Trasplante hepático

Liver transplantation is an efficient therapeutic option for terminal hepatic diseases. The principal indications of liver transplantation are hepatic cirrhosis, hepatic tumours (mainly, hepotocellular carcinoma) and acute liver failure. Over the years, the absolute contraindications for a transplant have lessened. Surgical techniques have also undergone changes. The results of liver transplant have improved so that survival one year after the transplant is close to 90% and after five years some 80% of transplanted patients continue to live

Trasplante pancreático

Diabetes mellitus is a health concern of the first order, given the high level of associated morbidity and mortality. The objective, in order to slow down the advance of its complications before they become irreversible, is based on correct metabolic control. The high rate of morbidity associated with the surgery of the vascularized pancreas transplant and the high index of rejection have for three decades formed an obstacle to this being considered a valid alternative in the treatment of these patients. Nowadays the pancreas transplant has come to occupy a key position, thanks to the new regimes of immunosuppression and to the perfection of surgical techniques. In this article we review the evolution of the pancreas transplant from its beginnings to its present state

Totally Laparoscopic Roux-en-Y Duct-to-Mucosa Pancreaticojejunostomy After Middle Pancreatectomy A Consecutive Nine-case Series at a Single Institution

To present the results of a series of laparoscopic middle pancreatectomies with roux-en-Y duct-to-mucosa pancreaticojejunostomy. SUMMARY OF BACKGROUND DATA: Middle pancreatectomy makes it possible to preserve pancreatic parenchyma in the resection of lesions that traditionally have been treated by distal splenopancreatectomy or cephalic duodenopancreatectomy. The laparoscopic approach could minimize the invasiveness of the procedure and enhance the benefits of middle pancreatectomy. METHODS: From March 2005 to October 2007, 9 consecutive patients with benign or low malignant potential lesions in the pancreatic neck or body underwent surgery. Laparoscopic middle pancreatectomy with a roux-en-Y duct-to-mucosa pancreaticojejunostomy was planned on all of them. In the first 2 patients, the pancreas was transected by endostapler; in the last 7, the staple line was reinforced with absorbable polymer membrane. RESULTS: The intervention was concluded laparoscopically in every case except 1 (laparoscopic-assisted) in which pancreaticojejunostomy was performed by means of minilaparotomy. Mortality was 0% and perioperative morbidity was 33%, (fistula of the cephalic stump in the first 2 patients (22%)). The pancreaticojejunostomy fistula rate was 0%. The median postoperative hospital stay was 5 days (range, 3-41). In the last 7 patients, in which pancreas was transected with staple line reinforcement material there were no stump fistulas; morbidity decreased to 14% and the median hospital stay was 4 days (range, 3-30). CONCLUSIONS: Laparoscopic middle pancreatectomy is feasible and safe. Duct-to-mucosa pancreaticojejunostomy can be performed safely using this approach. The method of pancreatic transection seems to be decisive in the incidence of cephalic stump fistulas

Cirugía laparoscópica hepática y pancreática

The development of laparoscopic surgery also includes the more complex procedures of abdominal surgery such as those that affect the liver and the pancreas. From diagnostic laparoscopy, accompanied by laparoscopic echography, to major hepatic or pancreatic resections, the laparoscopic approach has spread and today encompasses practically all of the surgical procedures in hepatopancreatic pathology. Without forgetting that the aim of minimally invasive surgery is not a better aesthetic result but the reduction of postoperative complications, it is undeniable that the laparoscopic approach has brought great benefits for the patient in every type of surgery except, for the time being, in the case of big resections such as left or right hepatectomy or resections of segments VII and VIII. Pancreatic surgery has undergone a great development with laparoscopy, especially in the field of distal pancreatectomy due to cystic and neuroendocrine tumours where the approach of choice is laparoscopic. Laparoscopy similarly plays an important role, together with echolaparoscopy, in staging pancreatic tumours, prior to open surgery or for indicating suitable treatment. In coming years, it is to be hoped that it will continue to undergo an exponential development and, together with the advances in robotics, it will be possible to witness a greater impact of the laparoscopic approach on the field of hepatic and pancreatic surgery

Portal Revascularization in the Setting of Cavernous Transformation Through a Paracholedocal Vein: A Case Report

Diffuse thrombosis of the entire portal system (PVT) and cavernomatous transformation of the portal vein (CTPV) represents a demanding challenge in liver transplantation. We present the case of a patient with nodular regenerative hyperplasia and recurrent episodes of type B hepatic encephalopathy concomitant with PVT as well as CTPV, successfully treated with orthotopic liver transplantation. The portal inflow to the graft was carried out through the confluence of 2 thin paracholedochal varicose veins, obtaining good early graft function and recovery of the encephalopatic episodes. This alternative should be kept in mind as an option to assure hepatopetal splanchnic flow in those cases of diffuse thrombosis and cavernomatous transformation of portal vein. CI - Copyright (c) 2010 Elsevier Inc. All rights reserved

Conversion From Calcineurin Inhibitors to Mycophenolate Mofetil in Liver Transplant Recipients With Diabetes Mellitus

