Laparoscopic Living Donor Hepatectomy for Pediatric Liver Transplantation: the First 7 Cases in Spain.

Herein we report on laparoscopic donor hepatectomy (left lateral sectionectomy) for pediatric living donor liver transplantation by using a pure laparoscopic approach. Seven laparoscopic living donor procedures were performed during the period March 2016 to February 2017 at our institution. The average age of donors was 33.3 years. Preoperative liver function was normal in all donors. Four donors required 1 or more Pringle maneuver(s). The etiology was biliary atresia (n = 3), metabolic disorders (n = 2) (OTC deficiency), Alagille syndrome (n = 1), and neonatal ductopenia (n = 1). The graft was implanted orthotopically in 6 patients; we performed an auxilliary transplantation in a patient with an OTC deficiency. The time of donor surgery was 363 minutes. Dindo-Clavien complications among donors were type I (n = 1), type IIa (n = 1), and type IIb (n = 2). The mean hospital stay for the recipients was 14 days. The mean donor stay was 3.7 days. Perioperative donor and recipient mortality was 0%. Graft survival was 87.5% with 1 graft loss secondary to inadequate venous outflow. In conclusion, we can propose the laparoscopic approach in experienced centers as a "standard of practice" due to its minimal complication rate and short hospital stay.

Planning Generational Change in a Liver Transplant Team.

Liver transplantation (LT) is a demanding and stressful practice. It requires full dedication and great personal sacrifice. It carries with it a long, difficult learning curve. We present the current situation with one LT team and carried out a critical analysis on the current problems in LT units with regard to access to leadership the future generational changes. An LT team has several similarities with a family-owned company. A generation change planning in liver transplantation may address 3 important aspects: the succession of the leader; establishment and reinforcement of the talent pool; and accessibility to the working group. An LT team is manned by highly qualified personnel. The ideal scenario is when the successor surgeon is accepted by every member in a joint agreement; all the surgeons on the team have the potential to be the next team leader; and the working group presents a high level of personal effort and a motivated attitude. There is an ongoing problem in LT units, however-the growing lack of interest from young surgeons to be part of a transplant team. There are many reasons for this, but it primarily involves the high level of dedication required. The formation of a good transplant team, with a pool of high-quality young surgeons and the realization of a proper generational change, could improve its operation and its results in the future.

Rescue of Discarded Grafts for Liver Transplantation by Ex Vivo Subnormothermic and Normothermic Oxygenated Machine Perfusion: First Experience in Spain.

BACKGROUND: Ex vivo machine perfusion (MP) has been reported as a possibly method to rescue discarded organs. The main aim of this study was to report an initial experience in Spain using MP for the rescue of severely marginal discarded liver grafts, and to, secondarily, define markers of viability to test the potential applicability of these devices for the real increase in the organ donor pool. METHODS: The study began in January 2016. Discarded grafts were included in a research protocol that consisted of standard retrieval followed by 10 hours of cold ischemia. Next, either normothermic (NMP) or controlled subnormothermic (subNMP) rewarming was chosen randomly. Continuous measurements of portal-arterial pressure and resistance were screened. Lactate, pH, and bicarbonate were measured every 30 minutes. The perfusion period was 6 hours, after which the graft was discarded and evaluated as potentially usable, but never implanted. Biopsies of the donor and at 2, 4, and 6 hours after ex vivo MP were obtained. RESULTS: A total of 4 grafts were included in the protocol. The first 2 grafts were perfused by NMP and grafts 3 and 4 by subNMP. The second and third grafts showed a clear trend toward optimal recovery and may have been used. Lactate dropped to levels below 2.5 mmol/L with stable arterial and portal pressure and resistance. Clear biliary output started during MP. Biopsies showed an improvement of liver architecture with reduced inflammation at the end of the perfusion. CONCLUSION: This preliminary experience has demonstrated the potential of MP devices for the rescue of severely marginal liver grafts. Lactate and biliary output were useful for viability testing of the grafts. The utility of NMP or subNMP protocols requires further research.

