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BACKGROUND: Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most feared complication following pancreaticoduodenectomy (PD). There is increasing evidence that very early postoperative factors can be helpful to identify high-risk patients. The aim of this study is to analyze whether postoperative day one (POD1) systemic inflammatory response can be used as an early biomarker of CR-POPF development. METHODS: All patients undergoing PD from 2014 to 2020 were considered. Variables were extracted from a prospectively held database. Clinical and perioperative variables, including POD1 systemic inflammatory response syndrome (SIRS) and C-reactive protein level were collected. To elucidate the independent role of early CR-POPF biomarkers, multivariate hierarchical logistic regression analyses were planned. RESULTS: Out of 243, 213 patients were included in this analysis. CR-POPF occurred in 49 (23.0%) patients and 90-day mortality was 1.4%. POD1 SIRS was reported in 65 (30.5%) patients. Following hierarchical logistic regression analyses, CR-POPF was independently associated with body mass index (OR = 2.787, p = 0.003), soft pancreatic texture (OR = 4.258, p = 0.002) and POD1 SIRS (OR = 50.067, p = 0.001). CONCLUSION: POD1 SIRS is powerfully associated with CR-POPF and therefore it could be used as a tool to optimize postoperative care of PD patients. Further prospective studies are needed to validate these findings.
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Páncreas , Fístula Pancreática , Humanos , Fístula Pancreática/diagnóstico , Fístula Pancreática/etiología , Factores de Riesgo , Páncreas/cirugía , Pancreaticoduodenectomía/efectos adversos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Biomarcadores , Estudios RetrospectivosRESUMEN
BACKGROUND: In 2007, a multicenter protocol was developed in Catalonia, Spain, combining neoadjuvant chemoradiotherapy and liver transplantation (LT) for those patients with unresectable hilar cholangiocarcinoma (hCCA). AIM: To analyse the effectiveness of the neoadjuvant chemoradiotherapy and LT for those patients enrolled in the protocol based on intention-to-treat. METHODS: Observational multicenter study which includes patients ≤ 68 years-old diagnosed with unresectable, solitary tumors ≤ 3 cm in radial diameter, without evidence of lymph node metastases. The protocol was based on a strategy of neoadjuvant therapy with high-dose radiation (45 Gy in total) plus intravenous fluorouracil (5-FU) given as a daily bolus for the first 3 days of radiation follow by oral capecitabine until transplantation. The patient was included in waiting list for LT if no evidence of disseminated disease was found. RESULTS: Between 2007 and 2018, 13 patients were enrolled in the transplant protocol. Of those, 61% (8/13) of the patients were transplanted. The average time spent on the waiting list was 122 days (range 5-192). Intent-to-treat survival was 69% and 39% at one and 5 years. Post-transplantation overall survival was 87% and 62% and 29% recurrence rate at 5 years. CONCLUSION: The suitability of the neoadjuvant chemoradiotherapy and LT protocol was 61% in our series with long-term overall survival and should be considered as an alternative to resection for patients with localized node-negative hCCA.
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BACKGROUND: Recipient hepatectomy during liver transplantation can be a challenging operation and can increase cold ischaemic time. The aim of this study is to assess factors associated with prolonged recipient hepatectomy. METHODS: From 2005 to 2015, 930 patients were submitted to liver transplantation in our hospital. Prolonged hepatectomy time was defined as operative time >180 min (from knife on skin to total hepatectomy). Patients undergoing early liver retransplantation and living donation were excluded. RESULTS: A total of 715 patients were included in our study. Median age at transplantation was 53 (18-70) years, and median BMI was 26.2 (16-40). Median hepatectomy time was 131 min. Prolonged hepatectomy time occurred in 89 (12.4%) patients. At univariate analysis, previous decompensated cirrhosis with variceal bleeding and/or ascites, higher BMI and previous abdominal surgery were associated with prolonged operating time. Higher surgeon experience and acute liver failure were associated with shorter hepatectomy time. At multivariate analysis, previous episodes of variceal bleeding (p = 0.027, OR 1.78), BMI > 27 (p = 0.01, OR 1.75), previous abdominal surgery (p = 0.04, OR 1.68) and surgeon experience (p = 0.007, OR 2.04) were independently associated with operating time. Prolonged hepatectomy time was significantly associated with cold and total ischaemic time and intraoperative bleeding (p < 0.001, p = 0.002 and p = 0.002, respectively). CONCLUSIONS: Recipient BMI, previous episodes of variceal bleeding, previous abdominal surgery and surgeon experience are independently associated with hepatectomy duration. These factors can be helpful to identify those patients with potentially prolonged hepatectomy time, and therefore, strategies can be put in place to optimize outcomes in this group of patients.
