Harmonizing Definitions and Perspectives in Extreme Liver Surgery: A Delphi Experts Consensus.

OBJECTIVE: To propose to our community a common language about extreme liver surgery. BACKGROUND: The lack of a clear definition of extreme liver surgery prevents convincing comparisons of results among centers. METHODS: We used a two-round Delphi methodology to quantify consensus among liver surgery experts. For inclusion in the final recommendations, we established a consensus when the positive responses (agree and totally agree) exceeded 70%. The study steering group summarized and reported the recommendations. In general, a five-point Likert scale with a neutral central value was used, and in a few cases multiple choices. Results are displayed as numbers and percentages. RESULTS: A two-round Delphi study was completed by 38 expert surgeons in complex hepatobiliary surgery. The surgeon´s median age was 58 years old (52-63) and the median years of experience was 25 years (20-31). For the proposed definitions of total vascular occlusion, hepatic flow occlusion and inferior vein occlusion, the degree of agreement was 97%, 81% and 84%, respectively. In situ approach (64%) was the preferred, followed by ante situ (22%) and ex situ (14%). Autologous or cadaveric graft for hepatic artery or hepatic vein repair were the most recommended (89%). The use of veno-venous bypass or portocaval shunt revealed the divergence depending on the case. Overall, 75% of the experts agreed with the proposed definition for extreme liver surgery. CONCLUSION: Obtaining a consensus on the definition of extreme liver surgery is essential to guarantee the correct management of patients with highly complex hepatobiliary oncological disease. The management of candidates for extreme liver surgery involves comprehensive care ranging from adequate patient selection to the appropriate surgical strategy.

Defining Global Benchmarks for Laparoscopic Right Posterior Sectionectomy/H67: An International Multicenter Study.

OBJECTIVE: We aimed to establish global benchmark outcomes indicators for L-RPS/H67. BACKGROUND: Minimally invasive liver resections has seen an increase in uptake in recent years. Over time, challenging procedures as laparoscopic right posterior sectionectomies (L-RPS)/H67 are also increasingly adopted. METHODS: This is a post hoc analysis of a multicenter database of 854 patients undergoing minimally invasive RPS (MI-RPS) in 57 international centers in 4 continents between 2015 and 2021. There were 651 pure L-RPS and 160 robotic RPS (R-RPS). Sixteen outcome indicators of low-risk L-RPS cases were selected to establish benchmark cutoffs. The 75th percentile of individual center medians for a given outcome indicator was set as the benchmark cutoff. RESULTS: There were 573 L-RPS/H67 performed in 43 expert centers, of which 254 L-RPS/H67 (44.3%) cases qualified as low risk benchmark cases. The benchmark outcomes established for operation time, open conversion rate, blood loss ≥500 mL, blood transfusion rate, postoperative morbidity, major morbidity, 90-day mortality and textbook outcome after L-RPS were 350.8 minutes, 12.5%, 53.8%, 22.9%, 23.8%, 2.8%, 0% and 4% respectively. CONCLUSIONS: The present study established the first global benchmark values for L-RPS/H6/7. The benchmark provided an up-to-date reference of best achievable outcomes for surgical auditing and benchmarking.

Impact of Liver Cirrhosis, Severity of Cirrhosis, and Portal Hypertension on the Difficulty and Outcomes of Laparoscopic and Robotic Major Liver Resections for Primary Liver Malignancies.

BACKGROUND: Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies. METHODS: A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis. RESULTS: A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM. CONCLUSIONS: The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables.

Factors Associated with and Impact of Open Conversion in Laparoscopic and Robotic Minor Liver Resections: An International Multicenter Study of 10,541 Patients.

