Transplantation-mediated alloimmune thrombocytopenia successfully treated by retransplantation.

INTRODUCTION: Transplantation-mediated alloimmune thrombocytopenia (TMAT) is a rare complication affecting the recipient of an organ from a donor with immune thrombocytopenia (ITP). METHODS: We present a case of TMAT following liver transplantation successfully treated by retransplantation, along with a review of previously published cases.Clinical presentation: The liver donor had lupus and ITP and died from an intracranial hemorrhage. The recipient's platelet count fell to 2x109/L on postoperative day 2. Due to the lack of response to medical treatment, emergency retransplantation was undertaken with a steady recovery of the platelet count within a few days. DISCUSSION: Six additional cases of transplantation-mediated alloimmune thrombocytopenia after liver transplantation have been reported. In all cases, severe thrombocytopenia ensued within 3 days after liver transplantation. Four patients suffered hemorrhagic complications. Three patients died. Early retransplantation was needed in three out of four patients receiving a graft from a donor with ITP and splenectomy. All recovered shortly after the new graft was in place. CONCLUSION: Severe refractory transplantation-mediated alloimmune thrombocytopenia can develop in liver recipients from donors with ITP, especially those with previous splenectomy. Early retransplantation should be considered if there is no rapid response to medical therapy.

Recidiva parietal de colangiocarcinoma hiliar. ¿Es el drenaje biliar transparietohepático el de elección en los pacientes con colangiocarcinoma hiliar? / Parietal recurrence of hiliar cholangiocarcinoma: Is percutaneous transhepatic biliary drainage the best choice in patients with hiliar cholangiocarcinoma?

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Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain.

INTRODUCTION: 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: 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.

Esófago negro tras doble trasplante hepatorrenal / Black esophagus after combined liver-kidney transplantation

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Encuesta a los jefes de Unidad y residentes de Cirugía sobre la accesibilidad y el trabajo en los equipos de trasplante hepático en España / A survey of Heads of Surgery and Residents on accessibility and employment in liver transplant teams in Spain

Introducción: El acceso de los cirujanos a los equipos de trasplante hepático en España se realiza de manera heterogénea. El objetivo de este estudio ha sido cuantificar los recursos humanos de los equipos de trasplante españoles, la distribución de las diferentes tareas del trasplante entre los miembros del equipo, el mecanismo mediante el cual se adquieren las habilidades, la visión de sus líderes sobre su continuidad, así como las motivaciones de los residentes de cirugía general españoles para elegir el trasplante como su futura carrera profesional. Métodos: Se elaboraron dos encuestas diferentes, para los jefes de equipo y para residentes, sobre número de personas, capacitación, reclutamiento, organización de tareas y motivación para trabajar en trasplantes. Los cuestionarios se enviaron por correo electrónico tanto a los directores de programa de trasplante como a los residentes de cirugía. Resultados: Hay en promedio 8 cirujanos en cada unidad de trasplante. Más de 4 cirujanos realizan la hepatectomía en el 54,2% de los grupos, mientras que el implante lo realiza más de 4 cirujanos en solo el 25% de los centros. El 42% de los jefes de trasplante hepático aboga por un sistema tipo fellowship y el 87,5% cree que el recambio generacional está garantizado. De los 525 residentes, 101 respondieron. Respecto a la formación, un 12,8% no tiene interés en el trasplante. En cuanto a sus preferencias laborales, el 37,6% no está interesado en el trasplante por ser excesivamente exigente, y el 52,5% no desea ser parte de un equipo de trasplante de hígado en el futuro. Conclusiones: El recambio generacional parece estar garantizado según los directores de programa de trasplante de hígado. Las nuevas generaciones de cirujanos generalmente optan por otras áreas de cirugía diferentes al trasplante. Son necesarios estudios con mayor número de respuestas para validar estos resultados

Introduction: The access of surgeons to liver transplant teams in Spain is heterogeneous. This study aims to portray the current human resources of Spanish transplant teams, distribution of transplant duties among team members, how transplant team members acquire their skills, their leaders' view of their future, as well the motivations of Spanish General Surgery residents to choose transplantation as their future career choice. Methods: Two different surveys were created, one for head surgeons and one for residents, about the number of team members and their training, recruitment, organization of tasks and motivation to work in transplantation. The questionnaires were e-mailed to both the transplant program directors and the surgical residents. Results: There are on average 8 surgeons in each transplant unit. More than four surgeons perform the hepatectomy in 54.2% of the groups, while the graft implantation is performed by more than 4 surgeons at just 25% of the centers. Forty-two percent of the transplant chiefs advocated a fellowship training system, and 87.5% believe that generational turnover is guaranteed. Out of 525 residents, 101 responded. Regarding training, 12.8% had no interest in transplantation. Concerning their work preferences, 37.6% were not interested in transplantation because it is excessively demanding, and 52.5% would not like to be part of a liver transplant team in the future. Conclusions: The generational turnover seems to be guaranteed according to liver transplant program directors. The new generations of surgeons generally opt for other areas of surgery other than transplantation. Studies with a greater number of responses are necessary to validate these results

A survey of Heads of Surgery and Residents on accessibility and employment in liver transplant teams in Spain. / Encuesta a los jefes de Unidad y residentes de Cirugía sobre la accesibilidad y el trabajo en los equipos de trasplante hepático en España.

