transplante (92.8% n=84) como no pós-transplante (90.4% n=51); ii) em relação à excreção oral e viremia dos poliomavírus, apenas observamos a presença do BK na saliva em uma amostra (2%) na segunda e uma amostra (2%) na quinta semana pós-Tx; e no plasma em uma amostra (2%) na terceira e em uma amostra (2%) na quinta semana pós-Tx. O JC não foi detectado em nenhuma das amostras analisadas; iii) em relação à QV do doador, foi possível verificar uma diferença estatisticamente significativa nos domínios relacionados à capacidade funcional (média no pré-Tx= 85.4 e média no pós-Tx= 47.6; p<0.001), limitação por aspectos físicos (média no pré-Tx= 82.5 e média no pós-Tx= 52.5; p<0.001), dor (média no pré-Tx= 83.9 e média no pós-Tx= 60.5; p=0.002) e limitação por aspectos emocionais (média no pré-Tx= 82.5 e média no pós-Tx= 52.5; p<0.001). Conclui-se que as crianças possuíam uma boa condição bucal no pré e pós-transplante apesar de terem sido encontradas alterações na mucosa no pré-transplante e alterações em lábios e dentes no pós-transplante. A presença do poliomavírus BK é um evento raro em pacientes pediátricos no processo de transplante hepático. No que diz respeito ao impacto da QV nos doadores, houve uma piora no pós-transplante considerando os aspectos físicos e emocionais.

Nefrolitotomía Endoscópica ex vivo del injerto renal de donante vivo con instrumento flexible / Living-donor kidney graft ex vivo endoscopic nephrolithotomy with flexible instrument

INTRODUCTION: The finding of an asymptomatic stone in the study of a living kidney donor does not necessarily contraindicate donation, however, there is no consensus on the management of these cases. The use of a graft with lithiasis may represent a risk of recurrence in the remaining kidney in the donor and eventual obstructive complications in the transplanted kidney. The objective of this work is to present the usefulness of ureteroscopy (URS) to resolve lithiasis ex vivo before transplantation. MATERIAL AND METHODS: Donors with a small, asymptomatic kidney stone and with an analysis of lithogenic factors without relevant findings were considered to continue in the donation process. The kidney unit with stone was selected for nephrectomy. RESULTS: Four donor kidneys underwent flexible URS after nephrectomy under hypothermic preservation conditions during bench preparation. The average time of the procedure was 35 minutes and the stone was extracted in all cases without incident. The transplant was carried out in the usual way and the evolution of the recipients was without complications and with excellent renal function. During follow-up, no recurrence of lithiasis was observed in donors or recipients. CONCLUSIONS: In this experience, the URS of the donor kidney was a feasible procedure and was not associated with adverse consequences for the graft. The main advantage of this procedure is to avoid the potential risk to the recipient of an obstructive graft complication.

Protocolos de atención quirúrgica en el donante vivo y el receptor de trasplante renal / Surgical care protocols in the living donor and kidney transplant recipient

En El Salvador las enfermedades crónicas no transmisibles se han incrementado progresivamente en las últimas décadas, actualmente ocupan un lugar relevante en la ocurrencia de morbilidad y mortalidad en la población. El aparecimiento de nuevos casos, sumado a la alta cifra de los ya existentes, ha producido un incremento en la demanda de servicios de salud, tanto de atenciones ambulatorias, como de hospitalizaciones. Como parte esencial de este esfuerzo y con participación de especialistas del MINSAL y del ISSS, se han actualizado los protocolos médicos para el trasplante de riñón que fueron elaborados en el año 2019. EL presente documento contiene la inclusión de nuevos criterios, con los que se ha actualizado el contenido técnico, en relación con los procedimientos médicos que regirán la realización de los procesos de trasplante renal en la red de hospitales del SNIS, involucrados en la donación y trasplante con donantes vivos y que proporcionarán a pacientes que los reciban, la oportunidad de una mejor calidad de vida

In El Salvador, chronic noncommunicable diseases have increased progressively in recent decades, currently occupying a relevant place in the occurrence of morbidity and mortality in the population. The appearance of new cases, added to the high number of existing ones, has produced an increase in the demand for health services, both for outpatient care and hospitalizations. As an essential part of this effort and with the participation of MINSAL and ISSS specialists, the medical protocols for kidney transplantation that were prepared in 2019 have been updated. This document contains the inclusion of new criteria, with which has updated the technical content, in relation to the medical procedures that will govern the performance of kidney transplant processes in the SNIS network of hospitals, involved in donation and transplantation with living donors and that will provide patients who receive them, the opportunity of a better quality of life

Utilizing ultra-small volume graft in auxiliary liver transplantation for portal hypertension / 中华外科杂志