INTRODUCTION: Despite the increasing widespread adoption and experience in minimally invasive liver resections (MILR), open conversion occurs not uncommonly even with minor resections and as been reported to be associated with inferior outcomes. We aimed to identify risk factors for and outcomes of open conversion in patients undergoing minor hepatectomies. We also studied the impact of approach (laparoscopic or robotic) on outcomes. METHODS: This is a post-hoc analysis of 20,019 patients who underwent RLR and LLR across 50 international centers between 2004-2020. Risk factors for and perioperative outcomes of open conversion were analysed. Multivariate and propensity score-matched analysis were performed to control for confounding factors. RESULTS: Finally, 10,541 patients undergoing either laparoscopic (LLR; 89.1%) or robotic (RLR; 10.9%) minor liver resections (wedge resections, segmentectomies) were included. Multivariate analysis identified LLR, earlier period of MILR, malignant pathology, cirrhosis, portal hypertension, previous abdominal surgery, larger tumor size, and posterosuperior location as significant independent predictors of open conversion. The most common reason for conversion was technical issues (44.7%), followed by bleeding (27.2%), and oncological reasons (22.3%). After propensity score matching (PSM) of baseline characteristics, patients requiring open conversion had poorer outcomes compared with successful MILR cases as evidenced by longer operative times, more blood loss, higher requirement for perioperative transfusion, longer duration of hospitalization and higher morbidity, reoperation, and 90-day mortality rates. CONCLUSIONS: Multiple risk factors were associated with conversion of MILR even for minor hepatectomies, and open conversion was associated with significantly poorer perioperative outcomes.

Better liver transplant outcomes by donor interventions?

PURPOSE OF REVIEW: Donor risk factors and events surrounding donation impact the quantity and quality of grafts generated to meet liver transplant waitlist demands. Donor interventions represent an opportunity to mitigate injury and risk factors within donors themselves. The purpose of this review is to describe issues to address among donation after brain death, donation after circulatory determination of death, and living donors directly, for the sake of optimizing relevant outcomes among donors and recipients. RECENT FINDINGS: Studies on donor management practices and high-level evidence supporting specific interventions are scarce. Nonetheless, for donation after brain death (DBD), critical care principles are employed to correct cardiocirculatory compromise, impaired tissue oxygenation and perfusion, and neurohormonal deficits. As well, certain treatments as well as marginally prolonging duration of brain death among otherwise stable donors may help improve posttransplant outcomes. In donation after circulatory determination of death (DCD), interventions are performed to limit warm ischemia and reverse its adverse effects. Finally, dietary and exercise programs have improved donation outcomes for both standard as well as overweight living donor (LD) candidates, while minimally invasive surgical techniques may offer improved outcomes among LD themselves. SUMMARY: Donor interventions represent means to improve liver transplant yield and outcomes of liver donors and grafts.

European Society for Organ Transplantation (ESOT) Consensus Statement on Outcome Measures in Liver Transplantation According to Value-Based Health Care.

Liver transplantation is a highly complex, life-saving, treatment for many patients with advanced liver disease. Liver transplantation requires multidisciplinary teams, system-wide adaptations and significant investment, as well as being an expensive treatment. Several metrics have been proposed to monitor processes and outcomes, however these lack patient focus and do not capture all aspects of the process. Most of the reported outcomes do not capture those outcomes that matter to the patients. Adopting the principles of Value-Based Health Care (VBHC), may provide an opportunity to develop those metrics that matter to patients. In this article, we present a Consensus Statement on Outcome Measures in Liver Transplantation following the principles of VBHC, developed by a dedicated panel of experts under the auspices of the European Society of Organ Transplantation (ESOT) Guidelines' Taskforce. The overarching goal is to provide a framework to facilitate the development of outcome measures as an initial step to apply the VMC paradigm to liver transplantation.

Impact of neoadjuvant chemotherapy on short-term outcomes after simple and complex minimally invasive minor hepatectomy for colorectal liver metastases: A propensity-score matched and coarsened exact matched study.

BACKGROUND: In the last three decades, minimally invasive liver resection has been replacing conventional open approach in liver surgery. More recently, developments in neoadjuvant chemotherapy have led to increased multidisciplinary management of colorectal liver metastases with both medical and surgical treatment modalities. However, the impact of neoadjuvant chemotherapy on the surgical outcomes of minimally invasive liver resections remains poorly understood. METHODS: A multicenter, international, database of 4998 minimally invasive minor hepatectomy for colorectal liver metastases was used to compare surgical outcomes in patients who received neoadjuvant chemotherapy with surgery alone. To correct for baseline imbalance, propensity score matching, coarsened exact matching and inverse probability treatment weighting were performed. RESULTS: 2546 patients met the inclusion criteria. After propensity score matching there were 759 patients in both groups and 383 patients in both groups after coarsened exact matching. Baseline characteristics were equal after both matching strategies. Neoadjuvant chemotherapy was not associated with statistically significant worse surgical outcomes of minimally invasive minor hepatectomy. CONCLUSION: Neoadjuvant chemotherapy had no statistically significant impact on short-term surgical outcomes after simple and complex minimally invasive minor hepatectomy for colorectal liver metastases.