Diabetes mellitus, a frequent metabolic complication in liver transplant recipients, may be produced by the diabetogenic effect of calcineurin inhibitors cyclosporine and tacrolimus. The aim of this study was to investigate the safety and metabolic effects of a gradual switch from cyclosporine or tacrolimus to mycophenolate mofetil among 12 diabetic liver transplant recipients. One patient was withdrawn from the study due to gastrointestinal side effects. Of the 11 remaining patients, cyclosporine or tacrolimus was completely withdrawn in five patients. Two patients developed suspected acute rejection episodes that were controlled by increasing the tacrolimus dosage. Glycosylated hemoglobin A1C and C-peptide levels were significantly lower at 3 and 6 months after the initiation of mycophenolate mofetil (P<.03 in all cases). Furthermore, urea and uric acid levels were significantly reduced after the change of treatment. In conclusion, a switch from cyclosporine/tacrolimus to mycophenolate mofetil may produce beneficial metabolic effects in diabetic liver transplant recipients, but poses a risk of graft rejection

Herpes Zoster After Liver Transplantation: Incidence, Risk Factors, and Complications

Herpes zoster is the consequence of the reactivation of latent varicella-zoster infection. Immunosuppression may be a predisposing factor for herpes zoster. We have retrospectively assessed the risk of herpes zoster, the risk factors for its occurrence, and its evolution in a population of 209 consecutive liver transplant recipients. Herpes zoster developed in 25 (12%) of patients. One-, 3-, 5-, and 10-year actuarial rates of herpes zoster were 3%, 10%, 14%, and 18%, respectively. In a case-control study, patients developing herpes zoster were younger, received a higher number of immunosuppressive drugs, and were more frequently receiving mycophenolate mofetil or azathioprine. In multivariate analysis, the only factor related to herpes zoster occurrence was treatment with mycophenolate mofetil or azathioprine. Eight patients (31%) developed postherpetic neuralgia. In conclusion, herpes zoster is a relatively common complication after liver transplantation. It is related to immunosuppressive therapy. Postherpetic neuralgia develops in one third of patients with posttransplant herpes zoster

Liver Transplantation in Patients with Hepatocellular Carcinoma Across Milan Criteria

Milan criteria are the most frequently used limits for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC), but our previous experience with expanded criteria showed encouraging results. The aim of this study was to investigate whether our expanded Clinica Universitaria de Navarra (CUN) criteria (1 nodule up to 6 cm or 2-3 nodules up to 5 cm each) could be used to select patients with HCC for LT. Eighty-five patients with HCC fulfilling CUN criteria were included as candidates for LT. Survival of transplanted HCC patients was compared with survival of patients without HCC (n = 180). After the exclusion of 2 patients with tumor seeding of the chest wall due to pre-LT tumor biopsy, survival and recurrence rates were compared according to tumor staging. Twenty-six out of 85 (30%) patients exceeded Milan criteria. Twelve patients had tumor progression on the waiting list. Patients exceeding Milan criteria had a higher dropout rate due to tumoral progression. One-, 3-, 5-, 7-, and 10-year survival rates of the 73 transplanted HCC patients were 86%, 74%, 70%, 61%, and 50%, respectively. Survival of patients with HCC was significantly lower than that of patients without HCC, but by multivariate analysis, HCC was not associated with lower survival. Tumor recurrence and survival rates were similar for patients fulfilling Milan and CUN criteria. Pathological staging showed 55 patients within Milan criteria, 7 patients exceeding them but within CUN criteria, and 9 patients exceeding CUN criteria. Tumor recurrence rates were 2/55 (4%), 0/7 (0%), and 4/9 (44%) in each of these groups, respectively. In conclusion, following CUN criteria could increase the number of HCC patients who could benefit from LT, without worsening the results. Because of the short number of patients in this series, these data need external validation

Surgery and radioembolization of liver tumors

Surgical resection is considered the curative treatment par excellence for patients with primary or metastatic liver tumors. However, less than 40% of them are candidates for surgery, either due to nonmodifiable factors (comorbidities, age, liver dysfunction. . .), or to the invasion or proximity of the tumor to the main vascular requirements, the lack of a future liver remnant (FLR) adequate to maintain postoperative liver function, or criteria oftumor size and number. In these lastfactors, hepatic radioembolization has been shown to play a role as a presurgical tool, either by hypertrophy of the FLR or by reducing tumor size that manages to reduce tumor staging (term known as downstaging ¨ ¨ ). To these is added a third factor, which is its ability to apply the test oftime, which makes it possible to identify those patients who present progression of the disease in a short period of time (both locally and at distance), avoiding a unnecessary surgery. This paper aims to review RE as a tool to facilitate liver surgery, both through the experience of our center and the available scientific evidence.La resección quirúrgica se considera eltratamiento curativo por excelencia para los pacientes con tumores hepáticos primarios o metastásicos. Sin embargo, menos del 40% de ellos son candidatos a cirugía, ya sea por factores no modificables (comorbilidades, edad, disfunción hepática. . .), como por la invasión o proximidad del tumor a los principales pedículos vasculares, la falta de un futuro remanente hepático (FRH) adecuado para mantener una función hepática postoperatoria, o criterios de tamano˜ y numero tumoral. En estos últimos factores, la radioembolización hepática ha mostrado tener un papel como herramienta prequirúrgica, ya sea mediante la hipertrofia del FRH o mediante la reducción del tamano˜ tumoral que consigue disminuir la estadificación tumoral (término conocido como “downstaging”). A estos se suma un tercer factor, que es su capacidad de aplicar el test del tiempo, que permite identificar aquellos pacientes que presenten en un plazo corto de tiempo progresión de la enfermedad (tanto a nivel local como a distancia), evitándoles una cirugía innecesaria. En este trabajo se pretende hacer una revisión de la RE como herramienta facilitadora de la cirugía hepática, tanto a través de la experiencia de nuestro centro como de la evidencia científica disponible