Objective: To examine the clinical effect of auxiliary liver transplantation with ultra-small volume graft in the treatment of portal hypertension. Methods: Twelve cases of portal hypertension treated by auxiliary liver transplantation with small volume graft at Liver Transplantation Center,Beijing Friendship Hospital, Capital Medical University between December 2014 and March 2022 were studied retrospectively. There were 8 males and 4 females,aged 14 to 66 years. Model for end-stage liver disease scores were 1 to 15 points and Child scores were 6 to 11 points. The grafts was derived from living donors in 9 cases,from split cadaveric donors in 2 cases,from whole cadaveric liver of child in 1 case. The graft recipient body weight ratios of 3 cadaveric donor livers were 0.79% to 0.90%, and of 9 living donor livers were 0.31% to 0.55%.In these cases, ultra-small volume grafts were implanted. The survivals of patient and graft, complications, portal vein blood flow of residual liver and graft, abdominal drainage and biochemical indexes of liver function were observed. Results: All the grafts and patients survived. Complications included outflow tract torsion in 2 cases, acute rejection in 1 case, bile leakage in 1 case, and thyroid cancer at the later stage of follow-up in 1 case, all of which were cured. The torsion of outflow tract was attributed to the change of anastomotic angle after the growth of donor liver. After the improvement of anastomotic method, the complication did not recur in the later stage. There was no complication of portal hypertension. The measurement of ultrasonic portal vein blood flow velocity showed that the blood flow of residual liver decreased significantly in the early stage after operation, and maintained a very low blood flow velocity or occlusion in the long term after operation, and the blood flow of transplanted liver was stable. Conclusions: Auxiliary liver transplantation can implant ultra-small donor liver through compensation of residual liver. This method may promote the development of living donor left lobe donation and split liver transplantation. However, the auxiliary liver transplantation is complex, and it is difficult to control the complications. Therefore, this method is currently limited to centers that are skilled in living related liver transplantation and that have complete ability to monitor and deal with complications.

Urgent liver retransplantation due to transmission of intrahepatic cholangiocarcinoma by donor: the first report in the literature / Retransplante de fígado urgente devido à transmissão de colangiocarcinoma intra-hepático pelo doador: o primeiro relato da literatura

ABSTRACT BACKGROUND: Liver transplantation represents the best therapeutic modality in end-stage chronic liver disease, severe acute hepatitis, and selected cases of liver tumors. AIMS: To describe a double retransplant in a male patient diagnosed with Crohn's disease and complicated with primary sclerosing cholangitis, severe portal hypertension, and cholangiocarcinoma diagnosed in the transplanted liver. METHODS: A 48-year-old male patient diagnosed with Crohn's disease 25 years ago, complicated with primary sclerosing cholangitis and severe portal hypertension. He underwent a liver transplantation in 2018 due to secondary biliary cirrhosis. In 2021, a primary sclerosing cholangitis recurrence was diagnosed and a liver retransplantation was indicated. Recipient's hepatectomy was very difficult by reason of complex portal vein thrombosis requiring extensive thromboendovenectomy. Intraoperative ultrasound with liver doppler evaluation was performed. Two suspicious nodules were incidentally diagnosed in the donor's liver and immediately removed for anatomopathological evaluation. RESULTS: After pathological confirmation of carcinoma, probable cholangiocarcinoma, at frozen section, the patient was re-listed as national priority and a new liver transplantation was performed within 24 hours. The patient was discharged after 2 weeks. CONCLUSIONS: The screening for neoplasms in donated organs should be part of our strict daily diagnostic arsenal. Moreover, we argue that, for the benefit of an adequate diagnosis and the feasibility of a safer procedure, the adoption of imaging tests routine for the liver donor is essential, allowing a reduction of the costs and some potential risks of liver transplant procedure.

RESUMO RACIONAL: O transplante de fígado representa a melhor modalidade terapêutica na doença hepática crônica terminal, hepatite aguda grave e casos selecionados de tumores hepáticos. OBJETIVOS: Descrever um retransplante duplo em paciente do sexo masculino, diagnosticado com doença de Crohn e complicado com colangite esclerosante primária, hipertensão portal grave e colangiocarcinoma diagnosticado no fígado transplantado. MÉTODOS: Paciente do sexo masculino, 48 anos, diagnosticado com doença de Crohn há 25 anos e complicado com colangite esclerosante primária e hipertensão portal grave. Foi submetido a um transplante de fígado em 2018 devido a cirrose biliar secundária. Em 2021, foi diagnosticada recidiva de colangite esclerosante primária e indicado retransplante hepático. A hepatectomia do receptor foi de alta complexidade devido à trombose complexa da veia porta, exigindo extensa tromboendovenectomia. Foi realizada ultrassonografia intraoperatória com doppler hepático. Dois nódulos suspeitos foram diagnosticados incidentalmente no fígado do doador e imediatamente removidos para avaliação anatomopatológica. RESULTADOS: Após confirmação patológica de carcinoma, provável colangiocarcinoma, pela congelação, o paciente foi relistado como prioridade nacional, e novo transplante hepático foi realizado em 24 horas. O paciente teve alta após 2 semanas. CONCLUSÕES: O rastreamento de neoplasias em órgãos doados deve fazer parte de nosso estrito arsenal diagnóstico diário. Além disso, defendemos que, em benefício de um diagnóstico correto e da viabilidade de um procedimento mais seguro, a adoção de uma rotina de exames de imagem é essencial em doadores hepáticos, permitindo a redução dos custos e alguns riscos potenciais do procedimento de transplante hepático.

Lineamientos técnicos para la evaluación de pacientes para trasplante renal / Technical guidelines for the evaluation of kidney transplant patients

Los presentes lineamientos técnicos han sido elaborados como una herramienta destinada a orientar la realización de este proceso de evaluación inicial en pacientes con ERC en estadio 5 y establece las directrices básicas esenciales para asegurar la valoración médica correcta de cada uno de estos pacientes, para definir si están aptos para ser incluidos como candidatos a trasplante renal, a través de donantes vivos o para ser incluidos en una lista de espera nacional con donantes en condición de muerte cerebral. Los médicos especialistas responsables del manejo clínico de estos pacientes, deben asegurar la óptima utilización clínica de los aspectos individuales del perfil de un candidato en la evaluación de los pacientes en los que exista la posibilidad de realizarles un trasplante de riñón