Experiencia de una unidad de urgencias de cirugía durante la pandemia provocada por el SARS-CoV-2 / Experience of an emergency surgery department during the pandemic caused by SARS-CoV-2 infection

No disponible

Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain / Resultados de una encuesta sobre el soporte nutricional perioperatorio en la cirugía pancreática y biliar en España

INTRODUCTION: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. METHODS: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. RESULTS: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (< 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. CONCLUSIONS: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country

INTRODUCCIÓN: realizamos una encuesta sobre soporte nutricional perioperatorio en cirugía pancreática y biliar en hospitales españoles en 2007, que mostró que pocos grupos quirúrgicos seguían las guías de ESPEN 2006. Diez años después enviamos un cuestionario para comprobar la situación actual. MÉTODOS: treinta y ocho centros recibieron un cuestionario con 21 preguntas sobre tiempo de ayunas antes y después de la cirugía, cribado nutricional, duración y tipo de soporte nutricional perioperatorio, y número de procedimientos. RESULTADOS: respondieron 34 grupos. La mediana de pancreatectomías (cabeza/total) fue de 29,5 (IC 95 %: 23,0-35; rango, 5-68) (total, 1002), la de cirugías biliares malignas de 9,8 (IC 95 %: 7,3-12,4; rango, 2-30) y la de resecciones biliares por patología benigna de 10,4 (IC 95 %: 7,6-13,3; rango, 2-33). Solo el 41,2 % de los grupos utilizaban soporte nutricional antes de la cirugía (< 50 % habian efectuado un cribado nutricional). El tiempo medio de ayuno preoperatorio para sólidos fue de 9,3 h (rango, 6-24 h), y de 6,6 h para líquidos (rango, 2-12). Tras la pancreatectomía, el 29,4 % habían intentado administrar una dieta oral precoz, pero el 88,2 % de los grupos usaron algún tipo de soporte nutricional y el 26,5 % usaron NP en el 100 % de los casos. Los demás grupos usaron diferentes porcentajes de NP y NE en sus casos. En la cirugía biliar maligna, el 22,6 % utilizaron NP siempre y NE en el 19,3 % de los casos. CONCLUSIONES: la NP es el soporte nutricional más utilizado tras la cirugía de cabeza pancreática. Solo el 29,4 % de las unidades usan nutrición oral precoz y el 32,3 % emplean la NE tras este tipo de cirugía. El 22,6 % de las instituciones usan NP habitualmente tras la cirugía de tumores biliares malignos. Las guías ESPEN 2006 no se siguen de forma habitual en nuestro país tras más de 10 años desde su publicación

Cirugía endocrina cervical mínimamente invasiva / Minimally-invasive endocrine neck surgery

Los abordajes quirúrgicos mínimamente invasivos en cirugía endocrina cervical son el resultado del esfuerzo de varios cirujanos para extrapolar los beneficios comprobados de técnicas mínimamente invasivas en otras regiones del cuerpo, como la reducción del dolor, la morbilidad y el tiempo de hospitalización. Sin embargo, el principal argumento que condujo a la introducción de estas técnicas fue la mejora de los resultados estéticos. Los abordajes endoscópicos y robóticos a través de pequeñas incisiones se han desarrollado durante los últimos 25 años y continúan en un constante refinamiento. El objetivo de esta revisión es describir el estado actual de la literatura, a través de una evaluación sistemática, de las diferentes técnicas disponibles dentro de la cirugía endocrina cervical mínimamente invasiva ya sea con acceso cervical o remoto, describiendo sus características principales y evaluando sus ventajas, desventajas y controversias, para discutir finalmente su papel en la cirugía actual y el futuro que tienen estos procedimientos

Minimally invasive approaches for endocrine surgery of the neck are the result of efforts by several surgeons to extrapolate to neck surgery the proven benefits of minimally invasive techniques from other regions of the body, including less pain, morbidity and hospital stay. However, the main argument that led to the introduction of these techniques was the improvement of esthetic results. Endoscopic and robotic remote-access endocrine neck approaches through small incisions have been developed over the last 25 years and are constantly being refined. The objective of this review is to determine the current state of the literature through a systematic evaluation of the different techniques available in minimally invasive endocrine surgery of the neck, either with or without remote access, by describing their main characteristics and evaluating their advantages, disadvantages and controversies, while discussing their role and future in neck surgery