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Hepatectomía/métodos , Trasplante de Hígado/métodos , Adolescente , Adulto , Anciano , Índice de Masa Corporal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Adulto JovenRESUMEN
BACKGROUND AND AIMS: In the context of the shortage of donors, adult living donor liver transplantation (aLDLT) represents a feasible alternative for patients within as well as beyond the Milan criteria. METHODS: From 2001, we performed 42 aLDLTs for hepatocellular carcinoma (HCC). Sixteen of the recipients were within the Milan criteria, whereas 26 fulfilled the Barcelona-Clinic Liver Cancer Group (BCLC) expanded criteria (1 tumor ≤7 cm, 5 tumors ≤3 cm, or tumors 3 ≤5 cm without macrovascular invasion or down-staging to Milan after loco-regional therapies). The objective of the current study was to compare the post-transplantation results of these two groups. RESULTS: Six Milan-in and 16 beyond Milan patients received neo-adjuvant loco-regional therapies. One Milan-in and nine patients from the beyond Milan group presented an explant histological stage beyond Milan. After a median follow-up of 64 months, 5- and 10-year overall survival rates were 60.2% and 51.6% in the Milan-in group and 78% and 65% in the beyond Milan group. Five- and 10-year disease-free survival rates were 64.5% and 55.3% in the Milan-in patients and 67.9% and 56.6% in the beyond Milan patients. Being beyond up-to-seven criteria in the histology of the explant was a significant factor for HCC recurrence. CONCLUSION: The use of aLDLT in patients with HCC within and beyond Milan but within the BCLC expanded criteria offers acceptable survival and recurrence rates. Therefore, we believe that its use in this scenario is justified.
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Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado/métodos , Adulto , Anciano , Carcinoma Hepatocelular/patología , Supervivencia sin Enfermedad , Femenino , Humanos , Neoplasias Hepáticas/patología , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Donadores Vivos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/etiología , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
: Postoperative venous thromboembolism has a poor prognosis in patients with cancer. We aimed to investigate the utility of thromboelastometry in detecting the risk of postoperative venous thromboembolism in patients with cholangiocarcinoma. We prospectively included patients submitted to liver resection for cholangiocarcinoma at our hospital between May 2011 and July 2014. Patients undergoing major hepatectomy for adult living donor transplantation in the same time period served as a control group. Thromboelastometry was performed before anesthesia. Postoperative venous thrombotic events were recorded in the 6 months after surgery. Twenty-seven patients with cholangiocarcinoma and 17 living-donor liver transplantation patients were included. Maximum clot firmness and its derivative parameter G, pointed to hypercoagulability in patients with cholangiocarcinoma, whereas all parameters were within normal ranges in controls. Six postoperative thrombotic events were recorded: four portal vein thrombosis and two deep venous thrombosis, all in patients with cholangiocarcinoma. Patients with cholangiocarcinoma who displayed thrombotic complications showed a nonsignificant trend to more pronounced hypercoagulability compared with those without. The results suggest that first, in patients with cholangiocarcinoma, despite standard thromboprophylaxis, thrombotic events remain a substantial problem, and, second, thromboelastometry may be useful in identifying patients with cholangiocarcinoma at risk of postoperative venous thromboembolism. Large prospective studies are warranted to confirm these results.
