Trasplante hepático con injerto procedente de donación después de muerte cardiocirculatoria controlada. Situación actual

An increasing pressure on the liver transplant waiting list, forces us to explore new sources, in order to expand the donor pool. One of the most interesting and with a promising potential, is donation after cardiac death (DCD). Initially, this activity has developed in Spain by means of the Maastricht type II donation in the uncontrolled setting. For different reasons, donation after controlled cardiac death has been reconsidered in our country. The most outstanding circumstance involved in DCD donation is a potential ischemic stress, that could cause severe liver graft cell damage, resulting in an adverse effect on liver transplant results, in terms of complications and outcomes. The complex and particular issues related to DCD Donation will be discussed in this review.     

Trasplante ortotópico de hígado en la poliquistosis hepática

Introduction

There is currently no effective medical therapy for polycystic liver (PCL). Cyst puncture and sclerotherapy, cyst fenestration, or partial hepatic resections have been used as palliative treatments. Orthotopic liver transplantation (OLT) has become the treatment of choice for terminal PCL, being indicated in patients with limiting symptoms not susceptible to any other medical treatment. It is also difficult to determine the priority on the waiting list using the Model for End-Stage Liver Disease (MELD).

Methods

A retrospective analysis of OLT for PCL was conducted in our centre. Inclusion criteria were patients with limiting symptoms, bilateral cysts liver, and insufficient remaining liver. In all cases a deceased donor liver transplantation with piggy-back technique without veno-venous bypass was performed.

Results

Six patients underwent liver transplantation for PCL between April 1992 and April 2010, one of them a combined liver-kidney transplantation. The mean intraoperative packed red blood cell transfusion was 3.25 L and fresh frozen plasma was 1.200 cc. Mean operation time was 299 min, and 498 min in the liver-kidney transplantation. There was no peri-operative mortality. The mean hospital stay was 6.5 days. All patients are healthy after a mean follow-up of 71 months.

Conclusion

OLT offers an excellent overall survival. Results are better when OLT is performed early; thus these patients should receive additional points to be able to use the MELD score as a valid prioritisation system for waiting lists.     

IV Reunión de consenso de la Sociedad Española de Trasplante Hepático (SETH) 2012. Trasplante hepático con injertos no convencionales: bipartición hepática (split) y donante en asistolia

The disbalance between the number of candidates to liver transplant and the number of liver grafts leads to waiting list mortality. Two potential ways of increasing the number of liver grafts are split liver transplantation and the transplantation of grafts from non-heart beating donors. Both of them were discussed in a consensus meeting of the Spanish Society of Liver Transplantation in October 2012. This paper outlines the conclusions of that meeting.     

La resección laparoscópica de los segmentos del lóbulo hepático izquierdo debe ser el abordaje inicial en centros con experiencia

Introduction

The resection of tumours of the anatomical left lobe is normally straightforward using either left lateral sectionectomy (LLSEC) or segmentectomy II or III. Our objective is to present the results of the laparoscopic approach and to consider whether this could be the “ideal technique” in liver surgery units where the surgeons have experience of laparoscopic liver surgery (LLSURG).

Patients and methods

We have studied patients with resected solid tumours of the anatomical left lobe using LLSURG (n=18): 10 cases with LLSEC and 8 cases with segmentectomy II or III. We carried out a comparative study with a control group of 18 patients operated on using the same surgical technique using open surgery (OS).

Results

There were no cases of mortality in either of the 2 groups (n=36). Morbidity was similar (5.5% per group). For LLSEC, the LLSURG group (n=10) had a shorter hospital stay (p=0.005) and less surgical time (141 vs. 159 min) (differences not significant.), than the OS group. For segmentary resections II or III, in the LLSURG group (n=8) there was greater use of the Pringle manoeuvre (p=0.05), greater surgical time (p=0.05) and a shorter hospital stay (4.8 vs. 5.6 days) (differences not significant), than in the OS group.

Conclusions

LLSEC should be carried out by laparoscopy in centres where they have considerable experience. The patients may have a shorter hospital stay and spend less time in surgery than when OS is performed, with the same morbidity and mortality rates. Segmentectomy resections II or III carried out by laparoscopy involve a shorter hospital stay but longer surgery time and therefore the advantages are not as evident as they are for LLSEC.     

Mamoplastia de reducción en la cirugía del cáncer de mama

Reduction mammaplasty techniques enable the breast cancer surgeon to provide an integral surgical treatment, thus significantly increasing and improving surgical options. These techniques are used to correct problems after the conservative treatment of type 1 breast cancer and to achieve symmetry between the breasts after mastectomy. They are also the basis of cosmetic reconstruction techniques in conservative oncoplastic surgery.     