Preservación de corteza adrenal funcionante. Una buena razón para realizar un abordaje endoscópico retroperitoneal posterior / Functional adrenal cortex preservation: A good reason for posterior retroperitoneal endoscopic approach

INTRODUCCIÓN: La adrenalectomía con preservación cortical se indica como tratamiento del feocromocitoma bilateral hereditario y esporádico, en casos de bajo riesgo de malignidad, para reducir la posibilidad de insuficiencia suprarrenal asumiendo la eventualidad de una recidiva local. El objetivo del estudio es analizar los resultados funcionales de la adrenalectomía parcial por vía endoscópica retroperitoneal en pacientes monoadrenales o que necesiten una adrenalectomía bilateral. MÉTODOS: Entre enero de 2015 y febrero de 2016 se incluyeron de forma prospectiva pacientes con feocromocitoma asociado a mutaciones con bajo riesgo para malignidad, que aceptaron participar en el estudio. Todos fueron operados por cirujanos especialmente entrenados en este tipo de cirugía, utilizando la misma técnica quirúrgica. Se recogieron variables demográficas y características clínicas, realizando posteriormente el análisis descriptivo de dichas variables. RESULTADOS: Se registraron un total de 6 pacientes, cuatro asociados al síndrome MEN tipo 2 y dos en contexto del síndrome VHL. No fue precisa ninguna conversión a abordaje laparoscópico o abierto y tampoco complicaciones postoperatorias, la estancia hospitalaria media fue de 2,5 días. Se logró la preservación de corteza adrenal funcionante sin requerimiento corticoideo en 5 (83%) de 6 casos. Con un seguimiento medio de 26,2 ± 6 meses, estos 5 pacientes presentan una función adrenal conservada sin aporte hormonal sustitutivo. CONCLUSIONES: La adrenalectomía con preservación cortical por vía endoscópica retroperitoneal, en manos expertas, es segura y factible para el tratamiento del feocromocitoma hereditario y esporádico en contexto de baja malignidad, permitiendo evitar la necesidad de aporte corticoideo en la mayoría de los casos

INTRODUCTION: Cortical-sparing adrenalectomy is a suitable treatment for hereditary and sporadic bilateral pheochromocytoma, in cases of low risk of malignancy, to reduce the possibility of adrenal insufficiency assuming the chance of local recurrence. The aim of the study is to analyze the functional results of partial adrenalectomy by retroperitoneal endoscopic approach in single-adrenal patients or patients requiring bilateral adrenalectomy. METHODS: Prospective study between January 2015 and February 2016 including pheochromocytoma patients diagnosed with low risk of malignant mutations. All patients agreed to be included in the study. Experienced endocrine surgeons who have been trained in minimally invasive endocrine surgery performed the procedure using the same surgical technique. Demographic variables and clinical characteristics were collected, subsequently carrying out the descriptive analysis of the data. RESULTS: A total of 6 patients were registered, four associated with MEN type 2 syndrome and two in the context of VHL syndrome. Retroperitoneoscopic resection was performed without laparoscopic or open conversion and no postoperative complications; the average hospital stay was 2.5 days. Preservation of the functional cortex without corticosteroids was achieved in 5 (83%) of out 6 cases with a follow-up of 26.2 ± 6 months. Today, these 5 patients have a preserved adrenal function without hormone replacement. CONCLUSIONS: Cortical-sparing adrenalectomy by the retroperitoneal endoscopic approach, in expert hands, is safe and feasible for the treatment of hereditary and sporadic pheochromocytoma in a context of low malignancy, making it possible to avoid the need for corticoid replacement in most cases

Trasplante hepático debido a fallo hepático agudo / Liver transplantation for acute liver failure

Antes de que el trasplante hepático fuera una opción terapéutica ampliamente disponible, la tasa de mortalidad del fallo hepático agudo alcanzaba el 85%. En la actualidad, el fallo hepático agudo es una indicación de trasplante relativamente frecuente, pero sus resultados en este contexto son peores cuando se comparan con los de las enfermedades hepáticas crónicas. En este trabajo, tratamos las indicaciones y contraindicaciones para el trasplante hepático urgente. También examinamos el papel del trasplante hepático auxiliar, del incompatible-ABO y del trasplante hepático urgente con donante vivo, así como la utilidad de la realización de una hepatectomía total y un shunt portocava cuando existe síndrome de hígado tóxico en el paciente en alerta cero

