Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon.

BACKGROUND: Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial. We studied the results of initial conservative treatment (antibiotics and percutaneous drainage if necessary, with or without interval appendectomy) compared with immediate surgery. METHODS: We undertook an observational, retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon, treated in our hospital between January 1997 and March 2009. Patients younger than 14, with severe sepsis or with diffuse peritonitis were excluded. A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment. A control group was composed of the other patients, who all underwent urgent appendectomy, matched for age and later randomized 1:1. The infectious risk stratification was established with the National Nosocomial Infections Surveillance System (NNIS) index. Dependent variables were hospital stay and surgical site infection. Analysis was with SPSS, with p < 0.05 considered significant. RESULTS: Interval appendectomy was performed in 7 study group patients. Surgical site infection episodes were more frequent in the control group (6 vs. 0, p < 0.001). A greater percentage of high risk patients (NNIS ≥ 2) was identified in the control group (80 vs. 28.7%, p < 0.03), mostly related with contaminated or dirty procedures in this group (p < 0.001). No significant difference between groups was found in hospital stay. CONCLUSION: Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon.

An alternative method of reconstruction of hepatic venous outflow in domino liver transplantation.

The double piggyback technique has been proposed for domino liver transplantation. To make this possible, it is necessary to reconstruct the venous outflow of the domino liver graft on the back table. We describe an alternative method of reconstruction of hepatic venous outflow, in which a neocaval segment is obtained using both common iliac veins from the cadaveric donor.

Adverse effects on the lipid profile of immunosuppressive regimens: tacrolimus versus cyclosporin measured using C2 levels.

Immunosuppression has improved graft and recipient survival in transplantation but is accompanied by several adverse effects like dyslipidemia and cardiovascular disease. Herein, we performed an observational, descriptive study to analyze the relationship of dyslipemia (hypercholesterolemia [hypercho] and hypertriglyceridemia [hypertg]) and cardiovascular disease with two different immunosuppressive regimens in liver transplantation: cyclosporine treatment based upon C2 levels (CsA2) and tacrolimus (Tac), both in combination with steroids. Seventy-four liver transplantation patients were included during a 2-year period: 35 with CsA2 and 39 with Tac. The mean follow-up was 40 months. There were no significant differences between the groups in terms of age, gender, Model for End-stage Liver Disease Score, Child stage, and indication for transplantation. The distribution of patients with HyperCho and HyperTg was independent of the immunosuppressive agent (P = NS), both in a global and in a stratified analysis at 6, 12, 24, and 60 months. The analysis of cardiovascular events revealed no differences between the groups (CsA2 14.3%; Tac 18.9%; P = NS). We suggest that CsA monitoring using C2 levels shows a safety profile similar to that of Tac with regard to the development of dyslipidemia and cardiovascular events.

Comparison of 3 Explant-Based Prognostic Models as Predictors of Hepatocellular Carcinoma Recurrence After Liver Transplantation: Analysis of Our Experience.

Tumor load is often underdiagnosed on radiological examination previous to liver transplantation (LT) for hepatocarcinoma (CHC). Thus, post-liver transplant explant analysis is required following transplantation to assess the risk of the recurrence of CHC. The objectives were to compare the characteristics of CHC on pre-LT radiological examination and explant histology and validate three models for the prediction of recurrence based on data from a cohort of patients treated in our hospital. METHODS: A retrospective study was undertaken of 105 LTs for CHC performed in our unit between January 2006 and January 2015. The minimum follow-up was five years. The preoperative radiological tumor stage was compared to the explant-based histologic stage. Three prognostic models were validated using our cohort of patients. RESULTS: Following Milan's criteria, the tumor load was underdiagnosed on pre-LT radiological examination in 20 patients, which accounted for 19% of the total sample. The 5-year overall recurrence was 6.6% for scores <4 and 33.3% for scores ≥4 according to Decaens' model; 7% for scores ≤7 and 25% for scores >7 in the Up-to-Seven model; and 3.6% for PCRS ≤0, 27.8% for PCRS1-2, and 100% for PCRS≥3 according to Chan's model. The predictive model for 5-year recurrence after LT with the greatest area under the curve was Chan's model (0.813 [95% CI: 0.650-0.977]) versus Decaens' model (0.674 [95% CI: 0.483-0.866]) and the Up-to-Seven model (0.481 [95% CI: 0.296-0.667]). CONCLUSIONS: A pre-LT radiological examination leads to the underdiagnosis of tumor load, and the risk for recurrence must be recalculated following LT. In light of the results obtained, Chan's model is more accurate in predicting 5-year recurrence of CHC post-LT based on 3 levels of risk. New prognostic models are needed to optimize the prediction of recurrence after liver transplantation for hepatocarcinoma.