These technical guidelines have been developed as a tool to guide the performance of this initial evaluation process in patients with stage 5 CKD and establish the essential basic guidelines to ensure the correct medical assessment of each of these patients, to define whether are eligible to be included as kidney transplant candidates through living donors or to be included on a national waiting list with brain-dead donors. Specialist physicians responsible for the clinical management of these patients must ensure optimal clinical use of the individual aspects of a candidate's profile in the evaluation of patients in whom there is the possibility of performing a kidney transplant

Caracterización inmunogenética de donantes cadavéricos cubanos en el año 2019 / Immunogenetic characterization of Cuban cadaveric donors in 2019

Introducción: El trasplante es la opción terapéutica más favorable para las personas con insuficiencia renal crónica. El donante puede ser cadavérico o donante vivo, emparentado o no. Los resultados del trasplante están en relación con varios factores inmunológicos y no inmunológicos. Objetivo: Caracterizar inmunogenéticamente a los donantes cadavéricos cubanos para trasplante renal. Métodos: Se realizó un estudio transversal y descriptivo de los donantes cadavéricos durante el año 2019. Se analizó la región de procedencia, sexo, color de la piel y rangos de edades de los donantes, así como, grupo sanguíneos ABO y Rhesus Rh; serología para VIH, Virus de hepatitis B(VHB) y Virus de hepatitis C (VHC); y hábitos tóxicos. Resultados: Se estudió un total de 95 donantes cadavéricos, 62 provenientes del occidente y 33 del centro del país. El 63,2 por ciento fueron masculinos y 36,8 por ciento femenino. El grupo de edad de mayor frecuencia fue 40 - 60 años y la edad media de 49,45 años. El 58,95 por ciento de los pacientes fueron de grupo sanguíneo O; 30,53 por ciento grupo A y los grupos B y AB tuvieron 5,26 por ciento de prevalencia; y solo 8 fueron Rh negativos. Todos tuvieron serología para VIH, VHB y VHC negativas. Las enfermedades asociadas más frecuentes fueron la hipertensión arterial y la diabetes mellitus. Conclusiones: Los donantes cadavéricos durante el año 2019 mostraron características similares a las reportadas por otros estudios. El aumento de las edades de los donantes incide en la aparición de enfermedades asociadas y esto pudiera repercutir en el resultado del trasplante(AU)

Introduction: Transplantation is the most favorable therapeutic option for people with chronic renal failure. The donor can be a cadaveric or living donor, related or not. Transplant outcomes are related to various immunological and non-immunological factors. Objective: To characterize Cuban cadaveric donors for renal transplantation Materials and methods: A cross-sectional and descriptive study of cadaveric donors was carried out during the year 2019. The region of origin, sex, skin color and age ranges of the donors were analyzed, as well as ABO and Rhesus Rh blood groups; serology for HIV, Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV), and toxic habits. Results: A total of 95 cadaveric donors were studied, 62 from the West and 33 from the Center of the country. 63.2 percent were male and 36.8 percent female due to the most frequent age group being 40-60 years and the mean age of 49.45 years. 58.95 percent of the patients were of blood group O, 30.53 percent group A and groups B and AB had 5.26 percent prevalence; and only 8 were Rh negative. All had negative serology for HIV, HBV and HCV. The most frequent associated diseases were arterial hypertension and diabetes mellitus. Conclusions: The cadaveric donors during the year 2019 showed characteristics similar to those reported by other studies. The increase in the age of the donors affects the appearance of associated diseases and this could affect the result of the transplant(AU)

Segmentectomía lateral izquierda laparoscópica en donante vivo para trasplante hepático adulto-pediátrico / Laparoscopic living donor left lateral sectionectomy for pediatric liver transplantation

Introducción: La segmentectomía lateral izquierda es el procedimiento más empleado para la cirugía del donante en trasplante hepático con donante vivo adulto-pediátrico (THDVA-P), y ha demostrado ser seguro y reproducible. Sin embargo, la información aún es escasa respecto al abordaje laparoscópico. Objetivo: El objetivo de este artículo es dar a conocer los resultados posoperatorios de la segmentectomía lateral izquierda laparoscópica (SLI-L) para THDVA-P. Materiales y Método: Realizamos un estudio retrospectivo, observacional, de un solo centro, Hospital del Salvador; con vasta experiencia en trasplante hepático y en resecciones hepáticas laparoscópicas. Se ofreció realizar el procedimiento de SLI-L para la cirugía del donante vivo. Se describe la técnica quirúrgica y los resultados posoperatorios de los donantes. Resultados: Entre abril de 2015 y enero de 2021, 36 pacientes, 25 de ellos hombres, fueron sometidos a SLI-L. El 86% eran madre o padre del receptor, con una mediana de 30 años (19-45). Mediana de tiempo operatorio de 360 min (240-480). Hubo conversión en un caso debido a sangrado venoso de difícil manejo y en dos oportunidades se utilizó técnica mano asistida por la misma causa. Morbilidad Clavien-Dindo III en un paciente debido a fuga biliar precoz, manejada con prótesis vía colangiopancreatografía retrógrada endoscópica exitosamente. La mediana de hospitalización fue de 4 días (3-12) y no hubo mortalidad. Conclusión: La SLI-L ha evolucionado, desde un procedimiento innovador hasta convertirse en el actual procedimiento estándar para THDVA-P. Los buenos resultados en términos de morbimortalidad sugieren que podría ser una técnica segura y reproducible en contextos similares al del centro.