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Colangiocarcinoma/complicaciones , Hepatectomía/efectos adversos , Tromboelastografía/métodos , Tromboembolia/etiología , Adulto , Colangiocarcinoma/patología , Femenino , Hepatectomía/métodos , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Patients undergoing liver transplantation (LT) have a high risk of bleeding. The goal of this study was to assess whether the first derivative of the velocity waveform (V-curve) generated by whole blood rotation thromboelastometry (ROTEM®) can predict blood loss during LT. METHODS: Preoperative V-curve parameters were retrospectively evaluated in 198 patients. Patients were divided into quartiles based on blood loss: low (LBL) in the first quartile and high (HBL) in the higher quartiles. A subgroup analysis was performed with patients stratified according to cirrhosis aetiology. A logistic regression model and receiver operator characteristics (ROC) curve were used to test the capacity of the V-curve, to discriminate between LBL and HBL. RESULTS: In the HBL group, the V-curve showed a lower maximum velocity of clot generation (MaxVel), a lower area under maximum velocity curve (AUC), and a higher time-to-maximum velocity (t-MaxVel) than in the LBL group. t-MaxVel was the only parameter showing a capacity to discriminate between the two groups, with a ROC area of 0.69 (95% CI; 0.62-0.74). The ROC area was 0.78 (95% CI; 0.75-0.83) for the 148 patients with cirrhosis, 0.73 (0.60-0.82) for patients with viral hepatitis and 0.83 (0.78-0.96) for patients with alcoholic hepatitis, the group that showed the best discriminative capacity. Moderate but significant correlations were found between all parameters of V-curve and BL. CONCLUSIONS: Pre-transplant V-curve obtained from ROTEM is a promising tool for predicting BL risk during LT, particularly in patients with cirrhosis.
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Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Trasplante de Hígado/efectos adversos , Tromboelastografía/métodos , Tromboelastografía/estadística & datos numéricos , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , EspañaRESUMEN
Colorectal cancer (CRC) is one of the most common cancers in the developed countries, and nearly 70% of patients with CRC develop colorectal liver metastases (CRLMs). During the last decades, several scores have been proposed to predict recurrence after CRLM resection. However, these risk scoring systems do not accurately reflect the prognosis of these patients. Therefore, this investigation was designed to identify a proteomic profile in human hepatic tumor samples to classify patients with CRLM as "mild" or "severe" based on the 5-year survival. The study was performed on 85 CRLM tumor samples. Firstly, to evaluate any distinct tumor proteomic signatures between mild and severe CRLM patients, a training group of 57 CRLM tumor samples was characterized by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry, and a classification and regression tree (CART) analysis was subsequently performed. Finally, 28 CRLM tumor samples were used to confirm and validate the results obtained. Based on all the protein peaks detected in the training group, the CART analysis was generated, and four peaks were considered to be the most relevant to construct a diagnostic algorithm. Indeed, the multivariate model yielded a sensitivity of 85.7% and a specificity of 86.1%, respectively. In addition, the receiver operating characteristic (ROC) curve showed an excellent diagnostic accuracy to discriminate mild from severe CRLM patients (area under the ROC: 0.903). Finally, the validation process yielded a sensitivity and specificity of 68.8% and 83.3%, respectively. We identified a proteomic profile potentially useful to determine the prognosis of CRLM patients based on the 5-year survival.
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BACKGROUND: Reduction of perioperative blood loss and intraoperative transfusion are two major factors associated with improving outcomes in liver surgery. There is currently no consensus as to the best technique to achieve this. METHODS: An international Panel of Experts (EP), made up of hepatobiliary surgeons from well-known high-volume centres was assembled to share their experience with regard to the management of blood loss during liver resection surgery. The process included: a review of the current literature by the panel, a face-to-face meeting and an on-line survey completed by the EP prior to and following the face-to-face meeting, based on predetermined case scenarios. During the meeting the most frequently researched surgical techniques were appraised by the EP in terms of intraoperative blood loss. RESULTS: All EP members agreed that high quality research on the subject was lacking. Following an agreed risk stratification algorithm, the EP concurred with the existing research that a haemostatic device should always be used along with any user preferred surgical instrumentation in both open and laparoscopic liver resection procedures, independently from stratification of bleeding risk. The combined use of Ultrasonic Dissector (UD) and saline-coupled bipolar sealing device (Aquamantys(®)) was the EP preferred technique for both open and laparoscopic surgery. CONCLUSIONS: This EP propose the use of a bipolar sealer and UD for the best resection technique and essential equipment to minimise blood loss during liver surgery, stratified according to transfusion risk, in both open and laparoscopic liver resection.