Donation After Cardiac Death in Liver Transplantation: An Additional Source of Organs With Similar Results to Donation After Brain Death.

BACKGROUND: As new sources of organs are needed, liver transplantation using donors after cardiac death (DCD) is progressively increasing, but outcomes with this method are still questioned. This study was accomplished to verify that DCD outcomes are comparable to those seen in donation after brain death (DBD). METHODS: This was a prospective cohort study including 100 liver transplantation performed between 2014 and 2017, divided according to donor type in 75 DBD and 25 DCD. RESULTS: DCD donors were younger (mean age: DCD 56 years, DBD 59 years; P = .009). Mean Modified End-stage Liver Disease (MELD) score was lower for DCD (DCD 16, DBD 19; P < .001). No differences were found regarding ischemia times and development of postreperfusion syndrome or coagulopathy. Primary graft dysfunction was more frequent in DCD (60%, DCD 29.3%; P = .006). Rates of primary graft nonfunction (DCD 0%, DBD 1.3%; P = .562) and acute rejection (DCD 20%, DBD 16.4%; P = .685) were similar. Acute kidney injury occurred more often in DBD (DCD 32%, DBD 12%; P = .051). Length of stay was comparable. Rates of biliary complications (DCD 20%, DBD 26.7%; P = .505) were similar, unlike ischemic cholangiopathy (DCD 12%, DBD 1.3%; P = .018). Retransplantation rates were also similar (DCD 8%, DBD 4%; P = .427) as was survival rate after 3 years (DCD 84%, DBD 86.7%; P = .739). CONCLUSION: DCD represents an additional graft source with results that are encouraging and may be comparable to DBD with a careful donor and recipient selection.

Impact of donor age on the results of liver transplantation in hepatitis C virus-positive recipients.

OBJECTIVE: Hepatitis C virus (HCV)-cirrhosis is the most frequent indication for orthotopic liver transplantation (OLT) among adults in most European and American transplant centers. The aim of this study was to analyze the impact of donor age on graft survival among HCV-positive cirrhotic transplant patients. MATERIALS AND METHODS: We performed an observational, retrospective study between March 1997 and December 2004, analyzing 340 liver transplantations. The patients were divided into 4 groups, considering whether the HCV infection was the indication for OLT and whether the age of the donor was older or younger than 48 years: group 1 (HCV, <48 years); group 2 (HCV, >48 years); group 3 (non-HCV, <48 years); and group 4 (non-HCV, >48 years). RESULTS: A univariate analysis showed that posttransplantation graft survival was clearly influenced by recipient HCV serologic status (P = .018). However, no graft survival differences were found when the analysis variable was age (>48 or <48 years). When both variables were studied, a positive HCV serology did not modify graft survival when the donor age was <48 years (P = .32), but had a statistically significant negative impact when the age was >48 years (P = .02). CONCLUSIONS: The use of older donors for HCV recipients resulted in worse graft and patient survivals in our study. This difference in survival was not present in non-HCV recipients or when grafts for HCV recipients were procured from younger donors. Donor age <30 years was a protective factor for graft survival among HCV recipients.

Influence of immunosuppression and effect of hepatitis C virus on new onset of diabetes mellitus in liver transplant recipients.