Introduction: Living donor left lateral sectionectomy is a well-established alternative in cadaveric donor pediatric liver transplantation. This procedure has proven to be safe and reproducible. However, laparoscopic approach is still under development and evidence of its feasibility is limited. Aim: The aim of this article is to present the surgical technique and postoperative outcomes of the cases of laparoscopic left lateral sectionectomy performed in this center. Materials and Method: A retrospective, observational, single center study was conducted in Hospital del Salvador. From 04/2015 - 01/2021 laparoscopic left lateral sectionectomy was offered for donor surgery. We present the surgical technique, perioperative care, and early postoperative outcomes in donors. Results: This series includes 36 patients, 25 (69%) of them were males. A total of 31 (86%) donors were mother or father of the recipient. Median age of donors was 30 years (19-45), median operative time was 360 min (240-480). All the patients underwent laparoscopic left lateral sectionectomy. Conversion was necessary in one case due to difficult management of a venous bleeding. Clavien-Dindo Morbidity III, in one patient who required endoscopic retrograde cholangiopancreatography due to an early bile leak. Median hospitalization was 4 days (3-14). There was no mortality. Conclusion: Laparoscopic left lateral sectionectomy has proven to be safe and reproducible. This technique has evolved from an innovative procedure to become the current standard of practice in our center, with excellent results in terms of morbidity and mortality.

Modelo de impresión 3D para planificación quirúrgica en trasplante hepático con donante vivo adulto-adulto / Three-dimensional printing of a liver model for surgical planning in adult-to-adult living donor liver transplantation

Gracias a los grandes avances de la tecnología, los últimos diez años, la impresión en tres dimensiones (3D) se ha convertido en una herramienta accesible, útil e innovadora para distintas áreas de la medicina. Entre ellas planificación quirúrgica, creación de implantes y prótesis, educación médica e incluso comunicación médico-paciente. Con respecto a planificación quirúrgica, la impresión 3D cobra especial relevancia en cirugías de alta complejidad. En el caso del trasplante hepático con donante vivo, donde es prioritario garantizar la máxima seguridad para el donante, al mismo tiempo que la mejor calidad del injerto para el receptor, la planificación quirúrgica es mandatoria. En este aspecto, la impresión 3D de un modelo de hígado, anatómicamente comparable al del donante, entrega al cirujano la posibilidad de obtener una imagen más clara, directa y tangible, desde cualquier ángulo del órgano, que una imagen virtual tradicional. De esta forma, el cirujano tiene a su alcance una herramienta adicional para plantear el mejor abordaje quirúrgico, anticipar variaciones anatómicas e incluso, cuando el material de impresión lo permite, practicar el procedimiento. En Clínica Las Condes, el centro de trasplante junto al Centro de Innovación, trabajaron en conjunto en la impresión 3D de dos modelos de hígado, utilizados para la planificación quirúrgica de los primeros dos trasplantes hepáticos con donante vivo adulto-adulto realizados en Latinoamérica, donde la hepatectomía del donante se realizó de manera totalmente laparoscópica. El objetivo de este trabajo es describir el proceso de impresión 3D y analizar las dificultades y beneficios del proceso y sus resultados.

The last ten years, thanks to the great advances in technology, three-dimensional (3D) printing has become an accessible, useful, and innovative tool for different areas of medicine. These include surgical planning, implant and prosthetic creation, medical education, and even doctor-patient communication. Regarding surgical planning, 3D printing takes on special relevance in highly complex surgeries. In the case of living donor liver transplantation where it is a priority to guarantee maximum safety for the donor, as well as the best quality of the graft for the recipient, surgical planning is mandatory. Regarding this, 3D printing of an anatomically comparable liver model of the donor, gives the surgeon the possibility of obtaining a clearer, more direct, and tangible image, from any angle of the organ, than a traditional virtual image. In this manner, the surgeon has an additional tool to plan the best surgical approach, anticipate anatomical variations and even, when the impression material allows it, to practice the procedure. Transplant center of Clinica las Condes, together with Innovation laboratory worked together on the 3D printing process liver models used for surgical planning of the first two liver transplants with an adult-adult laparoscopic living donor. The objective of this work is to describe the 3D printing process and analyze the difficulties and benefits of the process and its results.

Hepatectomía derecha totalmente laparoscópica para trasplante hepático con donante vivo adulto-adulto: técnica quirúrgica y experiencia inicial en Chile / Pure laparoscopic right hepatectomy for adult-to-adult living donor liver transplantation: surgical technique and initial experience in Chile

Resumen El trasplante hepático con donante vivo (THDV) es un procedimiento complejo y desafiante para el cirujano, ya que exige garantizar tanto la máxima seguridad para el donante, así como también, la mejor calidad del injerto para el receptor. Debido a lo anterior, la implementación de la cirugía mini-invasiva ha sido lenta en esta área. Sin embargo, en los últimos 10 años, gracias a los avances que ha experimentado la cirugía hepática laparoscópica, ha aumentado el interés de algunos grupos altamente especializados por incorporar la cirugía mini-invasiva a la cirugía del donante, principalmente en trasplante hepático donante vivo adulto-pediátrico (THDVA-P). Los favorables resultados obtenidos en esta área incluso han llevado a los expertos en el tema, a categorizar el abordaje laparoscópico para la cirugía del donante como el procedimiento estándar en THDVA-P. Contrario a lo anterior, la implementación de la laparoscopía para trasplante hepático donante vivo adulto-adulto (THDVA-A), es más compleja y requiere en su mayoría, una hepatectomía de lóbulo derecho o izquierdo para cumplir con las necesidades volumétricas del receptor. Esta cirugía es de mayor dificultad y riesgo para el donante, por lo que su indicación por vía mini-invasiva está limitada a centros de alto volumen y preparación, tanto en laparoscopía, como en trasplante hepático. En este trabajo, se busca dar a conocer la técnica quirúrgica y nuestra experiencia inicial con la primera hepatectomía derecha totalmente laparoscópica (HDTL) para THDVA-A realizada en Chile.