Estado actual y perspectivas futuras del trasplante de hepatocitos

The imbalance between the number of potential beneficiaries and available organs, originates the search for new therapeutic alternatives, such as Hepatocyte transplantation (HT).Even though this is a treatment option for these patients, the lack of unanimity of criteria regarding indications and technique, different cryopreservation protocols, as well as the different methodology to assess the response to this therapy, highlights the need of a Consensus Conference to standardize criteria and consider future strategies to improve the technique and optimize the results.Our aim is to review and update the current state of hepatocyte transplantation, emphasizing the future research attempting to solve the problems and improve the results of this treatment.     

Cuatro años de experiencia con el libro informático del residente de la AEC

Introduction

The introduction of the Spanish Association of Surgeons resident's electronic book (AEC-E-Book), has meant that we can perform particular and overall assessments of each resident. The objective of this article has been to find out the mean health care, scientific and surgical activities according to the speciality program.

Material and method

A register of the activities of residents in the AEC-E-Book. The overall activity per year and per rotation has been measured. The relationships of assisted interventions performed and their level of complexity have been analysed. The mean scientific and health care activities and the mean on-call periods per month.

Results

A total of 8 residents have registered their activity in the AEC-E-Book since the year 2004. They assisted in a mean of 1514 operations, of which 922 were performed as surgeon (62%). They assisted in 185 laparoscopic interventions, of which they performed 72 (39%). As surgeon, 864 (94%) of the 922 procedures 64% were level 1, 75% level 2, and 53% were level 3. They were on-call a mean of 5.75 times per month. They attended a total of 21 courses and congresses during residency. They took part in 24 presentations and posters, as well as in 6 journal publications during residence.

Conclusions

The AEC-E-Book enables the activity of the resident to be continually assessed. We have been able to find out the mean activities carried out by each resident during a particular rotation and year, thus being able to know exactly if they have fulfilled the defined minimums.     

Resultados tras resección hepática laparoscópica: una opción adecuada en patología maligna

Introduction

The laparoscopic approach is not yet widely used in liver surgery, but has proven to be safe and feasible in selected patients even in malignant disease. The experience and results of a hepato-pancreato-biliary (HPB) surgery unit in the treatment of malignant liver disease by laparoscopic approach is presented.

Material and methods

Between February 2002 and May 2011, 71 laparoscopic liver resections were performed, 43 for malignant disease (only patients with more than one year of follow-up were included). Mean age was 63 years old and 58% of the patients were male. Forty-nine per cent of the lesions were located in segments ii-iii. Thirty segmentectomies were performed, 7 limited resections and 6 major hepatectomies.

Results

The median operative time was 163 min. There were 3 conversions. Five cases (11%) required blood transfusion. The oral intake began at 32 h and the median hospital stay was 6.7 days. There were no reoperations and there was one case of mortality. Nine patients (21%) had postoperative complications. The mean number of resected lesions was 1.2, with an average size of 3.5 cm. All resections were R0. The median survival after resection of colorectal liver metastases (CLM) was 69% and 43.5% at 36 and 60 months, respectively, and 89% and 68% at 36 and 60 months, respectively, in hepatocellular carcinoma (HCC).

Conclusion

The laparoscopic liver resection in malignant disease is feasible and safe in selected patients. The same oncological rules as for open surgery should be followed. In selected patients it offers similar long-term oncological results as open surgery.     

Cambios en el manejo diagnóstico-terapéutico del traumatismo hepático. Estudio retrospectivo comparando 2 series de casos en periodos diferentes (1997-1984 vs. 2001-2008)

Introduction

We present a series of 146 cases of hepatic trauma (HT) treated in our hospital over a period of 8 yearsm (2001-2008), and comparing it with a previous series of 92 cases (1977-1984).

Material and method

The mean age in the current series was 28.6 years and the majority were male. The closed traumas were mainly penetrating, with the most frequent cause being road traffic accidents.

Results

The American Association for the Surgery of Trauma (AAST) classification was used to evaluate the grade of the hepatic injury. Associated abdominal and /or extra-abdominal injuries were seen in 79.5% of the patients, with the most frequent being chest trauma, compared to bone fractures in the previous series. The most common associated intra-abdominal injury was the spleen in both series. The most used diagnostic technique in the current series was abdominal CT. Simple peritoneal puncture and lavage (PLP) were the most used examinations used in the previous series. Non-surgical treatment (NST) was given in 98 cases and the surgery was indicated in the remaining 48. In the previous series, 97.8% of patients were operated on. In the current series, on the 15 patients with severe liver injuries, 5 right hepatectomies, 2 segmentectomies and 6 packing compressions were performed, with the remaining two dying during surgery due to hepatic avulsion. The overall mortality was 3.4%, being 1% in the NST group and 8.3% in the surgical patients. In the previous series, the overall mortality was 29.3%.

Conclusions

The key factor for using NST is to control haemodynamic stability, leaving surgical treatment for haemodynamically unstable patients.     

