Safety and anti-HCV effect of prolonged intravenous silibinin in HCV genotype 1 subjects in the immediate liver transplant period.

BACKGROUND & AIMS: Reinfection of the graft is the rule in patients with HCV cirrhosis undergoing liver transplantation, and HCV-RNA reaches pre-transplantation levels within the first month. Short-term intravenous silibinin monotherapy is safe and shows a potent in vivo anti-HCV effect. We aimed at evaluating the safety and antiviral effect of prolonged intravenous silibinin, started immediately before liver transplantation. METHODS: Single centre, prospective, pilot study, to assess the safety and effect on HCV-RNA kinetics during at least 21 days of intravenous silibinin monotherapy (20 mg/kg/day) in 9 consecutive HCV genotype 1 subjects, in comparison to a control, non-treated group of 7 consecutive prior transplanted subjects under the same immunosuppressive regimen (basiliximab, steroids, delayed tacrolimus, micophenolate). RESULTS: Intravenous silibinin led to significant, maintained and progressive HCV-RNA decreases (mean HCV-RNA drop at week 3, -4.1 ± 1.3 log(10)IU/ml), and lack of viral breakthrough during administration. Four patients (44%) reached negative HCV-RNA, maintained during silibinin treatment, vs. none in the control group, but HCV-RNA relapsed in all of them after a median of 21 days (16-28), following silibinin withdrawal. Partial responders to silibinin showed marked decreases in HCV-RNA when compared to controls, but lower than complete responders. There were no clinical adverse effects, and silibinin led to asymptomatic transient hyperbilirubinemia (week 2, 4.2 ± 2.2 vs. 2.5 ± 3.6 mg/dl; p=0.02). CONCLUSIONS: Prolonged intravenous silibinin monotherapy was safe in the immediate liver transplantation period, leading to a potent and time dependent antiviral effect and lack of HCV-RNA breakthrough during administration. However, HCV-RNA rebounded after withdrawal, and silibinin monotherapy did not avoid reinfection of the graft.

Luschka Duct Leak: An Unexpected Cause of Choleperitoneum After Liver Transplant.

The anatomic variabilities in ducts of Luschka put patients at risk during hepatobiliary surgery. Clinically relevant bile leakage is the cause of 0.4% to 1.2% of complications of cholecystectomies, with almost one-third of complications caused by an inadvertent injury to the duct of Luschka. However, bile leakage from a duct of Luschka after liver transplant is rare, and only one previously published report has been found. Here, we report a case of a 67-year-old male patient who underwent liver transplant for cirrhosis due to hepatitis C virus infection. After transplant, the patient had a choleperitoneum caused by bile leakage from a duct of Luschka. The donor surgery had been performed by surgeons from another institution, and they had also performed the previous cholecystectomy. Fifteen days after surgery, a cholangiography showed bile leakage near the anastomosis. A new intervention was decided. After confirmation of the integrity of the anastomosis, methylene blue was injected through the Kehr's tube, which escaped from a duct of Luschka. The duct was closed, and an intraoperative cholangiography confirmed that the biliary tree was intact. After this intervention, a new bile leakage was observed, resulting in an endoscopic retrograde cholangiopancreatography scan and sphincterotomy. The Kehr's tube was kept open until leak resolution. Although unusual after liver transplant, this complication should be considered in cases of bile leakage. The ducts of Luschka are difficult to see during cholecystectomy in the graft due to perivesicular edema.

Increase and Redistribution of Sex Hormone Receptors in Premenopausal Women Are Associated with Varicose Vein Remodelling.

In chronic venous insufficiency of the lower limbs, data show that the clinical manifestation is varicose veins (VVs), and VV epidemiology suggests that sex hormones directly influence disease development through intracellular receptors. This study aimed to determine the presence and localization of oestrogen receptors (ERs), progesterone receptors (PRs), and androgen receptors (ARs) in both healthy and VV wall cells and their relationship with gender. In this study, samples from patients without a history of venous disease (CV) (n = 18) and with VV (n = 40) were used. The samples were divided by gender: CV women (CVw) = 6, CV men (CVm) = 12, VV women (VVw) = 25, and VV men (VVm) = 15. RT-qPCR and immunohistochemical techniques were performed, and increased ER and PR protein expression was found in VVw in all tunica layers. ARs were localized to the adventitial layer in the CV and were found in the neointima in VVs. mRNA expression was increased for ER and PR in VVw. AR gene expression was significantly decreased in VVm. The increase in the number of these receptors and their redistribution through the wall reinforces the role of sex hormones in varicose vein development.