Living donor liver transplantation is a complex and challenging procedure. The surgeon needs to guarantee maximum safety for the donor, as well as the best quality of the graft for the recipient. For this reason, the implementation of mini-invasive surgery has been slow in this area. However, in the last 10 years, due to the advances in laparoscopic liver surgery, the interest of some highly specialized groups has increased in incorporating mini-invasive surgery into donor surgery, mainly in pediatric living donor liver transplantation. The favorable results obtained in this field, have even led to turn this procedure, into the technique of choice for pediatric living donor liver transplantation. Nevertheless, this procedure is even more challenging for adult-to-adult living donor transplantation. To meet the volumetric criteria of an adult, a complete hepatectomy of right or left lobe is mostly required. This surgery is of greater complexity and risk for the donor, so its indication by minimally invasive approach is limited to high-volume centers with preparation, both in laparoscopy and liver transplants. In this report we seek to present our surgical technique and initial experience with the first pure laparoscopic right hepatectomy for adult-to-adult living donor liver transplantation carried out in Chile.

Trajetória de vida de doadores renais: memórias, resiliência e altruísmo / Renal donor's life path: memories, resilience and altruism

OBJETIVO:analisar as narrativas que marcam a trajetória de vida dos doadores renais. METODOLOGIA:pesquisa exploratória, descritiva e de abordagem qualitativa. Após a apreensão e preparo analítico dos relatos gravados em áudio, por meio da técnica da história oral de vida, realizou-se a análise de conteúdo de Bardinque consiste das etapas: pré-análise, exploração do material ou codificação, tratamento dos resultados, inferência e interpretação dos eixos temáticos que emergiram. RESULTADOS:a amostra de 12 doadores renais que se submeteram ao transplante no Hospital Universitário Onofre Lopes-UFRN, respondeu às questões norteadoras: como era sua vida antes da doação renal? Como é sua vida após a doação renal? As narrativas convergiram para as temáticas "experiências vividas antes da doação renal" e "experiências vividas após a doação renal". Os colaboradores enredaram o acometimento da doença como um momento trágico e a doação renal como meio de minimizar o sofrimento vivido pela família.CONCLUSÃO:os colaboradores reconhecem mais interferências positivas da doação renal, principalmente a melhoria na qualidade de vida dos doadores e o reconhecimento social da nobreza do ato da doação renal

OBJECTIVE:to analyze how narratives that mark the life trajectory of renal donors.METHODOLOGY: Exploratory, descriptive research and a qualitative approach. After the apprehension and analytical preparation of the audio recorded reports, using the oral life history technique, Bardin's content analysis was carried out, which consists of the stages: pre-analysis, exploration of the material or coding, treatment of results, inference and interpretation of the thematic axes that emerged. RESULTS:The sample of 12 kidney donors who underwent transplantation at Hospital UniversitarioOnofre Lopes-UFRN, answered the guiding questions: How was your life before kidney donation. How is your life after kidney donation. The narratives converged on the themes "experiences lived before kidney donation" and "experiences lived after kidney donation".Employees identified the disease as a tragic moment and kidney donation as a means of minimizing the suffering experienced by the family. CONCLUSION:Employees recognize more positive interferences from kidney donation, mainly the improvement in the quality of life of donors and the social recognition of the nobility of the kidney donation act.

Short- and mid- term impact of tobacco smoking on donor renal function following living kidney donation at a tertiary referral hospital

Background: The negative impact of tobacco smoking on renal function has been widely studied. However, there is limited knowledge about the effect of smoking on pre-operative and post-operative renal function in living kidney donors. Objective: The objective of the study was to evaluate the short- and mid-term impact of smoking on donor renal function. Methods: This is a retrospective study of 308 patients who underwent living donor nephrectomy (LDN) at a tertiary referral hospital. We compared baseline characteristics as well as functional outcomes following LDN according to history of tobacco smoking. Estimated glomerular filtration rate (eGFR) was calculated with the modification of diet in renal disease equation in 6 time periods: pre-operative, 1 week, 1 month, 6 months, 12 months, and 24 months after surgery. We performed a Kaplan-Meier analysis for chronic kidney disease (CKD) outcome and binary logistic regression analysis to identify risk factors associated with CKD at 24 months of follow-up. Results: Among donors, 106 (34.4%) reported a smoking history before nephrectomy. Smoking donors had worse pre-operative eGFR than non-smokers (90 ± 26.3 mL/min/1.73m2 vs. 96 ± 27 mL/min/1.73 m2, respectively; p = 0.02) and lower eGFR at 1 week (p = 0.01), 1 month (p ≤ 0.01), 6 months (p = 0.01), and 12 months (p = 0.01) after LDN. Tobacco smoking (OR 3.35, p ≤ 0.01) and age ≥ 40 years at donation (OR 6.59, p ≤ 0.01) were associated with post-operative development of CKD at 24 months after LDN. Conclusions: Living kidney donors with a tobacco smoking history had an increased risk of developing chronic kidney disease following nephrectomy. Smoking-cessation strategies should be implemented.