III Consensus Meeting of the Spanish Society of Liver Transplantation. Hepatitis C, living-donor liver transplantation, quality of liver grafts and of liver transplantation programs

The constant updating in the field of liver transplant led to the holding of the III Consensus Meeting of the Spanish Liver Transplant Association. Three current topics of great clinical interest were debated during this meeting; transplant in patients with liver cirrhosis due to hepatitis C, live donor liver transplant and the evaluation of the quality of liver grafts. A subject of great interest to Liver Transplant Units was also discussed: the assessment of their quality.     

Una nueva técnica quirúrgica para la hepatectomía derecha extendida: torniquete en la cisura umbilical y oclusión portal derecha (ALTPS). Caso clínico

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy), in 2-stage liver resections, achieves hypertrophy of the functional liver remnant (FLR) in 7 days, and the objective of this technique is the occlusion of the intrahepatic collaterals. In March 2012 we published a new surgical technique associating the insertion of a tourniquet in Cantlie’ line and right portal vein ligation (ALTPS: Associating liver tourniquet and right portal vein occlusion for staged hepatectomy). In this paper we present this ALTPS technique placing the tourniquet in the umbilical fissure to obtain hypertrophy of segments II-III. It was performed in a 51 year-old patient with a recurrent right renal hypernephroma which involved all the anatomic right lobe and inferior vena cava. Preoperative FLR was 380 ml (20% of the total volume) increasing 150% at 7 days (to 953 ml, 31% of the total). In the second step, we performed a right trisectionectomy and retrohepatic inferior vena cava resection, replacing it by a 2 cm-ring goretex graft.     

Quimioembolización previa a la resección hepática laparoscópica en el carcinoma hepatocelular precoz en pacientes cirróticos

Objective

To assess whether preoperative transarterial chemoembolisation (TACE) reduces haemorrhage during laparoscopic resection, thus making the Pringle manoeuvre unnecessary and avoiding any subsequent complications.

Patients and methods

We present 3 cirrhotic Child A patients with early hepatocellular carcinoma, all of whom had been given the same treatment involving resection by laparoscopy and preoperative TACE of the segments to remove. All the nodules were located in the right hepatic lobe. One case was treated using total laparoscopic surgery and the two remaining cases were converted to the hand-assisted technique. In the first case we carried out bisegmentectomy VI-VII; in the second, segmentectomy VI plus radiofrequency of a second nodule in segment VII, and in the third case, segmentectomy V.

Results

There was no morbidity or mortality. Blood transfusion was not required by any of the patients; in fact blood losses were 100, 50 and 150 ml, respectively, and it was not necessary to carry out the Pringle manoeuvre. Surgical margin was greater than 1 cm in the three cases and hospital stay was less than 3, 3 and 4 days, respectively.

Conclusion

TACE prior to early hepatocellular carcinoma resection in cirrhotic patients seems to improve surgical safety with low blood losses without the use of the Pringle manoeuvre. Prospective random studies should be carried out on a larger number of patients in order to assess this technique.     

Tratamiento del traumatismo cerrado de hígado,indicaciones de cirugía y desenlaces

Introduction

The liver is the most frequently injured organ in blunt abdominal trauma. Patients that are hemodynamically unstable must undergo inmmediate surgical treatment. There are 2 surgical approaches for these patients; Anatomical Liver resection or non-anatomic liver resection. Around 80-90% of patients are candidates for non-operative management. -Several risk factors have been studied to select the patients most suited for a non operative management.

Materials and methods

We performed a retrospective study based on a prospective database. We searched for risk factors related to immediate surgical management and failed non-operative management. We also described the surgical procedures that were undertaken in this cohort of patients and their outcomes and complications.

Results

During the study period 117 patients presented with blunt liver trauma. 19 patients (16.2%) required a laparotomy during the initial 24 h after their admission. There were 11 deaths (58%) amongst these patients. Peri-hepatic packing and suturing were the most common procedures performed. A RTS Score < 7.8 (RR: 7.3; IC 95%: 1.8-30.1), and ISS Score > 20 (RR 2,5 IC 95%: 1.0-6.7), and associated intra-abdominal injuries (RR: 2.95; IC 95%: 1.25-6.92) were risk factors for immediate surgery. In 98 (83.7%) patients a non-operative management was performed. 7 patients had a failed non-operative management.

Conclusion

The need for immediate surgical management is related to the presence of associated intra-abdominal injuries, and the ISS and RTS scores. In this series the most frequently performed procedure for blunt liver trauma was peri-hepatic packing.     