Before liver transplantation became widely applicable as a treatment option, the mortality rate for acute liver failure was as high as 85%. Today, acute liver failure is a relatively common transplant indication in some settings, but the results of liver transplantation in this context appear to be worse than those for chronic forms of liver disease. In this review, we discuss the indications and contraindications for urgent liver transplantation. In particular, we consider the roles of auxiliary, ABO-incompatible, and urgent living donor liver transplantation and address the management of a «status 1» patient with total hepatectomy and portocaval shunt for toxic liver syndrome

Resección hepática mayor: una cirugía segura y eficaz / Hepatic resection: a safe and effective surgery

Introducción: Se analizan las resecciones hepáticas mayores realizadas en 10 años, con el objetivo principal de evaluar los resultados perioperatorios. Como objetivos secundarios, se evalúan los factores relacionados con las complicaciones mayores y el análisis comparativo de 2 periodos de 5 años. Métodos: Análisis retrospectivo de pacientes intervenidos mediante una resección hepática mayor (3 o más segmentos) desde enero de 2005 hasta diciembre de 2014, de los datos pre-, intra- y postoperatorios. Se utiliza la clasificación de Clavien para el análisis de la morbilidad postoperatoria. Resultados: Se realizaron 416 hepatectomías mayores, con necesidad de transfusión en 38 pacientes (9,1%) y maniobra de Pringle en el 47,7% de los casos. La mitad de los pacientes no presentaron ninguna complicación y únicamente 96 pacientes (23%) presentaron una complicación mayor. La fuga biliar fue la complicación más frecuente (n = 72; 17,3% de los pacientes), sobre todo, por enfermedad maligna y derivación biliar, con ASA elevado (III-IV) y tiempo quirúrgico prolongado. Trece pacientes cumplían criterios de insuficiencia hepática, de los cuales 7 murieron (5 asociaban sobreinfección bacteriana). La estancia hospitalaria media fue de 12,5 días, con una tasa de reingreso del 11,8%. Al comparar 2 periodos de 5 años, se operan pacientes más complejos, con menor incidencia de transfusiones y de complicaciones (ns). Conclusiones: La cirugía hepática ha aumentado de forma significativa en los últimos años. El manejo quirúrgico del hígado permite en la actualidad ofrecer una cirugía segura y eficaz, con un índice de complicaciones muy bajo. El límite de la resecabilidad viene marcado por el volumen hepático residual (AU)

Introduction: We analyze major liver resections performed in 10 years, with the objective of evaluating perioperative results. As secondary objectives, factors related to major complications and comparative analyses of 2 5-year periods are evaluated. Methods: Retrospective analysis of patients undergoing major hepatic resection (3 or more segments) from January 2005 to December 2014, from pre, intra and postoperative data. The Clavien classification is used for postoperative morbidity. Results: A total of 416 major hepatectomies were performed. Transfusions were performed in 38 patients (9.1%). A Pringle maneuver was used in 47.7% of the cases. Half of the patients had no complications, and only 96 patients (23%) had a major complication. Bile leakage was the most frequent complication (n = 72, 17.3% of patients), especially due to malignant disease and biliary reconstruction, high risk ASA (III-IV) and prolonged surgical time. Thirteen patients met criteria for liver failure, of which 7died (5 associated a bacterial infection). The mean hospital stay was 12.5 days, with an 11,8% readmission rate. When comparing 25-year periods, at present more complex patients are operated on, with a lower incidence of transfusions and complications (ns). Conclusions: Liver surgery has increased significantly in recent years. Surgical management of the liver now allows safe and effective surgery, with a very low complication rate. The limit of resectability depends on the residual hepatic volume (AU)

Análisis de los resultados a largo plazo del trasplante hepático de donante vivo en adulto / Analysis of the long-term results of living donor liver transplantation in adults