INTRODUCTION: New-onset posttransplantation diabetes mellitus (PTDM), with an incidence of 10% to 30%, increased graft and patient morbidity and mortality. Such causal factors as age, obesity, therapy, immunosuppression, and hepatitis C virus (HCV) contribute to this disease. OBJECTIVE: We sought to determine the incidence of PTDM and impaired fasting glucose (IFG) concentration in transplant recipients to define the causal variables. MATERIAL AND METHODS: The study included 127 patients. Patients with pretransplantation diabetes and those with less than 6 months of follow-up were excluded. A descriptive observational study to assess the association between PTDM and IFG and the immunosuppression therapy used was performed by monitoring the potential confounding variables of age, obesity, and HCV. RESULTS: During mean follow-up of 73.7 months (range, 7-120 mo), 93 patients received cyclosporine A (CyA) and 34 received tacrolimus (Tac) therapy. Thirty patients (23.6%) developed PTDM or IFG including 15 (16%; PTDM, six IFG, nine) in the CyA group and 15 (PTDM, seven; IFG, eight) in the Tacrolimus group (P = .001; odds ratio [OR], 4.1). They were homogeneous with respect to confounding variables except for HCV (P = .01). Of the 55 patients with HCV infection, 12 developed PTDM or IFG, including three in the CyA group and nine in the tacrolimus group (P = .03; OR, 7.7), whereas in the 72 patients without HCV infection, the CyA or tacrolimus association with PTDM or IFG was significant (P = .05), Mantel-Haenszel test; OR, 4.9). The interaction between HCV and immunosuppression therapy was primarily produced in the IFG group (HCV-positive; P = .008; OR, 8). CONCLUSION: We observed an association between the use of tacrolimus and the development of PTDM or IFG. There is greater risk in HCV-positive patients, in particular in relation to IFG. The choice of immunosuppressive treatment might be decided on the basis of the patient's pretransplantation status.

Combined Flush With Histidine-Tryptophan-Ketoglutarate and University of Wisconsin Solutions in Liver Transplantation: Preliminary Results.

INTRODUCTION: Ischemia reperfusion injury (IRI) is the main cause of early allograft dysfunction (EAD) and subsequent primary allograft failure (PAF). OBJECTIVES: The purpose of this study is to compare IRI, EAD, and PAF in liver transplantation in a cohort of patients perfused with histidine-tryptophan-ketoglutarate (HTK) solution and University of Wisconsin (UW) solution versus HTK alone. METHODS: A randomized trial was performed to compare outcomes in liver recipients who underwent transplantation surgery in the University Regional Hospital of Malaga, Spain. Forty patients were randomized to two groups. Primary endpoints included IRI, EAD, PAF, re-intervention, acute cellular rejection, retransplantation, arterial complications, and biliary complications at postoperative day 90. RESULTS: Postoperative glutamic oxaloacetic transaminase (1869.15 ± 1559.75 UI/L vs. 953.15 ± 777.27 UI/L; P = .004) and glutamic pyruvic transaminase (1333.60 ± 1115.49 U/L vs. 721.70 ± 725.02 U/L; P = .023) were significantly higher in patients perfused with HTK alone. A clear tendency was observed in recipients perfused with HTK alone to present moderate to severe IRI (7 patients in the HTK + UW solution group vs. 15 patients in the HTK-alone solution group; P = .06), EAD (0 patients in the HTK + UW solution group vs. 0 patients in the HTK-alone solution group; P = .76), and PAF (3 patients in the HTK + UW solution group vs. 8 patients in the HTK-alone solution group; P = .15). CONCLUSIONS: Initial perfusion with HTK solution followed by UW solution in liver transplantation improves early liver function as compared to perfusion with HTK alone.

Tratamiento del síndrome de Budd-Chiari agudo intraoperatorio mediante colocación de prótesis de silicona / Treatment of acute intraoperative Budd-Chiari syndrome by placement of silicone prosthesis

La movilización hepática completa para resecciones mayores provoca, en ocasiones, basculación del hígado secundaria a la liberación de sus elementos suspensorios. Esto puede ocasionar una malposición hepática con obstrucción aguda al flujo venoso a nivel de las suprahepáticas (síndrome de Budd-Chiari). Para salvar esta complicación se han descrito técnicas como colocación de sondas de Foley, balón Sengstaken-Blakemore o implantación de endoprótesis vasculares en el postoperatorio. Aquí presentamos el caso de un paciente al que se le realizó una movilización completa para resección de un tumor renal derecho y resección de vena cava inferior por trombosis de ésta hasta entrada de las venas suprahepáticas. Durante el proceso se produjo un Budd-Chiari agudo por malposición del hígado que fue resuelto con la colocación de dos prótesis de silicona en la celda hepática (AU)

Complete liver mobilization for major resections sometimes causes liver tilting due to the release of the suspensory elements of the liver. Rarely this may take to a liver abnormal position with acute obstruction to venous flow at the suprahepatic level (Budd-Chiari syndrome). To avoid this complication, techniques such as post-operative stent implantation have been described. The case of a patient who underwent a complete mobilization of the liver for resection of the inferiour venous cava and a right renal tumor, was reported. After that, an acute Budd-Chiari Syndrome was observed caused of the liver malposition, which was solved with the placement of two silicone prostheses in the liver cell (AU)

True impact of the indication of cirrhosis and the MELD on the results of liver transplantation.