Preservation fluid cultures. Clinical significance in liver transplantation / Cultivos de líquido de preservación en trasplante hepático. Significancia clínica

Abstract The aim of this study was to determine the incidence of preservation fluids (PF) bacterial positive cultures, identify the germs involved, determine their correlation with infections in recipients during the postoperative period and compare outcomes in terms of morbidity, hospital stay and both patient and graft survival. We describe incidence and etiology of germs developed in PF cultures in our series and evaluate its impact on recipients. A prospective study in deceased donor liver transplants (LT) recipients was carried out from January 2014 to December 2017. Back table PF cultures were analized considering positive the development of any germs and negative to no signs of growth after 5 days. PF were classified as contamination or pathogens. Targeted antibiotic therapy was administered in the last ones. Recipients were divided in: PF (-) and PF(+). Recipients infections related to positive PF were analyzed. These were identified as "direct correlation" when the same germ grew up in PF. Hospital stay and 30 days follow up were compared. Eighty-eight patients PFs were included, 38% (33) had positive cultures, 28 (85%) of these were considered contamination and only 5 as pathogens. We found no differences in postoperative infections (p 0.840), ICU and total hospital stay (p 0.374 and 0.427) between both groups. Postoperative infections and hospital stay seem not to be influenced by PF cultures positivity. Treatment of isolated pathogens could have prevented infections, therefore, those groups that perform PF cultures should consider treatment in these cases and conclude prophylaxis when PF is negative or contaminated.

Resumen Las infecciones bacterianas son frecuentes en pacientes sometidos a trasplante hepático. Describimos la incidencia y etiología de los cultivos de líquidos de preservación (LP) positivos en nuestra serie y analizamos su importancia clínica. Se trata de un trabajo prospectivo de pacientes trasplantados hepáticos, entre enero 2014 a diciembre 2017. Se analizaron muestras de LP tomadas al finalizar la mesa de banco, considerándose positivo el desarrollo de cualquier germen y negativo la ausencia del mismo luego de 5 días. Los LP positivos se clasificaron en: con contaminantes y con patógenos. Los pacientes con LP patógenos recibieron tratamiento antibiótico de acuerdo al antibiograma. Los pacientes fueron divididos en dos grupos: con LP + y LP-. Las infecciones relacionadas a los LP fueron analizadas. Se consideró "correlación directa" cuando el mismo germen desarrolló en el LP y en el recipiente. Se comparó estadía hospitalaria en ambos grupos. Se incluyeron 88 pacientes, 38% (33) presentaron LP+, de los que el 85% (28) fueron por contaminación y 5 por pa tógenos. No se hallaron diferencias significativas en infecciones postoperatorias (p 0.840) y estadía hospitalaria (p 0.427) entre ellos. No hubo casos de "correlación directa". Las infecciones postoperatorias y la estadía hospitalaria de los pacientes no parecen estar influidas por la positividad de los cultivos de LP. El tratamiento dirigido a los gérmenes aislados como patógenos pudo prevenir infecciones, por lo tanto, los grupos que realizan cultivos de rutina deberían considerar el tratamiento en estos casos y finalizar la profilaxis cuando el LP sea negativo o contaminado.

Effect of learning curve on the perioperative course of robotic-assisted laparoscopic donor nephrectomy compared with laparoscopic donor nephrectomy

Summary OBJECTIVE: This study was designed to compare the standard and robotic-assisted laparoscopic donor nephrectomy in terms of perioperative course, short-term postoperative outcome, and to evaluate the effect of surgeon's learning curve on these parameters. METHODS: This was a prospective randomized study including 60 patients (mean age, 47 years; age, 21-72 years; 26 males, 34 females) who had been planned laparoscopic donor nephrectomies in our clinic. For comparison of standard and robot-assisted techniques and to evaluate the impact of learning curve, patients were randomized into three groups by a computer, each group containing 20 patients. Group 1: standard laparoscopic donor nephrectomies; Group 2: the first 20 patients who underwent robot-assisted laparoscopic donor nephrectomy; and Group 3: the next 20 patients who underwent robot-assisted laparoscopic donor nephrectomy. RESULTS: Operative time was significantly higher in Group 2 (221.0±45.1 min) than both Group 1 (183.5±16.9 min, p=0.001) and Group 3 (186.5±20.6 min, p=0.002). Similarly, time for laparoscopic system setup was significantly higher in Group 2 (39.5±8.6 min), which contained the first cases of robot-assisted laparoscopic donor nephrectomy where surgeon had least experience than Group 1 (19.3±3.7 min, p<0.001) and Group 3 (24.0±9.4 min, p<0.001). On the other hand, duration of operation and time for laparoscopic system setup was similar between Groups 1 and 3. CONCLUSIONS: Learning curve extends the operative time and laparoscopic system setup time in robotic-assisted laparoscopic donor nephrectomy, however, after the learning process was completed, these parameters were similar between robotic-assisted and standard laparoscopic nephrectomy.

Boa qualidade de vida após mais de uma década de transplante hepático inter-vivos / Good quality of life after more than a decade of living donor liver transplantation

ABSTRACT BACKGROUND: Receptors of living donor liver transplantation (LDLT) have higher rate of postoperative biliary and vascular complications that may reduce posttransplant quality of life (QOL) due to the need of invasive and repetitive treatments. OBJECTIVE: The purpose of our study is to assess the various aspects of QOL of receptors undergoing LDLT after 10 years of transplantation and to identify potential factors that might be associated with impaired QOL. METHODS: Data of all patients with more than 10 years of LDLT were retrospectively evaluated. Patients were interviewed through a quality of life questionnaire (SF-36). RESULTS: From a total of 440 LT performed in 17 years (from September 1991 through December 2008), 78 patients underwent LDLT, of which 27 were alive and 25 answered completely the questionnaire. There were 17 (68%) men and 8 (32%) women, with a mean age of 38.6±18.5 years at the time of transplantation and mean follow up time of 15.1±1.9 years. The average MELD was 16.4±4.9 and the main indication for LT was hepatic cirrhosis caused by hepatitis B virus (32%). When compared to the general po­pulation, LDLT patients had lower mental health score (66.4 vs 74.5, P=0.0093) and higher vitality score (87.8 vs 71.9, P<0.001), functional aspects (94.6 vs 75.5, P=0.002), social aspects (93 vs 83.9, P=0.005), physical aspects (92 vs 77.5, P=0.006), and emotional aspects (97.33 vs 81.7, P<0.001). General health status (73.28 vs 70.2, P=0.074) and pain (78.72 vs 76.7, P=0.672) scores were similar in both groups. CONCLUSION: It is concluded that the various aspects LDLT recipients' QOF are similar to those of the general population more than a decade after the transplant, except for the mental health domain which is lower.