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Hemostasis Quirúrgica/métodos , Hepatectomía/métodos , Hemostasis Quirúrgica/instrumentación , Humanos , Laparoscopía/métodosRESUMEN
Unexpected donation after circulatory determination of death (uDCD) liver transplantation is a complex procedure, in particular when it comes to perioperative recipient management. However, very little has been published to date regarding intraoperative and immediate postoperative care in this setting. Herein, we compare perioperative events in uDCD liver recipients with those of a matched group of donation after brain death liver recipients. We demonstrate that the former group of recipients suffers significantly greater hemodynamic instability and derangements in coagulation following graft reperfusion. Based on our experience, we recommend a proactive recipient management strategy in uDCD liver transplantation that involves early use of vasopressor support; maintaining adequate intraoperative levels of red cells, platelets, and fibrinogen; and routinely administering tranexamic acid before graft reperfusion.
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Trastornos de la Coagulación Sanguínea/etiología , Muerte Encefálica , Hemorragia/etiología , Trasplante de Hígado/efectos adversos , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos/métodos , Anciano , Manejo de la Enfermedad , Femenino , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Atención PerioperativaRESUMEN
It has been suggested that vascular stasis during cardio-circulatory arrest leads to the formation of microvascular thrombi and the viability of organs arising from donation after circulatory determination of death (DCDD) donors may be improved through the application of fibrinolytic therapy. Our aim was to comprehensively study the coagulation profiles of Maastricht category II DCDD donors in order to determine the presence of coagulation abnormalities that could benefit from fibrinolytic therapy. Whole blood from potential DCDD donors suffering out-of-hospital cardiac arrest was sampled after declaration of death in the emergency department, and rotational thromboelastomeric analysis was performed. Between July 2012 and December 2013, samples from 33 potential DCDD donors were analyzed. All patients demonstrated hyperfibrinolysis (HF), as reflected by maximum clot lysis of 98-100% in all cases, indicating that there is no role for additional fibrinolytic therapy in this setting. As well, we observed correlations between thromboelastomeric lysis parameters and maximum hepatic transaminase levels measured in potential donors and renal artery flows measured during ex situ hypothermic oxygenated machine perfusion, indicating that further studies on the utility of thromboelastometry to evaluate organ injury and perhaps even viability in unexpected DCDD may be warranted.
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Coagulación Sanguínea , Fibrinólisis , Trasplante de Órganos , Donantes de Tejidos , Circulación Sanguínea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
This exploratory phase II study evaluated the safety and efficacy of belatacept in de novo adult liver transplant recipients. Patients were randomized (N = 260) to one of the following immunosuppressive regimens: (i) basiliximab + belatacept high dose [HD] + mycophenolate mofetil (MMF), (ii) belatacept HD + MMF, (iii) belatacept low dose [LD] + MMF, (iv) tacrolimus + MMF, or (v) tacrolimus alone. All received corticosteroids. Demographic characteristics were similar among groups. The proportion of patients who met the primary end point (composite of acute rejection, graft loss, death by month 6) was higher in the belatacept groups (4248%) versus tacrolimus groups (1538%), with the highest number of deaths and grafts losses in the belatacept LD group. By month 12, the proportion surviving with a functioning graft was higher with tacrolimus + MMF (93%) and lower with belatacept LD (67%) versus other groups (90%: basiliximab + belatacept HD; 83%: belatacept HD; 88%: tacrolimus). Mean calculated GFR was 1534 mL/min higher in belatacept-treated patients at 1 year. Two cases of posttransplant lymphoproliferative disease and one case of progressive multifocal leukoencephalopathy occurred in belatacept-treated patients. Follow-up beyond month 12 revealed an increase in death and graft loss in another belatacept group (belatacept HD), after which the study was terminated.