"Super-rapid" Technique in Donation After Circulatory Death Liver Donors: Advantages and Disadvantages.

In recent years, donation after circulatory death (DCD) has increased as an option to overcome the organ donor shortage crisis and to decrease the large number of patients on liver transplant waiting lists. The "super-rapid" technique is now the "gold standard" procurement method because of its availability, reproducibility, low cost, and extensive experience. Recently, extracorporeal support has been implemented, with encouraging results. Strict donor acceptance criteria have proven to be essential to optimize the DCD liver graft outcomes and minimize biliary complication rates. In this study we assessed the state of the art of DCD liver transplantation with regard to its development and the actual strategies to prevent graft complications, with aim of expanding the pool of marginal liver donors.

Use of Peritoneovenous Shunt for the Management of Refractory Ascites.

BACKGROUND: Guidelines for the management of refractory ascites (RA) recommend transjugular intrahepatic portosystemic shunting (TIPS), diuretics, and paracentesis as the main strategies, discouraging use of surgical peritoneovenous shunts (PVSs). However, PVSs, including both Denver (DS) or saphenoperitoneal (SPS) modalities, may still have indications. Herein we report our experience with PVSs in the context of modern surgical and anesthetic management. METHODS: In our unit, PVSs are offered to patients with ascites refractory to diuretics in which TIPS are contraindicated. Heart function and spontaneous bacterial peritonitis must be assessed before surgical indication. RESULTS: Seven procedures were performed on 5 patients (6-DS, 1-SPS) in 2013. Their mean age was 61 (range, 54-68) years. In 3 patients, the indication was RA without options for liver transplant; 2 patients were on the waiting list for liver transplantation, which were performed to improve renal function and quality of life (QOL). The median hospital stay was 6.5 (range, 3-12) days. All patients were alive after 12 months. One patient died 2 years after the first DS and another later died due to liver insufficiency with patency of the DS. The ascites was well-controlled in 4 of 5 patients at up to 48 months of follow-up. Decreases in diuretics doses, proper weight maintenance, and a dramatic improvement in QOL (measured by a modified Ascites Symptom Inventory-7 [ASI-7] test) were observed after the procedures. CONCLUSION: PVSs are useful for the treatment of patients with RA who develop resistance to common therapies, leading to a major improvement in QOL. These surgical procedures should be included in the armamentarium of experienced liver surgeons.

Postoperative time course and utility of inflammatory markers in patients with ovarian peritoneal carcinomatosis treated with neoadjuvant chemotherapy, cytoreductive surgery, and HIPEC.

BACKGROUND: Inflammatory markers may help monitor postoperative evolution of surgical patients and detect complications. However, to date, the effect that neoadjuvant chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC) may have in the postoperative kinetics of these parameters remains unknown. METHODS: Between July 2011 and June 2014, all patients who underwent neoadjuvant chemotherapy, cytoreductive surgery, and HIPEC for ovarian peritoneal carcinomatosis were studied. Patients were divided into four groups: no complications, noninfective complication, and infective complications during the first and second postoperative weeks. Retrospectively, C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), white blood cell count, platelet-to-lymphocyte ratio, and prothrombin ratio were collected from postoperative days 1-14. Postoperative behavior of each parameter was carefully evaluated across groups. RESULTS: The study included 122 patients. Only CRP and NLR showed promising results. CRP presented a mean peak value at 48 h (186.1 mg/L), while NLR peaked at 24 h (10.21 mg/L). Both parameters rose with infective complications. Statistically significant differences were found at several time points compared with uncomplicated patients. A simple test comparing the peak value of CRP with the value when an infective complication was suspected accurately diagnosed these complications with sensitivity of 81 %, specificity of 91 %, and negative and positive predictive value of 93.1 and 76 %, respectively. This comparison presented lower diagnostic performance when NLR was used. CONCLUSIONS: Both CRP and NLR are useful in monitoring postoperative evolution in these patients; however, only CRP is useful for detecting infective complications.