Current allocation policy is favorable for patients with hepatocellular carcinoma waiting for liver transplantation.

BACKGROUND: Patients with hepatocellular carcinoma (HCC) are a growing population of the transplantation waiting list (WL) for orthotopic liver transplantation (OLT). There is no consensus to prioritize these patients while on the WL. AIMS: To assess whether patients with HCC were more prioritized than non-HCC patients based on their WL survival as primary outcome. METHODS: Restrospective cohort study including patients listed for elective OLT from January 2013 to January 2016. RESULTS: 165 patients with cirrhosis were listed for OLT: 64 in the HCC group (38.78%) and 101 in the non-HCC group (61.22%). Outcomes (HCC vs. non-HCC) were: OLT in 75.51% vs. 64.37%; death or dropout due to worsening in 20.41% vs. 27.59%, and delisting because of improvement in 4.08% vs. 8.05%. HCC patients had a significantly higher WL survival rate (HR = 0.45; 95% CI: 0.21-0.96); lower MELD score at transplantation (21 [20-24] vs. 24 [20-30]; p = 0.021); higher delta-MELD - the difference between MELD at transplantation and MELD at listing time - (3 [2-6] vs. 0 [0-5]; p = 0.024) and longer waiting time until OLT (143 [70-233] vs. 67 [21-164] days; p = 0.008). CONCLUSION: Despite having to wait longer, patients with HCC showed higher WL survival than non-HCC patients.

Value of third metastasectomy of colorectal adenocarcinoma.

62 year-old woman with a tumour in sigmoid colon invading left ovary and metastases in both hepatic lobes. Posterior pelvic exanteration and metastasectomy of left hepatic lesions were performed in the first surgery, right hepatectomy in the second one and metastasectomy of 2 new metastases in the third one. A new metastases in remanent portal pediculum was considered non-operable. The patient died 29 months after first surgery.

Midline abdominal wall closure: a new prophylactic mesh concept.

BACKGROUND: Despite intense research efforts, incisional hernias continue to be a problem in patients who undergo laparotomy. This study was designed to reinforce the midline laparotomy closure by including a new prosthetic design between the edges of the surgical wound. STUDY DESIGN: A midline incision was made in New Zealand white rabbits and closed by inserting a polypropylene strip, T-shaped in cross-section, between the incisional borders. The T was placed upside down such that the horizontal arm of the T, whose surface is coated with extra-low pore size expanded polytetrafluoroethylene, made contact with the visceral peritoneum. The mesh was secured by a mass polypropylene 3/0 running suture. Surgery outcomes in these animals were compared with those in which the surgical wound was closed by simple suture and with control, nonoperated animals. RESULTS: The T-mesh induced an increased amount of scar tissue at the midline, where neoformed recipient tissue appeared around the polypropylene mesh filaments. The expanded polytetrafluoroethylene lamina became appropriately mesothelialized. Compared with the simple suture, the T-mesh provided a significant gain in biomechanical strength at postoperative week 6 (43.99+/-4.17 Newtons and 56.96+/-10.94 Newtons, respectively, p < 0.05). At 6 months, the strength of the reinforced wound even surpassed, although not significantly, that of the control intact abdominal wall (82.25+/-7.60 Newtons versus 79.55+/-11.46 Newtons). Data were expressed as mean +/- standard deviation. CONCLUSIONS: The use of a nonabsorbable biomaterial for midline laparotomy closure significantly improves its biomechanical resistance. Used in high-risk patients or even prophylactically, this technique could reduce the incidence of incisional hernia.

Trasplante hepático urgente por hepatitis autoinmune en el epicentro de la pandemia COVID-19 en España / Successful urgent liver transplant due to fulminant autoimmune hepatitis during the height of the COVID-19 pandemic in Spain

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Leiomiosarcoma de vena cava inferior / Leiomyosarcoma of the inferior vena cava

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Repeated liver resection for recurrence of colorectal cancer metastases.

BACKGROUND: Resection of liver metastases is accepted as treatment for diverse tumours, implying a survival improvement. Metastases often recur after first hepatectomy and, very few would be potentially resectable. MATERIALS AND METHODS: A retrospective study of 18 patients undergoing repeated hepatectomies (two or more liver resections in the same patient) due to metastases of colorectal cancer between 1988 and 2006 was performed. RESULTS: Thirteen men and five women, mean age 57.55 years, participated. In all patients, repeated liver resection was performed due to recurrence of the metastases. Complications rate after first hepatectomy was 11.1% and after the second 16.6%. Mortality rate was 11.1% after second hepatectomy, and there was no mortality after third hepatectomy. Three- and 5-year survival after colectomy was 88.9% and 77.8%, respectively; after first hepatectomy 3- and 5-year survival was 88.9% and 61.1%, respectively; after second hepatectomy, 3- and 5-year survival was 83.3% and 61.1% respectively; and 3-year survival after third hepatectomy was 67%. CONCLUSION: Repeated resections by expert surgeons for recurrent liver metastases can be safely performed, with low morbidity and mortality rates similar to first hepatectomies. Repeated resections of liver metastases of colorectal cancer improve global survival.