Introducción: El trasplante hepático de donante vivo (THDV) es una alternativa al trasplante convencional dados sus excelentes resultados. El objetivo de este trabajo es la evaluación de los resultados a largo plazo en los receptores de THDV. Métodos: Cien receptores consecutivos de THDV del Hospital Clínic de Barcelona desde marzo de 2000 hasta octubre de 2015. La indicación principal de trasplante fue hepatopatía terminal (58%) seguido de hepatocarcinoma (41%). Los injertos consistieron en un 95% del hígado derecho del donante y en un 5% del izquierdo. Resultados: Tras una mediana de seguimiento de 65,5 meses, la supervivencia global a uno, 3 y 5 años de los pacientes y de los injertos fue del 93%, 80% y 74% y del 90%, 76% y 71% respectivamente, con una tasa de retrasplante global del 9%. La complicación a largo plazo más frecuente fue una estenosis biliar (40%), con un tiempo medio de aparición de 13,5±12 meses, que comportó repetidos ingresos y una media de 1,9±2 abordajes endoscópicos y 3,5±3 abordajes radiológicos por paciente. El tratamiento definitivo fue dilatación radiológica en un 40% de los casos, intervención quirúrgica en un 22,5% y retrasplante en un 7,5%. Conclusiones: Dados los resultados a largo plazo, el THDV se confirma como una alternativa al trasplante convencional. Sin embargo, la alta tasa de complicaciones biliares tardías conlleva repetidos ingresos y tratamientos invasivos que, si bien no comprometen la supervivencia, pueden afectar la calidad de vida del paciente (AU)

Introduction: Living donor liver transplantation (LDLT) is an alternative to conventional transplantation given its excellent results. The aim of this study is to evaluate long-term outcomes in LDLT recipients. Methods: 100 consecutive THDV recipients from the Hospital Clínic of Barcelona from March 2000 to October 2015 were included. The main indication for transplantation was end-stage liver disease (58%) followed by hepatocellular carcinoma (41%). 95% of grafts consisted of the right liver of the donor and the 5% of the left liver. Results: After a median follow-up of 65.5 months, patient and graft survival at 1, 3, and 5 years was 93%, 80% and 74% and 90%, 76%, and 71%, respectively. The overall re-transplant rate was 9%. The most common long-term complication was biliary stenosis (40%) with an average time of onset of 13.5±12 months, with repeated admissions and an average of 1.9±2 endoscopic procedures and 3.5±3 Radiological procedures per patient. The definitive treatment was radiological dilation in 40% of cases, surgical intervention in 22.5% and re-transplantation in 7.5%. Conclusions: Given the long-term results, LDLT is confirmed as an alternative to conventional transplantation. However, the high rate of late biliary complications involves repeated admissions and invasive treatments that, while not compromising survival, can affect the patient's quality of life (AU)

Trasplante hepático y renal en la enfermedad poliquística hepatorrenal / Liver and kidney transplantation in polycystic liver and kidney disease

Objetivo: Evaluar los resultados del trasplante hepático aislado y del trasplante combinado hepatorrenal en una serie retrospectiva de 32 pacientes con enfermedad poliquística hepatorrenal. Materiales y métodos: Estudio observacional retrospectivo en el que se incluyeron los pacientes con enfermedad poliquística hepática (EPH) y enfermedad poliquística hepatorrenal (EPHR), que fueron evaluados para trasplante desde enero de 1999 a diciembre de 2019 en el Hospital Clínic de Barcelona. Resultados: Se incluyeron un total de 53 pacientes; 32 (60,3%) tenían indicación de trasplante, de los cuales 12 recibieron trasplante hepático único y 20 doble trasplante hepático y renal. La edad media fue de 52 años y el 83,9% de los receptores fueron mujeres. La principal indicación de trasplante hepático fue la hepatomegalia sintomática incapacitante (93,5%). Dentro de las complicaciones postoperatorias, en el grupo de trasplante hepatorrenal, se detectaron una trombosis arterial hepática y una trombosis arterial renal. En ambos grupos se produjo una lesión de vena cava superior. Tres pacientes presentaron rechazo celular agudo que respondió a corticosteroides y un rechazo humoral que se trató con plasmaféresis. Durante el periodo de seguimiento 80 (27-121) meses, la supervicencia del injerto fue de 100% para el hígado y de 90% para el injerto renal. Fallecieron dos pacientes con trasplante hepatorrenal (uno por causas cardiovasculares y el otro por un adenocarcinoma intestinal). Conclusiones: El trasplante hepático aislado o combinado hepático y renal en pacientes seleccionados con enfermedad poliquística tiene unos resultados excelentes, con pocas complicaciones, muy buena sobrevida del injerto y excelente supervivencia del paciente (93,8%).(AU)