UNLABELLED: Our Aim was to determine the impact of cirrhosis and the preoperative MELD score on the immediate postoperative mortality and hospital stay as well as survival at 1, 5, and 8 years in liver transplantation. MATERIALS AND METHODS: Transplanted cirrhotic patients were selected who did not display some of the main known risk factors affecting recipient. Donor and surgical technique were included in this analysis. These exclusion criteria for recipient factors were emergency transplants and retransplants; for donor factors, age over 60 years, ischemia time over 10 hours, and moderate or severe steatosis on back-bench biopsy; and for surgery, prior complex upper abdominal surgery (mainly derivative and gastroduodenal surgery). Among 340 total liver transplants including 16 retransplants performed from March 1997 to December 2005, 197 patients met the selection criteria. The mean age of the recipients was 52 years (17-67) and the donors, 39 years (11-60). The transplant indication was cirrhosis in all cases: HCV in 69 cases (35%); alcohol in 55 (28%); hepatocarcinoma in 38 (19%); HBV in 19 (10%); PBC in 8 (4%), and other etiologies in 8 cases (4%). The MELD scores were divided as group 1, <10 points (33 cases = 17%); group 2, 10 to 18 points (136 cases = 69%); and group 3, >18 points (28 cases = 14%). The statistical analysis was performed with SPSS 11.0. RESULTS: Postoperative mortality (up to 3 months) was 16 cases (8%). The median ICU and hospital stays were 3 and 13.5 days, respectively. Overall survivals at 1, 5, and 8 years were 89%, 80%, and 77%, respectively. The survival for the same periods according to MELD group was 97%, 97%, and 97% for group 1; 87%, 76%, and 72% for group 2; and 85%, 81%, and 81% for group 3 (P = NS). The survival according to the three main indications at 1, 5, and 8 years was: HCV, 91%, 80%, and 80%; alcohol, 87%, 80%, and 71%; and hepatocarcinoma, 84%, 80%, and 80% (P = NS). No significant differences were observed among early deaths between MELD groups or transplant indications. CONCLUSIONS: In a favorable liver transplant setting including acceptable donors, absence of prior complex abdominal surgery in the recipient, and nonemergency transplants, neither the cause of the cirrhosis nor its severity, as measured preoperatively by the MELD, were predictive of early postoperative death or long-term survival.

Transfusion requirements during liver transplantation: impact of a temporary portacaval shunt.

UNLABELLED: We evaluated the consumption of blood products during liver transplantation in cirrhotic patients association with the placement of a temporary portacaval shunt (TPCS). PATIENTS AND METHODS: We retrospectively divided 349 cirrhotic patients transplanted in our unit between March 1997 and October 2005 into two groups: transplants without a TPCS (group I, 189 cases) and those with a TPCS (group II, 160 cases). In all cases, we preserved the inferior vena cava (piggyback). The dependent variables were consumption of blood-derived products (banked red cells, recovered red cells, fresh frozen plasma, platelets), surgery time, kidney function, intensive care unit stay, and hospital stay. RESULTS: Consumption of blood products was significantly lower among patients who received a TPCS. In group II, no platelet transfusion was required in 54% of the patients, and no banked red cells in 12% compared with 18% and 3%, respectively, among group I patients (P < .005). The mean overall transplant procedure time was 74 minutes shorter in group II (361 minutes) compared with group I (435 minutes) (P < .001). The overall hospital stay was shorter among patients transplanted after TPCS. CONCLUSION: Liver transplantation with a TPCS was accompanied by a reduction in the intraoperative use of blood-derived products, especially platelet transfusion. Among other advantages, this reduction resulted in a shorter posttransplant hospital stay.

Influence of degree of hepatic steatosis on graft function and postoperative complications of liver transplantation.