INTRODUCTION: The access of surgeons to liver transplant teams in Spain is heterogeneous. This study aims to portray the current human resources of Spanish transplant teams, distribution of transplant duties among team members, how transplant team members acquire their skills, their leaders' view of their future, as well the motivations of Spanish General Surgery residents to choose transplantation as their future career choice. METHODS: Two different surveys were created, one for head surgeons and one for residents, about the number of team members and their training, recruitment, organization of tasks and motivation to work in transplantation. The questionnaires were e-mailed to both the transplant program directors and the surgical residents. RESULTS: There are on average 8 surgeons in each transplant unit. More than four surgeons perform the hepatectomy in 54.2% of the groups, while the graft implantation is performed by more than 4 surgeons at just 25% of the centers. Forty-two percent of the transplant chiefs advocated a fellowship training system, and 87.5% believe that generational turnover is guaranteed. Out of 525 residents, 101 responded. Regarding training, 12.8% had no interest in transplantation. Concerning their work preferences, 37.6% were not interested in transplantation because it is excessively demanding, and 52.5% would not like to be part of a liver transplant team in the future. CONCLUSIONS: The generational turnover seems to be guaranteed according to liver transplant program directors. The new generations of surgeons generally opt for other areas of surgery other than transplantation. Studies with a greater number of responses are necessary to validate these results.

Liver transplantation following hepatic artery avulsion in a trauma patient.

BACKGROUND: Hepatic artery avulsion following politrauma is an extremely rare condition with a very high mortality rate. Management is based on damage control surgery given the precarious situation of these patients. Ligating the artery is one option under such circumstances, despite potential consequences including ischemic cholangiopathy (IC). Ischemic cholangiopathy, which can be caused by an insufficient blood supply to the bile duct, generally results in stricture and recurrent cholangitis, and the need for a liver transplant in extreme cases. CASE PRESENTATION: We present the case of a 37-year-old male with multiple traumas after falling from the third floor of a building. He was hemodynamically unstable upon arrival at the emergencies department, with no improvement on administration of aggressive fluid therapy. A Echo-FAST exam evidenced fluid in all quadrants, so the patient was transferred to the operating room where a 4-litre hemoperitoneum secondary to total avulsion of the proper hepatic artery was observed. The patient required massive transfusion and vasoactive drugs, with instability throughout the intervention; therefore, we decided to ligate the proper hepatic artery. Hepatic dysfunction and diffuse IC with multiple episodes of recurrent cholangitis were observed during the postoperative period. Given the irreversible clinical picture, we opted for a liver transplant 70 days after the patient's initial admission. The patient died on Day 34 post-transplant due to irreversible ischemic brain damage and a right occipital hemorrhage. CONCLUSIONS: Hepatic artery avulsion due to trauma is very rare and its management very complex, and in certain situations the artery must be ligated. The main consequence of ligating the hepatic artery is IC, which is more frequently observed secondary to iatrogenic lesions or systemic diseases, while very few cases have been published in which IC is secondary to hepatic artery avulsion caused by hepatic trauma. Treatment depends on the extent of ischemia, and when the damage is diffuse, as in our case, it may involve a liver transplant.

Quiste biliar del conducto cístico. Un caso de Todani tipo VI / Biliary cyst of the cystic duct: A case of Todani type VI

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Hematoma hepático iatrogénico gigante de morfología anómala / Giant iatrogenic hepatic hematoma with abnormal morphology

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Ausencia-desaparición de la vesícula biliar en un paciente diagnosticado de colelitiasis / Absence/disappearance of gallbladder in a patient diagnosed with cholelithiasis

Se presenta el caso de un paciente, con diagnóstico de colelitiasis, en quien no se encuentra quirúrgicamente la vesícula biliar durante una colecistectomía por laparoscopia ni tras su reconversión a cirugía abierta. Se descarta la ectopia vesicular y se discute la posibilidad de que se trate de un caso de agenesia vesicular. Sin embargo, al paciente se le han realizado 4 ecografías previas dentro de un protocolo de tratamiento con octreóctida y en ellas hay coincidencia en la presencia de la vesícula biliar. Se apunta la eventualidad de una lisis total de vesícula tras un proceso inflamatorio, y se recuerdan los criterios de Frey para la agenesia vesicular. Creemos que estamos ante un caso de lisis completa de la vesícula tras un proceso inflamatorio (AU)

We report the case of a patient with preoperatively demonstrated cholecystitis due to cholelithiasis but with no presence of gallbladder at laparoscopy or on conversion to open surgery. Gallbladder ectopy was ruled out and the possibility of gallbladder agenesia was discussed. However, four preoperative ultrasound scans performed within a protocol of treatment with octreotide, in the setting of acute cholecystitis, ruled out this possibility. We discuss the possibility of gallbladder destruction and digestion after a severe inflammatory process, as well as Frey's criteria for gallbladder agenesia. We believe that this is a case of complete gallbladder lysis due to an inflammatory process (AU)