Objective: To evaluate the results of isolated liver and combined liver and kidney transplantation in a retrospective series of 32 patients with hepatorenal liver and kidney disease. Materials and methods: A retrospective observational study that enrolled patients with polycystic liver disease (PLD) and polycystic liver and kidney disease (PLKD) who were evaluated for transplantation between January 1999 and December 2019 at Hospital Clínic de Barcelona [Clinical Hospital of Barcelona]. Results: We included a total of 53 patients enrolled, 32 (60.3%) had indication for transplantation, of which 12 received a single liver transplant and 20 received a double liver and kidney transplant. The mean age was 52 years and 83.9% of the recipients were women. The main indication for liver transplantation was disabling symptomatic hepatomegaly (93.5%). Among the postoperative complications, in the combined liver and kidney transplant group, hepatic artery thrombosis in one case and renal artery thrombosis in other were detected. In both groups there was one case of inferior vena cava lesion. Three patients presented acute cellular rejection responding to corticosteroids and one presented humoral rejection which was treated with plasmapheresis. During the follow-up period of 80 (27-121) months, the liver transplant survival rate was 100% and the kidney transplant survival rate was 90%. Two patients in the combined liver and kidney transplant group died (one due to cardiovascular causes and the other due to intestinal adenocarcinoma). Conclusions: Isolated liver transplantation or combined liver and kidney transplantation in selected patients with polycystic disease yields excellent results, with few complications, very good transplant survival and excellent patient survival (93.8%).(AU)

Tumor de Klatskin: Diagnóstico, evaluación preoperatoria y consideraciones quirúrgicas / Klatskin tumor: Diagnosis, preoperative evaluation and surgical considerations

El colangiocarcinoma hiliar es el colangiocarcinoma más frecuente, representando hasta un 10% de todos los tumores hepatobiliares. Es un tumor agresivo con una resecabilidad al diagnóstico del 47% y una supervivencia sin cirugía inferior a 12 meses. Las pruebas de imagen más utilizadas para valorar estadificación y resecabilidad son la tomografía computarizada y la colangiorresonancia magnética. La mayoría de los pacientes presentan prurito e ictericia al diagnóstico, por lo que el drenaje biliar preoperatorio está indicado, pudiendo realizarse por colangiopancreatografía retrógrada endoscópica o colangiografía transparietohepática. En la actualidad, el único tratamiento curativo consiste en la resección quirúrgica, siendo la resección amplia con resección en bloque y reconstrucción vascular la técnica que ha conseguido una supervivencia mayor a largo plazo. La resección R0, la afectación ganglionar y las metástasis a distancia siguen siendo los factores pronóstico más importantes

Hiliar cholangiocarcinoma is the most common type of cholangiocarcinoma, an represent around 10% of all hepatobiliary tumors. It is an aggressive malignancy, resectable in around 47% of the patients at diagnosis. Complete resection is the most effective and only potentially curative therapy, with a survival rate of less than 12 months in unresectable cases. Axial computerized tomography and magnetic resonance are the most useful image techniques to determine the surgical resectability. Clinically, jaundice and pruritus are the most common symptoms at diagnosis; preoperative biliary drainage is recommended using endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography. Surgery using extended liver resections with an en bloc resection of the liver with vascular reconstruction is the technique with the highest survival. Complete resection with histologically negative resection margins (R0), nodal involvement and metastases are the most important prognostic factors

Protocolo de monitorización hemodinámica hepática en el trasplante hepático de donante vivo en adultos / Hemodynamic monitoring protocol during living donor liver transplantation

Introducción El receptor de un trasplante hepático de donante vivo en adulto (THDVA) está sometido a grandes cambios hemodinámicos que pueden determinar la aparición del síndrome de «small-for-size» en el postoperatorio como consecuencia de un hiperaflujo portal. El objetivo de este trabajo es evaluar dichos cambios e intentar correlacionarlos con el flujo de la vena porta durante la reperfusión. Material y métodos Desde el 2003 se lleva a cabo un protocolo de monitorización de distintos datos hemodinámicos hepáticos del receptor de THDVA antes, durante y después de la intervención quirúrgica. Se analiza la evolución hemodinámica del receptor tras el trasplante, y se correlaciona el flujo de la vena porta durante la reperfusión con dichos datos hemodinámicos. Resultados No hubo ningún síndrome de small-for-size. Se halló una correlación significativa del flujo portal durante la reperfusión con la presión de la vena porta al inicio de la intervención (r = 0,46; p = 0,006) y con el flujo del shunt portocava durante la fase anhepática (r = 0,55; p < 0,001). Los receptores mostraron un estado hemodinámico esplácnico normal a los 3 meses del trasplante. Conclusiones La monitorización hemodinámica del receptor de THDV es fundamental para evitar el hiperaflujo portal. La correlación entre flujo durante la reperfusión y el flujo a través del portocava nos va a permitir identificar a los pacientes con mayor riesgo de hiperaflujo y poder modularlo antes de la reperfusión (AU)