The aim of this study was to evaluate the impact on initial graft function of the degree of steatosis detected in the back-table biopsy, and its repercussion on the clinical results of the transplant (early posttransplant mortality and morbidity). We undertook a retrospective analysis of 300 liver transplants performed at our center from 1997 to 2004. A wedge liver biopsy was done routinely during back-table surgery (available in 294 transplants). The degree of steatosis was classified as: S0-no steatosis, 201 transplants; S1-mild steatosis (<30%), 58 transplants; S2-moderate steatosis (30% to 60%), 18 transplants; and S3-severe steatosis (>60%), 17 transplants. The ischemia-reperfusion (I/R) injury, based on the maximum mean peak aspartate transferase in the first 72 posttransplant hours, tended to be greater as the degree of graft steatosis increased: S0, 1316; S1, 1985; S2, 2446; and S3, 2955 (P < .005 between S0 and S3). This greater initial hepatic dysfunction was correlated in the group with severe steatosis with a higher rate of severe renal failure requiring hemofiltration/hemodialysis: S0, 9%; S1, 15%; S2, 11%; and S3, 41% (P < .001); as well as with a higher early mortality (90 days): S0, 10%; S1, 21%; S2, 11%; and S3, 41% (P < .001). The Kaplan-Meier survival curve showed a significant difference (log-rank and Breslow) between the group with severe steatosis and the group with no steatosis (P = .002). We conclude that the degree of liver graft steatosis is an important determinant of I/R injury, although this progressive increase in the I/R injury with the degree of steatosis only had clinical repercussions in the case of severe steatosis.

Pancreas Preservation With Viaspan, Celsior, and Custodiol Solutions: An Initial Experience.

BACKGROUND: There is still controversy about which preservation solution in pancreas transplantation could be the best. The aim of this study was to analyze our initial experience with Custodiol solution (CuS) compared with Viaspan solution (VS) and Celsior solution (CS) in pancreas transplantation. METHODS: A retrospective study included 94 consecutive pancreatic transplants, from 2007 until 2015. We compared 3 groups, depending on preservation solution: Viaspan (n = 41), Celsior (n = 40), or Custodiol (n = 13). The primary end point was patient and pancreas survival at 1 year after pancreas transplantation. RESULTS: The recipient and donor characteristics were similar except in cold ischemia time; it was higher with Celsior. No differences were found in postoperative complications and pancreas graft function at 3 months, 6 months, and 1 year (glucose, HbA1c, C-peptide, creatinine). The pancreas and patient survival at 1 year was comparable (pancreas survival: VS, 80%; CS, 90%; CuS, 92%; log-rank, 0.875; and patient survival: VS, 92%; CS, 97%; CuS, 100%; log-rank, 0.9). CONCLUSIONS: In our institution, the Custodiol solution in pancreas transplantation presented similar outcomes in terms of postoperative complications, pancreas graft function, and 1-year survival.

Impact of Liver Graft Transport on Postoperative Results and Short-Term Liver Survival.

BACKGROUND: The Andalusian community has a specific management model of liver transplantation with a common waiting list, forcing transportation of 45% of hepatic grafts. These trips within the community have been made exclusively via expressway since 2012, sometimes surpassing 400 km in distance. The objective of this study was to analyze the effect of graft transportation on our community regarding postoperative results, primary dysfunction, and short-term graft survival. METHODS: This was a retrospective observational cohort study that included 110 patients recipients of liver transplants from 2009 to 2012. Group A (n = 53) were patients transplanted with grafts removed in Malaga, and group B (n = 57) were patients with transported grafts. RESULTS: In group B, significant increments in total and cold ischemia time (TIT and CIT) were found. We found a significant higher increase, mostly in 2012, in TIT and CIT in the greater transportation distance subgroup (>150 km). In postoperative variables analysis, differences were found in the bilirubin levels the 1st postoperative day, alkaline phosphatase levels the 1st and 3rd days, and factor V in the 1st day in favor of the nontransported grafts. In the multivariable analysis transport and distance travelled in km presented a relationship with the 1st day bilirubin levels and the primary dysfunction of the graft. CONCLUSIONS: Our results point to graft transportation having an influence on primary dysfunction and graft survival. This relationship can be multifaceted and influenced by currently unknown factors. This is a factor to consider regarding liver transplant management strategy decisions.

Results of Liver Transplantation With Donors Older than 75 Years: A Case-Control Study.