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Inmunoconjugados/uso terapéutico , Inmunosupresores/uso terapéutico , Trasplante de Hígado , Abatacept , Adulto , Anciano , Esquema de Medicación , Femenino , Tasa de Filtración Glomerular , Rechazo de Injerto , Supervivencia de Injerto , Hepatitis C/mortalidad , Hepatitis C/cirugía , Humanos , Inmunoconjugados/administración & dosificación , Terapia de Inmunosupresión , Inmunosupresores/administración & dosificación , Leucoencefalopatías/complicaciones , Fallo Hepático/mortalidad , Fallo Hepático/cirugía , Trastornos Linfoproliferativos/complicaciones , Masculino , Persona de Mediana Edad , Ácido Micofenólico/administración & dosificación , Ácido Micofenólico/análogos & derivados , Recurrencia , Tacrolimus/administración & dosificación , Resultado del TratamientoRESUMEN
Small-for-size (SFS) injury occurs in partial liver transplantation due to several factors, including excessive portal inflow and insufficient intragraft responses. We aim to determine the role somatostatin plays in reducing portal hyperperfusion and preventing the cascade of deleterious events produced in small grafts. A porcine model of 20% liver transplantation is performed. Perioperatively treated recipients receive somatostatin and untreated controls standard intravenous fluids. Recipients are followed for up to 5 days. In vitro studies are also performed to determine direct protective effects of somatostatin on hepatic stellate cells (HSC) and sinusoidal endothelial cells (SEC). At reperfusion, portal vein flow (PVF) per gram of tissue increased fourfold in untreated animals versus approximately threefold among treated recipients (p = 0.033). Postoperatively, markers of hepatocellular, SEC and HSC injury were improved among treated animals. Hepatic regeneration occurred in a slower but more orderly fashion among treated grafts; functional recovery was also significantly better. In vitro studies revealed that somatostatin directly reduces HSC activation, though no direct effect on SEC was found. In SFS transplantation, somatostatin reduces PVF and protects SEC in the critical postreperfusion period. Somatostatin also exerts a direct cytoprotective effect on HSC, independent of changes in PVF.
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Trasplante de Hígado , Hígado/efectos de los fármacos , Somatostatina/uso terapéutico , Animales , Células Cultivadas , Células Endoteliales/citología , Supervivencia de Injerto , Hemodinámica , Células Estrelladas Hepáticas/citología , Hormonas/uso terapéutico , Humanos , Hígado/patología , Masculino , Tamaño de los Órganos , Perfusión , Vena Porta/patología , Periodo Posoperatorio , Regeneración , Reperfusión , PorcinosRESUMEN
PURPOSE: To analyze the use of proteomic profiles to discriminate healthy from patients with colorectal liver metastases (CLM) and to predict neoplastic recurrence after CLM resection. METHODS: From April 2005 to October 2008, 70 patients operated for first curative resection of CLM and 60 healthy controls underwent determination of preoperative serum proteomic profile. We performed a preliminary training with patients and controls and obtained a classification system based on these patients' proteomic profiles training. The system was then tested about the ability to predict the colon versus rectum origin, metachronous or synchronous appearance, risk of recurrence after CLM resection and whether a sample was from a control or a CLM patient. RESULTS: Sensitivity, specificity, positive and negative predictive values for detecting CLM patients were 75, 100, 100 and 54.6 %, respectively. Best CLM appearance time identification was 50 % and primary tumor origin identification was 62.5 %. Best classifications of neoplastic recurrence within the first year after CLM resection and during the follow-up period were 47.5 and 45 %, respectively. Larger training sets and prevalence-based training sets led to better classification of patients and characteristics. CONCLUSION: Proteomic profiles are a promising tool for discriminating CLM patients from healthy patients and for predicting neoplastic recurrence (AU)
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Humanos , Masculino , Femenino , Neoplasias Colorrectales/inducido químicamente , Neoplasias Colorrectales/tratamiento farmacológico , Neoplasias Colorrectales/metabolismo , Neoplasias Colorrectales/radioterapia , Colon/anomalías , Recto/efectos de la radiaciónRESUMEN
PURPOSE: To analyze the use of proteomic profiles to discriminate healthy from patients with colorectal liver metastases (CLM) and to predict neoplastic recurrence after CLM resection. METHODS: From April 2005 to October 2008, 70 patients operated for first curative resection of CLM and 60 healthy controls underwent determination of preoperative serum proteomic profile. We performed a preliminary training with patients and controls and obtained a classification system based on these patients' proteomic profiles training. The system was then tested about the ability to predict the colon versus rectum origin, metachronous or synchronous appearance, risk of recurrence after CLM resection and whether a sample was from a control or a CLM patient. RESULTS: Sensitivity, specificity, positive and negative predictive values for detecting CLM patients were 75, 100, 100 and 54.6 %, respectively. Best CLM appearance time identification was 50 % and primary tumor origin identification was 62.5 %. Best classifications of neoplastic recurrence within the first year after CLM resection and during the follow-up period were 47.5 and 45 %, respectively. Larger training sets and prevalence-based training sets led to better classification of patients and characteristics. CONCLUSION: Proteomic profiles are a promising tool for discriminating CLM patients from healthy patients and for predicting neoplastic recurrence.