Ultrashort bowel syndrome: surgical management and long-term results of an exceptional case.

Management of the short bowel syndrome is a multidisciplinary and very complex problem. The authors report the successful long-term results of an original combination of autologous gastrointestinal reconstruction in a boy who at the age of 16 years lost all but 5 cm of the small bowel. This case demonstrates that lengthening and antipropulsive interposition of a long segment of the colon can be another alternative to early transplantation in exceptional cases.

Hernia interna tras sigmoidectomía laparoscópica / Internal hernia after laparoscopic sigmoidectomy

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Influencia de las características de los donantes en el desarrollo de una disfunción primaria en los pacientes sometidos a trasplante hepático / Influence of donor characteristics on the development of primary dysfunction after liver transplantation

Introducción. La disfunción primaria (DP) y su forma más grave, el fallo primario (FP), siguen siendo un problema muy importante en los pacientes sometidos a un trasplante hepático (TH), ya que se trata de una entidad de origen desconocido, con una incidencia elevada y con una gran repercusión en su evolución. Los objetivos de nuestro estudio son conocer la incidencia de la DP y la capacidad de 20 características de los donantes para inducir este cuadro. Pacientes y método. Se han estudiado de forma prospectiva los 248 TH realizados consecutivamente durante 79 meses en el Hospital Ramón y Cajal de Madrid en 206 pacientes. Los enfermos fueron clasificados en normofunción primaria y disfunción primaria, y en esta última se reagruparon los casos de FP y función primaria inadecuada. Se definió normofunción primaria o función primaria inadecuada según si las cifras de transaminasas y la actividad de protrombina eran superiores o inferiores a 2.000 U/ml y al 50 por ciento, respectivamente, entre los días segundo y séptimo tras el trasplante hepático. Resultados. La incidencia de DP fue del 9,3 por ciento (23 trasplantes hepáticos), de los cuales 12 (4,8 por ciento) casos fueron un fallo primario. El análisis univariable relacionó significativamente la edad del donante y la causa de la muerte cerebral de él con una mayor frecuencia de DP. El estudio multivariable únicamente lo relacionó con esta última variable (p = 0,04), con una odds ratio (OR) de 4,25 (intervalo de confianza [IC] del 95 por ciento, 1,13-16,0). Conclusiones. La DP es una entidad clínica con una incidencia importante. El único factor que ha demostrado su influencia en el desarrollo de una DP es una causa de muerte cerebral diferente de un traumatismo craneoencefálico (AU)

Bipartición hepática / Hepatic bipartition

La bipartición hepática representa en la actualidad un procedimiento de elección para el trasplante hepático de donante cadáver. La escasez del número de donantes existentes y el constante incremento en el número de receptores avalan este hecho. La realización de este procedimiento obliga a un riguroso protocolo de selección del donante, a una cuidadosa logística en la donación con el objetivo de no prolongar los tiempos de isquemia y al establecimiento de un consenso entre los dos equipos que van a realizar los dos implantes, a efectos de atender sus necesidades en función de la situación del receptor y las características anatómicas, y poder realizar una lógica repartición de los pedículos vasculobiliares. Dos procedimientos técnicos han sido descritos: procedimiento ex vivo e in situ. Este último está asociado con una menor incidencia de complicaciones quirúrgicas, hemorragia postoperatoria, trombosis de las reconstrucciones vasculares realizadas, complicaciones biliares y necrosis de áreas hepáticas. Si bien la bipartición hepática para un receptor adulto y otro pediátrico está claramente justificada, más dificultades existen para su realización con dos receptores adultos. Sólo debe plantearse ser efectuado con dos adultos de bajo peso, en donde el volumen hepático a implantar sea el adecuado. Los resultados obtenidos con la bipartición hepática confirman el gran beneficio para los programas pediátricos en función de la reducción de su lista de espera y las mínimas consecuencias en términos de complicaciones postoperatorias o pérdidas de injertos para los programas de adultos. (AU)