RESUMO CONTEXTO: Receptores de transplante hepático inter-vivo (THIV) apresentam elevada taxa de complicações biliares e vasculares pós-operatórias que podem reduzir a qualidade de vida (QV) devido à necessidade de tratamentos invasivos e repetitivos. OBJETIVO: O objetivo deste estudo é avaliar os vários aspectos da qualidade de vida dos pacientes submetidos a THIV após 10 anos de transplante e identificar possíveis fatores que possam estar associados à diminuição da QV. MÉTODOS: Os dados de todos os pacientes com mais de 10 anos de THIV foram avaliados retrospectivamente. Os pacientes foram entrevistados por meio de um questionário de qualidade de vida (SF-36). RESULTADOS: Do total de 440 transplantes hepáticos realizados em 17 anos (setembro de 1991 a dezembro de 2008), 78 pacientes foram submetidos a THIV, dos quais 27 estavam vivos e 25 responderam completamente ao questionário. Destes, 17 (68%) homens e 8 (32%) mulheres, com idade média de 38,6±18,5 anos no momento do transplante e tempo médio de acompanhamento de 15,1±1,9 anos. O MELD médio foi de 16,4±4,9 e a principal indicação para o transplante hepático foi cirrose hepática causada pelo vírus da hepatite B, 32%. Quando comparado com a população geral, os pacientes submetidos a THIV apresentaram menor escore de saúde mental (66,4 vs 74,5; P=0,0093) e escores mais altos de vitalidade (87,8 vs 71,9; P<0,001), aspectos funcionais (94,6 vs 75,5; P=0,002), aspectos sociais (93 vs 83,9; P=0,005), aspectos físicos (92 vs 77,5; P=0,006), e aspectos emocionais (97,33 vs 81,7; P<0,001). Os escores do estado geral de saúde (73,28 vs 70,2; P=0,074) e de dor (78,72 vs 76,7; P=0,672) eram similares nos dois grupos. CONCLUSÃO: Conclui-se que os vários aspectos da QV dos receptores de transplante hepático inter-vivo são semelhantes aos da população geral mais de uma década após o transplante, exceto o domínio da saúde mental que é menor.

Strategies for a successful hepatic artery anastomosis in liver transplantation: A review of 51 cases

INTRODUCTION@#Hepatic artery reconstruction is a critical aspect of liver transplantation. The microsurgeon faces several challenges when reconstructing the hepatic artery-the donor hepatic artery stalk is short and often a poor match for the usually hypertrophic recipient vessels. Previous inflammation impedes vessel dissection, and recipient vessels have a tendency to delaminate with manipulation. We review 51 consecutive liver transplantations to highlight these problems and propose strategies for a successful reconstruction of the hepatic artery.@*METHODS@#A prospective study involving all adult patients undergoing liver transplantation at the Singapore General Hospital from January 2015 to December 2018 was undertaken. All hepatic artery anastomoses were performed by 2 microsurgeons at 10x magnification. Patients were started on a standard immunosuppressive regimen. Postoperative ultrasound scans on days 1, 3, 5, 7, 9 and 14 were used to confirm arterial patency.@*RESULTS@#There were 51 patients who underwent liver transplantation during the study period. Of this number, 31 patients received deceased donor grafts and 20 received living donor grafts. A total of 61 anastomoses were performed (5 dual anastomosis, 4 radial artery interposition grafts) with 1 case of hepatic artery thrombosis that was successfully salvaged. The mean (range) postoperative resistive index and hepatic artery peak systolic velocity were 0.69 (0.68-0.69) and 1.0m/s (0.88-1.10m/s), respectively.@*CONCLUSION@#Hepatic artery thrombosis after liver transplantation is poorly tolerated. The challenges of hepatic artery reconstruction in liver transplantation are related to vessel quality and length. The use of microsurgical technique, appropriate recipient vessel selection, minimisation of vessel manipulation with modified instruments, variation in anastomosis techniques, and use of radial artery interpositional grafts are useful strategies to maximise the chances of success.

Development of Liver Normothermic Machine Perfusion Repair and Assessment System / 中国医疗器械杂志

This paper introduced a liver normothermic machine perfusion repair and assessment system. This system consists of a liver normothermic machine perfusion device, a fluorescence imaging system and a tissue oxygen detector. The normothermic machine perfusion device can continuously perfuse the donor liver and monitor and control the perfusion parameters in real time. The fluorescence imaging system can detect the indocyanine green metabolized by the liver to evaluate the microcirculation and the metabolism function of hepatocytes. The tissue oxygen detector can monitor the change of oxygen partial pressure of liver tissue in real time to evaluate the state of cell oxygen consumption.