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Proteínas Sanguíneas/análisis , Neoplasias Colorrectales/sangre , Neoplasias Colorrectales/patología , Neoplasias Hepáticas/sangre , Neoplasias Hepáticas/secundario , Proteómica/métodos , Anciano , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Espectrometría de Masas , Persona de Mediana Edad , Metástasis de la Neoplasia , Proyectos Piloto , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Proteoma , Recurrencia , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
AIM: To assess the prognostic value of noninvasive indocyanine green (ICG) clearance (ICG-pulse-densitometric method [PDR]) for the outcome of liver grafts after transplantation. METHODS: ICG-PDR, hepatic artery resistance index, cardiac output, transaminases, prothrombin time, bilirubin, albumin, hematocrit at 48 to 72 hours after transplantation were analyzed with reference to outcome among 59 liver graft recipients. RESULTS: Two grafts were lost at 10 and 88 days during the initial hospitalization. These two patients only differed from the other recipients in the need for packing (1/2 versus 3/57) and degree of hypoproteinemia (46 ± 0 versus 51 ± 7.8 g/L), whereas they had similar ICG-PDR values (16.7%/min and 21.8%/min versus 17.3%/min ± 7.2%/min). Seven patients showed an ICG-PDR ≤ 8.8%/min, a previously identified cutoff for early postoperative complications. These patients versus the other 52 significantly differed in prothrombin index (47.9% ± 15.9% versus 64.3% ± 11.7%, P = .001) and bilirubin (8.3 ± 3.2 versus 3.3 ± 2.9 mg/dL, P = .0001). Early postoperative complications--primary graft nonfunction, hepatic artery thrombosis, or septic shock--responsible for an ICG-PDR ≤ 8.8%/min were observed in 2/7 patients. Interestingly, six cases developed an early (range: 3-15 days) rejection episode. In all the cases rejection suspected by analytical abnormalities was confirmed by liver biopsy. Among the overall series of patients, ICG-PDR significantly correlated with serum albumin (r = 0.345; P = .007), bilirubin (r = -0.514; P = .0001), and hematocrit (r = 0.462; P = .0001) but not with transaminases, prothrombin index, cardiac output, or hepatic artery resistance index. Actuarial 72-month probability of graft survival was 75%. Overall, 14 grafts were lost over a median follow-up of 78 months (range 1-99 m). There were no significant differences among early ICG-PDR values among grafts lost vs retained upon follow-up. CONCLUSION: ICG-PDR measured once early after liver transplantation did not offer relevant information to predict individual patient outcomes in the immediate postoperative phase. This lack of prognostic value may have been due to the multiple confounding factors involved in ICG metabolism after liver transplantation.