Introduction The recipient of an adult living donor liver transplant (ALDLT) is subjected to great haemodynamic changes that could lead to the appearance of a “small-for-size” syndrome in the post-operative period due to portal hyperflow. The aim of this article is to evaluate these changes, and try to correlate them with portal vein flow during reperfusion. Material and methods A protocol for monitoring various liver haemodynamic data of the ALDLT recipient before, during and after surgery has been used since the year 2003. The haemodynamic outcome of the recipient after the transplant, as well as the correlation between the portal vein flow during reperfusion and the collected haemodynamic data is analysed. Results There was no small for size syndrome. A significant relationship was found between the portal flow during reperfusion and the portal vein pressure at the beginning of the operation (r=0.46, P<.006) and with the portocaval shunt flow during the anhepatic phase (r=0.55, P<.001). The recipients showed a normal splanchnic hemodynamic state at 3 months after the transplant. Conclusions Haemodynamic monitoring of the ALDLT recipient is essential to prevent portal hyperflow. The relationship between flow during reperfusion and flow through the portocaval shunt means that patients with a higher risk of hyperflow can be identified and can be modified before reperfusion (AU)

Las complicaciones biliares en el trasplante hepático de donante vivo no afectan los resultados a largo plazo / The biliary complications in live donor liver transplant do not affect the long-term results

Introducción El trasplante hepático de donante vivo (THDV) es un tratamiento eficiente para pacientes con hepatopatía crónica terminal, a pesar de la elevada incidencia de complicaciones biliares. El objetivo es evaluar los resultados y el impacto a largo plazo de las complicaciones biliares tras el THDV. Pacientes y métodos Desde 2000 hasta 2010, se llevaron a cabo 70 THDV usando el hígado derecho como injerto. Se recogieron prospectivamente y analizaron retrospectivamente las complicaciones biliares (fugas y estenosis) de estos 70 receptores de THDV. Resultados Un total de 39 pacientes (55,7%) presentaron algún tipo de complicación biliar. Veintinueve presentaron una fuga y, de ellos, 14 desarrollaron posteriormente una estenosis. Además, 10 pacientes más presentaron una estenosis sin una fuga previa. La mediana de tiempo hasta la aparición de una estenosis fue de casi un año. Los pacientes con una fuga biliar previa presentaron una mayor probabilidad de desarrollar una estenosis (58 vs. 29,5% a 5 años, p = 0,05). Con una mediana de seguimiento de 80 meses, el 70,8% de los pacientes fueron tratados satisfactoriamente mediante radiología intervencionista. Tras excluir la mortalidad inicial, no hubo diferencias de supervivencia en función de las complicaciones biliares. Se observó una disminución de las complicaciones biliares en los segundos 35 pacientes en comparación con los primeros. Conclusiones El THDV está asociado a una incidencia elevada de complicaciones biliares. Sin embargo, los resultados a largo plazo de los pacientes no se ven afectados. Tras un tiempo de seguimiento mediano de casi 7 años, la supervivencia en función de la aparición de complicaciones biliares permaneció sin diferencias (AU)

Introduction Living donor liver transplantation (LDLT) is an effective treatment for patients with terminal chronic liver disease, despite the high incidence of biliary complications. The objective is to evaluate the results and long-term impact of biliary complications after THDV. Patients and methods From 2000 to 2010, 70 right lobe LDLT were performed. Biliary complications (leakage and stenosis) of the 70 LDLT recipients were collected prospectively and analyzed retrospectively. Results A total of 39 patients (55.7%) had some type of biliary complication. Twenty nine presented a leak, and of these, 14 subsequently developed a stricture. In addition, 10 patients had a stenosis without prior leakage. The median time to onset of stenosis was almost a year. Patients with previous biliary leakage were more likely to develop stenosis (58% vs. 29.5% at 5 years, P=.05). With a median follow up of 80 months, 70.8% of patients were successfully treated by interventional radiology. After excluding early mortality, there were no differences in survival according to biliary complications. A decrease of biliary complications was observed in the last 35 patients compared with the first 35.ConclusionsLDLT is associated with a high incidence of biliary complications. However, long-term outcome of patients is not affected. After a median follow-up time of nearly seven years, no differences were found in survival according to the presence of biliary complications (AU)

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