BACKGROUND: The inclusion of elderly donors can increase the pool of organs available for transplantation. The objective of this study was to compare clinical outcomes and survival rates of patients who received livers from donors aged ≥75 years versus younger donors. METHODS: We considered all liver transplantations performed in our unit from January 2006 to January 2015. Thirty-two patients received a liver from a cadaveric donor aged ≥75 years (study group), and their outcomes were compared with those of patients who received a liver from a younger donor (control group) immediately before and after each transplantation in the study group. This is a descriptive, retrospective, case-control study carried out to analyze the characteristics of donors and recipients as well as the clinical course and survival of recipients of older and younger donors. RESULTS: Statistically significant differences were observed according to donors' age (53.3 ± 13.6 vs 79 ± 3.4 years; P < .001). In total, 6.2% of the recipients of a liver from a donor aged <75 years required retransplantation versus 15.6% of recipients of donors ≥75 years. Patient survivals at 1, 3, and 5 years, respectively, were 89%, 78.6%, and 74.5% for recipients of donors <75 years versus 83.4%, 79.4%, and 59.6% for the study group. CONCLUSIONS: Livers from older donors can be safely used for transplantation with acceptable survival rates. However, survival rates are lower for recipients of livers from older donors compared with younger donors, and survival only increased with retransplantation.

Up-to-7 Criteria for Hepatocellular Carcinoma Liver Transplantation: A Retrospective Analysis of Experiences.

INTRODUCTION: The expansion of criteria for hepatocellular carcinoma (HCC) liver transplantation should produce satisfactory outcomes in terms of survival and recurrence. OBJECTIVES: To investigate if the up-to-7 criteria are applicable to liver transplantation for HCC. METHODS: A review of all liver transplantations performed at our unit between January 2002 and December 2010 was conducted (645 patients). The 91 patients of the sample who had HCC were divided into 3 groups: in Milan criteria (MC; n = 74), in up-to-7 criteria (UTSC; n = 12), and outside of up-to-7 criteria (OUTSC; n = 5). A descriptive retrospective study was carried out to analyze the characteristics of liver tumors and recipients and to estimate recurrence and survival rates for this population of patients. RESULTS: The characteristics of transplant recipients of the 3 groups were comparable. Statistically significant differences were observed in the number of tumors (1 ± 0.65 for MC, 3 ± 1.05 for UTSC, 6 ± 4.10 for OUTSC; P < .001), largest tumor size (2.47 ± 1.12 cm for MC, 3.78 ± 0.04 cm for UTSC, 4.04 ± 1.73 cm for OUTSC; P < .001), and recurrence (5.4% for MC; 33.3% for UTSC; 20% for OUTSC; P = .008). Survival rates (MC, UTSC, and OUTSC) at 3 and 5 years were 71.6%, 66.7%, and 60%, and 58.1%, 58.3%, and 40%, respectively, whereas tumor-free survival rates were 70.3%, 58.3%, and 60%, and 58.1%, 50%, and 40%, respectively. CONCLUSIONS: Survival in patients with HCC transplanted under up-to-7 criteria is acceptable. However, the expansion of criteria involves an increase in the number of patients included in the waiting list and a higher probability of relapse.

Acute Liver Failure Caused by Primary Non-Hodgkin's Lymphoma of the Liver.

INTRODUCTION: Acute liver failure (ALF) is a rare syndrome involving maximum liver dysfunction. This disease is characterized by a less than 26-week history of coagulopathy (INR ≥1.5) and hepatic encephalopathy and generally occurs in patients without any previously known disease. METHODS: We report the case of a healthy 25-year-old subject who presented with fulminant liver failure caused by a primary non-Hodgkin's lymphoma of the liver that required emergency liver transplantation. Diagnosis was based on pathologic confirmation of T-cell/histiocyte-rich large B-cell lymphoma and submassive hepatocyte necrosis. One year after surgery, the patient remains in complete remission. CONCLUSIONS: Fulminant liver failure is a sudden-onset severe disease that can be caused by a primary non-Hodgkin's lymphoma of the liver, which accounts for <1% of extranodal lymphomas. The diagnosis of this rare disease demands high diagnostic suspicion, and progression can be prevented through liver transplantation.

Liver transplant results for hepatocellular carcinoma applying strict preoperative selection criteria.