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Colorantes , Verde de Indocianina , Pruebas de Función Hepática , Trasplante de Hígado/efectos adversos , Complicaciones Posoperatorias/diagnóstico , Adulto , Anciano , Arteriopatías Oclusivas/diagnóstico , Arteriopatías Oclusivas/etiología , Colorantes/farmacocinética , Supervivencia de Injerto , Arteria Hepática/cirugía , Humanos , Hipovolemia/diagnóstico , Hipovolemia/etiología , Verde de Indocianina/farmacocinética , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Valor Predictivo de las Pruebas , Disfunción Primaria del Injerto/diagnóstico , Disfunción Primaria del Injerto/etiología , Choque Séptico/diagnóstico , Choque Séptico/etiología , España , Trombosis/diagnóstico , Trombosis/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Maastricht type 2 donation after cardiac death (DCD) donors suffer sudden and unexpected cardiac arrest, typically outside the hospital; they have significant potential to expand the donor pool. Herein, we analyze the results of transplanted livers and all potential donors treated under our type 2 DCD protocol. Cardiac arrest was witnessed; potential donors arrived at the hospital after attempts at resuscitation had failed. Death was declared based on the absence of cardiorespiratory activity during a 5-min no-touch period. Femoral vessels were cannulated to establish normothermic extracorporeal membrane oxygenation, which was maintained until organ recovery. From April 2002 to December 2010, there were 400 potential donors; 34 liver transplants were performed (9%). Among recipients, median age, model for end-stage liver disease and cold and reperfusion warm ischemic times were 55 years (49-60), 19 (14-21) and 380 (325-430) and 30 min (26-35), respectively. Overall, 236 (59%) and 130 (32%) livers were turned down due to absolute and relative contraindications to donate, respectively. One-year recipient and graft survivals were 82% and 70%, respectively (median follow-up 24 months). The applicability of type 2 DCD liver transplant was <10%; however, with better preservation technology and expanded transplant criteria, we may be able to improve this figure significantly.
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Muerte , Trasplante de Hígado , Donantes de Tejidos , Adulto , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND AND AIM: Delayed introduction of calcineurin inhibitors (CNI) in liver transplantation (OLT) seeks to protect renal function, although the optimal length of the delay is not well established. The aim of this study was to analyze the effects on renal function of CNI initiation on different days after OLT. METHODS: We reviewed the charts of 260 OLT recipients. Group D1-a (n = 36) underwent the standard initial immunosuppression at our center: namely, CNI introduction on day 1 with further daily administration to achieve target levels of 8 to 15 ng/mL for tacrolimus or 150 to 300 ng/mL for cyclosporine. Due to renal concerns, 126 patients (group D1-b) had CNI introduced on day 1 either not daily or at doses to achieve less than the target on at least two occasions. In 43 patients (group D2), CNI were introduced on day 2 in 23 on day 3 (group D3), in 12 on day 4 (group D4), and at least at day 5 in 20 others (group D5). In periods without CNI treatment, patients received mycophenolate mofetil. Steroids were administered to all patients. The study period included the first 3 months post-OLT. Renal function was estimated as creatinine clearance (CrCl) using the Cockcroft-Gault equation. RESULTS: Changes in CrCl from pre-OLT to month 3 were -19% ± 28% in group D1-a; -27% ± 19% in group D1-b; -29% ± 19% in group D2; -23% ± 26% in group D3; -4% ± 38% in group D4, and +4% ± 33% in group D5 (P < .05 vs groups D1-a, D1-b, D2, and D3). On multivariate analysis, CNI introduction at day ≥ 5 was protective for kidneys when adjusted for other variables that potentially influence renal function. CONCLUSION: CNI should be introduced at day 5 after OLT to protect renal function.
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Inhibidores de la Calcineurina , Esquema de Medicación , Inmunosupresores/administración & dosificación , Riñón/fisiopatología , Trasplante de Hígado , Tacrolimus/administración & dosificación , Adulto , Femenino , Humanos , Pruebas de Función Renal , Masculino , Auditoría Médica , Persona de Mediana EdadRESUMEN
Neutralizing antibody (nAb) activity during the course of natural infection is believed to be crucial to combating virus propagation. The aim of this study was to measure the impact of nAb response on HCV early kinetics and genetic evolution in the liver transplantation (LT) setting. A cohort of 28 patients undergoing LT for HCV-related cirrhosis was included in the study. Viral load, nAb titers and hypervariable region 1 (HVR1) sequences were determined in serum samples obtained before and at different time points after LT. Serum nAb titers were assessed using HCV pseudoparticles (HCVpp). HVR1 sequences were obtained by direct sequencing. Patients were classified according to viral kinetic patterns (plateau or increasing), during the first week after LT. All patients demonstrated high titers of nAbs before LT, although this was not associated with early kinetic patterns or HVR1 evolution during the first week after LT. We found that in patients with plateau HCV early kinetics, the virus required adaptive mutations, while in those with increasing viral loads, the HVR1 region remained largely conserved (p = 0.015). These data suggest that HCV adaptation via selection of the best-fitted variants may account for early viral kinetics following LT.