Nota Técnica 1/2021 - GERTRAN/CCM - 19813 - orientação e fluxos gerais para realização de transplantes de rim, com doadores vivos, em Goiás / Technical Note 1/2021 - GERTRAN / CCM- 19813 - guidance and general flows for performing kidney transplants, with living donors, in Goiás

O transplante é um procedimento cirúrgico que consiste na reposição de um órgão (coração, pulmão, rim, pâncreas, fígado) ou tecido (medula óssea, ossos, córneas) de uma pessoa doente (receptor), por outro órgão ou tecido normal de um doador vivo ou morto. São classificados por dois tipos, sendo doador falecido e doador vivo. Neste último, apenas maiores de idade e capaz juridicamente poderão doar e o procedimento ocorre de modo a preservar a qualidade de vida e a manutenção fisiológica do doador, salvaguardando a segurança do indivíduo, concomitante a espontaneidade da doação. Esta nota técnica tem como objetivo orientar e organizar o fluxo para a realização do transplante com doador vivo em Goiás, de modo a atender a necessidade social e médica, preservando os princípios legais e norteadores do processo

Transplantation is a surgical procedure that consists of replacing an organ (heart, lung, kidney, pancreas, liver) or tissue (bone marrow, bones, corneas) from a sick person (recipient) with another organ or normal tissue from a living or dead donor. They are classified by two types, being deceased donor and living donor. In the latter, only those of legal age and legal capacity can donate and the procedure takes place in order to preserve the quality of life and maintenance physiological function of the donor, safeguarding the individual's safety, concomitant with the spontaneity of the donation. This technical note aims to guide and organize the flow for carrying out the transplant with a live donor in Goiás, in order to meet the social and medical needs, preserving the legal and guiding principles of the process

Strategies to keep kidney transplant alive amid the SARS-CoV-2 pandemic

SUMMARY OBJECTIVE: This study aims to describe the result of the strategies adopted to maintain the transplant program amid the COVID-19 pandemic. METHODS: Since March 2020, several measures have been adopted sequentially, including the compulsory use of personal protective equipment and the real-time polymerase chain reaction testing of collaborators, symptomatic patients, potential deceased donors, candidates for recipients, and in-hospital readmissions, regardless of symptoms. The living-donor transplantation was restricted to exceptional cases. RESULTS: Among 1013 health professionals, 201 cases of COVID-19 were confirmed between March and August 2020, with no severe cases reported. In this period, we observed a 19% institutional increase in the number of transplants from deceased donors compared with that observed in the same period in 2019. There was no donor-derived severe acute respiratory syndrome virus (SARS-CoV-2) infection. Four COVID-19-positive patients underwent transplantation; after 28 days, all were alive and with functioning allograft. Among the 11,875 already transplanted patients being followed up, there were 546 individuals with confirmed diagnosis, 372 who required hospitalization, and 167 on mechanical ventilation, resulting in a 27% mortality rate. CONCLUSIONS: These data confirm that the adoption of sequential and coordinated measures amid the pandemic was able to successfully maintain the transplant program and ensure the safety of health professionals and transplanted patients who were already in follow-up.

Disposal of donor livers in Brazil: how to optimize their utilization rate in transplants? / Descarte de fígados de doadores no Brasil: como otimizar sua taxa de utilização em transplantes?

ABSTRACT Objective: To understand the professionals´ perception of the use of deceased donor liver for transplantation, the reasons to decline them, and propose strategies to increase their use safely. Methods: This is a cross-sectional, descriptive qualitative-quantitative study. Professionals working with liver transplantation answered a self-administered, structured, and electronic questionnaire comprising 17 questions distributed into four sessions (demographic factors, perception of use of organs, reasons for disposal, and measures to favor their usage). Results: A total of 42 professionals participated in the study. The rate of use of organs was considered low by 71.43% (n=30) of respondents or very low by 19.05% (n=8). Everyone agreed that it was possible to increase it. Thirty-one (73.81%) participants believed the expansion of the population of extended criteria donors affected this index negatively. Donor-related conditions were the most frequent category of reasons for refusing a liver for transplantation, being the findings during organ retrieval the most frequent reason in clinical practice. Enhanced training of intensive care teams in the treatment of donors was the primary measure selected to favor the use of the organs, followed by investment in new technologies to optimize its preservation/evaluate its function before transplantation. Conclusion: Implementation of strategies to increase the rate of acceptance of livers is expected. Improvements in donor intensive care and implementation of new preservation technologies should favor the use of the organs.

RESUMO Objetivo: Compreender a percepção dos profissionais acerca do uso de fígado de doadores falecidos para transplante e os motivos para sua recusa, além de propor estratégias para ampliar sua utilização com segurança. Métodos: Estudo do tipo transversal, descritivo qualiquantitativo.Profissionais que trabalhavam com transplante hepático responderam a um questionário autoaplicável, estruturado e eletrônico, composto de 17 questões distribuídas em quatro seções (fatores demográficos, percepção sobre a utilização dos órgãos, razões para o descarte e medidas para favorecer sua utilização). Resultados: Participaram do estudo 42 profissionais. A taxa de utilização dos órgãos foi considerada baixa por 71,43% (n=30) dos respondentes ou muito baixa por 19,05% (n=8). Todos concordaram que era possível aumentá-la. Trinta e um (73,81%) participantes acreditavam que a expansão da população de doadores de critérios estendidos impacta negativamente nesse índice. Condições relacionadas ao doador foi a categoria mais frequente de razões para a recusa de um fígado para transplante, sendo os achados durante a cirurgia de extração o motivo mais frequente na prática clínica. O melhor treinamento das equipes da terapia intensiva nos cuidados com os doadores foi a principal medida selecionada para favorecer a utilização dos órgãos, seguido pelo investimento em novas tecnologias para otimizar sua preservação/avaliar sua função antes do transplante. Conclusão: A efetivação de estratégias para aumentar a taxa de aceite de fígados de doadores é aguardada. Melhorias no cuidado intensivo do doador e a implementação de novas tecnologias de preservação devem favorecer a utilização desses órgãos.