INTRODUCTION: Liver transplantation is currently the best therapeutic option for small hepatocellular carcinoma (HC) in selected cirrhotic patients. The main aim of this study was to analyze the results of a recent series of liver transplant cirrhotic patients with small HC applying strict preoperative selection criteria. PATIENTS AND METHODS: During a period of 6 years we performed 53 liver transplants with a final diagnosis of HC on cirrhosis. The selection criteria for liver transplantation (LT) by modern imaging techniques were the Milan criteria (TNM I and II of the modified classification). RESULTS: Of the 53 patients, 44 (83%) were transplanted with preoperatively known HC, and 9 (17%) with incidental HC. The mean time on the waiting list was 74 +/- 62 days. Despite using strict selection criteria, 23 patients (43%) exceeded the Milan criteria in the specimen and 17 (32%) even exceeded the extended criteria of the UCSF. With a mean follow-up of 2 years, only two patients have developed recurrences. The overall survival at 1, 3, and 5 years was 80%, 70%, and 70%, respectively. The survival of patients that exceeded the Milan or USF criteria at 1, 3, and 5 years was 72% and 76%; 67% and 69%; 67% and 69%, respectively. CONCLUSIONS: The results of liver transplantation for HC are excellent when applying strict preoperative selection criteria. The current imaging methods lead to a considerable infrastaging percentage (30% to 40%), extending the indications for liver transplant due to HC beyond the scope that clinical reports would justify.

Preoperative factors and models predicting mortality in liver transplantation.

We analyzed preoperative factors related to postoperative mortality after liver transplantation among a cohort of 268 consecutive liver transplant patients over 6 years. We studied the impact of 10 recipient variables, 14 donor features, and three operative aspects. We also studied the correlation with death and survival using various predictive scores (Child, Cordoba Score, MELD, and UCLA). Univariate analysis showed that the factors with a significant association with postoperative mortality were the use of noradrenaline in the donor, total ischemia time (>12 hours), and transplant indication (hepatitis C virus versus the rest). Multivariate analysis of mortality showed the impact of female donor sex, recipients over >60 years, recipient albumin less than 2.8, and total graft ischemia time more than 12 hours. Univariate analysis of 1-year survival showed a statistically significant relation with D/R gender similarity, as well as donor GOT (>170) and GPT (>140) values. Multivariate analysis of 1-year survival showed donor GOT (>170) and donor/recipient gender similarity to be significant. Concerning the prediction models, Child-Pugh (AB versus C) best determined postoperative mortality (P < .006), MELD was predictive of 1-year survival (P < .03). The most important variables related to postoperative mortality were total ischemia time over 12 hours, recipient albumin less than 2.8, and age above 60 years. The variable with most impact on 1-year survival was the degree of graft hepatocyte lesion as determined by GOT. The Child-Pugh system is still the best indicator of postoperative mortality, although MELD may also be a good predictor of survival.

Induction therapy in simultaneous pancreas-kidney transplantation: thymoglobulin versus basiliximab.

BACKGROUND: Induction therapy for simultaneous pancreas-kidney (SPK) transplantation. Both thymoglobulin (ATG) and basiliximab are the most-used types of induction antibodies therapies in clinical practice. The aim of our report was to analyze our experience comparing 2 induction therapies, for SPK transplantation in terms of pancreas and patient survival, as well as rejection rate. METHODS: We reviewed retrospectively a total of 97 SPK transplantations in our institution. The cases were divided according to induction therapy in 2 groups, basiliximab (n = 38) and ATG (n = 59). Rejection, patient and graft survival, and postoperative complications were analyzed. RESULTS: Survival in the ATG group was better without statistical difference at 1-, 3-, and 5-year follow-up (97%, 95%, and 95% versus 92%, 90%, and 87%, respectively). No difference was detected in pancreas graft survival after 1-, 3-, and 5-year follow-up (basiliximab 85%, 80%, and 77% versus ATG 84%, 84%, and 81%, respectively; log-rank, 0.847). Overall cellular rejection and early rejection were more common in the basiliximab group (30 versus 14%, and 21% versus 6%). In the multivariate analysis considering human leukocyte antigen (HLA) mismatches, the ATG group was a protective factor for cellular rejection. Major complications (Grade III-IV) and median length of the hospital stay were higher in the basiliximab group (55% versus 34%, P = .057, and 21 versus 16 days, P = .056). CONCLUSIONS: The pancreas graft survival was not affected by induction therapy. ATG induction therapy compared with basiliximab is associated with lower overall and early rejection rate. Over time this difference disappears.