Current status of islet transplantation

Due to the numerous advances in islet transplantation in the last few years, clinical outcomes following this procedure are continually improving. Novel immunosuppression protocols, improved donor and recipient selection, and careful attention to the process of organ extraction, preservation and islet isolation have contributed to long-term success. The present article reviews the results of clinical islet transplantation and their relationship with the different advances introduced. The use of new islet sources such as living and non-heart-beating donors, as well as recent advances in our knowledge of the mechanisms of rejection and its prevention, are also reviewed.     

El sistema de cierre asistido al vacío en el tratamiento del pie diabético avanzado

Introduction

Deep diabetic foot lesions pose an enormous therapeutic problem. The purpose of this study was to present the experience of the use of vacuum assisted closure (VAC) in the treatment of advanced and complicated diabetic foot lesions.

Material and methods

Five cases of advanced diabetic foot that were treated with VAC were prospectively studied. Three patients were diagnosed with renal failure, including one with renal transplant, who were receiving immunosuppression therapy. Four patients had undergone local foot surgery. The foot lesions were classified as grade 3 or 4 according to the Wagner classification. In all patients extensive debridement was performed that resulted in open minor amputations in four cases and resection of the metatarsophalangeal joint in one case. The VAC was applied during the same procedure. The median follow-up period of the patients was 9 months.

Results

Foot salvage was achieved in all cases. The median number of changes of VAC was 16 within median period of 8 weeks. Half of the changes were performed as an outpatient procedure. There were no major complications or clinical signs of infection observed. In one case before treatment with VAC began, angioplasty of the iliac artery and superficial femoral artery was performed. Other interventions carried out after the treatment was started were, two distal revascularizations and two partial transmetatarsal amputations.

Conclusions

VAC appears to be very useful in the treatment of advanced diabetic foot lesions.     

Sistema GRADE: clasificación de la calidad de la evidencia y graduación de la fuerza de la recomendación

The acquisition and classification of scientific evidence, and subsequent formulation of recommendations constitute the basis for the development of clinical practice guidelines. There are several systems for the classification of evidence and strength of recommendations; the most commonly used nowadays is the Grading of Recommendations, Assessment, Development and Evaluation system (GRADE). The GRADE system initially classifies the evidence into high or low, coming from experimental or observational studies; subsequently and following a series of considerations, the evidence is classified into high, moderate, low or very low. The strength of recommendations is based not only on the quality of the evidence, but also on a series of factors such as the risk/benefit balance, values and preferences of the patients and professionals, and the use of resources or costs.     

Evolución del cierre de ileostomía en una unidad de cirugía colorrectal. Análisis comparativo según la técnica

Introduction

The objective of this study is to assess whether the results of loop ileostomy closure in terms of morbidity and hospital stay are influenced by the type of anastomosis and suture used.

Method

All patients who underwent loop ileostomy closure were reviewed. A retrospective cohort study comparing morbidity and hospital stay according to the type of anastomosis (TT/LL) and the type of suture (hand sewn/mechanical) was performed.

Results

From January 2003 to November 2011 a total of 167 loop ileostomy closures were analized. The groups were: type of anastomosis (TT 95/LL 72) and type of suture (manual 105/stapled 62). In 76% of the observed population the underlying disease was cancer. Mortality occurred in one case. The stratified morbidity analysis by type of complications showed no significant differences between the groups in terms of local (7.4% TT, LL 8.3%, 6.7% hand sewn, stapled 9.7%), general (TT 9.5%, 16.7% LL, hand sewn 6.7%, 6.5% stapled) and surgical (TT 15.8%, 19.4% LL, hand sewn 17.1%, 17.7% stapled) complications, nor in the rate of reoperations (TT 6.3%, 6.9% LL, hand sewn 6.7%, 6.5% stapled) and hospital stay in days (TT 7.8, 8 LL, hand sewn 8.6, stapled 6.7)

Conclusions

Closure of loop ileostomy can be performed regardless of the type of suture or anastomosis used, with the same rate of morbidity and hospital stay.     

Presente y futuro del trasplante de islotes pancreáticos en el tratamiento de la diabetes mellitus

Diabetes treatment with insulin does no prevent the development of secondary complications. For this reason, treatments other than conventional ones are needed, which could bring about an «almost physiological» metabolic regulation. This can only be done by transplanting insulin producing tissue, such as vascularised pancreas transplantation, which is an already consolidated clinical procedure these days, or by islets transplantation, which is still a procedure in the clinical research phase. This has the same metabolic objectives as the vascularised transplant, but without the risks of major abdominal surgery, since the islets are implanted in the liver with minimal surgery or using interventionist radiology by means of a catheter. A clinical trial (Edmonton Protocol) was published in the year 2000, which improved the results after islet transplantation by obtaining normoglycaemia periods of more than one year in a consecutive patient series with type 1 diabetes and without using corticoids. This protocol has been endorsed in other centre in different trials. Although the initial results were good, the progress of these patients has shown that many islets transplantations do not manage to maintain insulin-independence indefinitely.