Asunto(s)
Anticuerpos Neutralizantes/inmunología , Formación de Anticuerpos/inmunología , Anticuerpos contra la Hepatitis C/inmunología , Hepatitis C/cirugía , Trasplante de Hígado , Adolescente , Adulto , Anciano , Reacciones Cruzadas , Femenino , Hepacivirus/genética , Hepatitis C/genética , Hepatitis C/virología , Humanos , Masculino , Persona de Mediana Edad , ARN Viral/sangre , ARN Viral/genética , Trasplante Homólogo , Carga Viral , Adulto JovenRESUMEN
We report the results of a prospective randomized controlled trial in liver transplantation assessing the efficacy and safety of antithymocyte globulin (ATG-Fresenius) plus tacrolimus monotherapy at gradually decreasing doses. Patients were randomized to either: (a) standard-dose tacrolimus plus steroids;or (b) peritransplant ATG-Fresenius plus reduced-dose tacrolimus monotherapy followed by weaning of tacrolimus starting 3 months after transplantation. The primary end-point was the achievement of very low-dose tacrolimus (every-other-day or once daily dose with <5 ng/mL trough levels) at 12 months after transplantation. Acute rejection occurring during the first 3 months after transplantation was more frequent in the ATG group (52.4% vs. 25%). Moreover, late acute rejection episodes occurred in all recipients in whom weaning was attempted and no recipients reached the primary end-point. This motivated the premature termination of the trial. Tacrolimus trough levels were lower in the ATG-Fresenius group but no benefits in terms of improved renal function, lower metabolic complications or increased prevalence of tolerance-related biomarkers were observed. In conclusion, the use of ATG-Fresenius and tacrolimus at gradually decreasing doses was associated with a high rate of rejection, did not allow for the administration of very low doses of tacrolimus and failed to provide detectable clinical benefits. ClinicalTrials.gov identifier: NCT00436722.
Asunto(s)
Suero Antilinfocítico/administración & dosificación , Trasplante de Hígado/métodos , Tacrolimus/administración & dosificación , Adulto , Femenino , Rechazo de Injerto/epidemiología , Humanos , Inmunosupresores/administración & dosificación , Inmunosupresores/efectos adversos , Masculino , Persona de Mediana Edad , Tacrolimus/efectos adversosRESUMEN
Introduccion: La apendicectomía laparoscópica es un procedimiento ampliamente utilizado en el tratamiento de la apendicitis aguda, que normalmente necesita tres o más trócares para poder llevarse a cabo. Presentamos nuestra experiencia inicial en la apendicectomía por laparoscopia con una sola incisión umbilical (SILS). Método: Estudio prospectivo realizado entre diciembre de 2008 y octubre 2009, en el que los pacientes que aceptaron participar. Fueron operados por cirujanos especialmente dedicados a la patología quirúrgica urgente. El ombligo fue el único punto de entrada en todos los casos y se utilizó la misma técnica quirúrgica en todos ellos. Resultados: Realizamos 52 apendicectomías mediante SILS. La intervención fue realizada con éxito en todos los pacientes: el tiempo operatorio medio fue de 41 min, no se produjo conversión a cirugía abierta ni se necesitó la colocación de otros trócares adicionales y no hubo complicaciones intra ni post operatorias. La estancia media hospitalaria fue de 2,7 días. Conclusión: La apendicectomía en pacientes adultos mediante SILS es una técnica segura, sencilla y fácilmente reproducible (AU)
Background and objective: Laparoscopic appendectomy for acute appendicitis is a widely used procedure. Three ormore trocars are normally required. We present our early experience performing appendectomy by means of singleincision laparoscopic surgery (SILS) for acute appendicitis. Methods: Prospective study from December 2008 to October 2009 in patients who gave their informed consent. Specialists in emergency surgery were responsible for carrying out the procedures. The navel was the point of entry in allcases. Results: We performed 52 emergency laparoscopic appendectomies using a single umbilical incision. The intervention was successful in all patients. The average operating time was 41 minutes. There were no conversions to open surgery or requirement for additional trocars. No complications were observed during or after the procedures. The mean hospital stay was 2.7 days. Conclusion: Adult appendectomy using SILS is a safe procedure that is reproducible and easy to perform (AU)