Purpose: Bleeding is a major intraoperative complication for hepatic surgeons. Adjunct hemostats are used to achieve intraoperative hemostasis and may lead to improved surgical outcomes. However, clinical studies investigating these agents have not used standardized definitions for intraoperative bleeding, making it difficult to make comparisons. Validated Intraoperative Bleeding Scale (VIBe Scale) is one of the most promising scales to standardize intraoperative bleeding. It was validated with excellent concordance by multiple specialties including HPB, however representation of HPB surgeons in the analysis was low (Lewis KM et al. 2017). We describe a Spanish multicenter study for the evaluation of VIBe in HPB surgery. Method: All participants viewed and graded 14 bleeding videos and answered 14 questions to assess intra- and inter-observer concordance, usability, clarity, and relevance. Data of the HPB units and the clinical practice of participating surgeons was collected, with results analyzed depending on surgeon experience and volume of surgeries. A total of 47 surgeons from 10 HPB units participated in the study. Results: Participating hospitals performed 23±16 major and 56±24 minor hepatectomies per year. Minimally invasive surgery (MIS) was performed in a mean of 40.5% of the procedures. 63.3% of participating surgeons were male with a mean age of 41.6 years. 17% were unit/department heads and 83% were senior consultants. Mean experience was 9.3 years, and the majority were experts (21.3%) or advanced (53.2%) in MIS. Only 23.4% had previous knowledge of VIBe, but all surgeons used hemostats in their clinical practice. VIBe Scale achieved an average intra-observer concordance of 0.985 and inter-observer concordance of 0.929, neither were influenced by surgeon experience or volume of surgeries per year (Table). Mean grading for all videos was 67% correct, in line with the original validation. The majority of surgeons considered the scale represented the range of bleeding severity in their procedures (91%), relevant for evaluating intraoperative hemostasis in clinical studies (96%) and clinical practice (87.2%), useful in MIS (96%), and also to differentiate hemostatic agents (81%). Conclusion: VIBe Scale shows excellent concordance status among HPB surgeons to define intraoperative bleeding, with the majority agreeing that it was relevant for evaluating hemostasis and hemostatic agents, and could become a useful tool in clinical trials.Tabled 1Kendall's coefficient of concordance (Kendall's W)Concordance statusAverage Intra-observer agreementAll surgeons (N=47)0.985ExcellentAccording to surgeon experience High experience (N=23)0.990Excellent Low experience (N=24)0.981ExcellentAccording to number of surgeries per year High number (N=20)0.995Excellent Low number (N27)0.979ExcellentInter-observer agreementAll surgeons (N=47)0.929ExcellentAccording to surgeon experience High experience (N=23)0.941Excellent Low experience (N=24)0.922ExcellentAccording to number of surgeries per year High number (N=20)0.940Excellent Low number (N27)0.923ExcellentA Kendall's coefficient of 0.70 or greater was considered to be evidence of a scoring system with appreciable concordance, a coefficient of 0.80 or greater was considered to be good concordance, and a coefficient of 0.90 or greater was considered to be excellent concordance. Median experience was 7 years: low experience was considered ≤7 years; high experience was considered >7 years. Median number of surgeries per year was 35: low number of surgeries was considered ≤35 surgeries per year; high number of surgeries was considered >35 surgeries per year. Open table in a new tab A Kendall's coefficient of 0.70 or greater was considered to be evidence of a scoring system with appreciable concordance, a coefficient of 0.80 or greater was considered to be good concordance, and a coefficient of 0.90 or greater was considered to be excellent concordance. Median experience was 7 years: low experience was considered ≤7 years; high experience was considered >7 years. Median number of surgeries per year was 35: low number of surgeries was considered ≤35 surgeries per year; high number of surgeries was considered >35 surgeries per year.

Purpose: The technical, human, scientific and medical assistance characteristics of the Units that attend a complex pathology are little studied and known. Material and Methods: Multi-institutional descriptive study (survey) on the characteristics of the Units where liver surgery (LS) is performed in Spain. Results: 88 surveys were sent. 60 centres answered (68.2%) belonging to all spanish autonomous communities (17). The sum of inhabitants attended was near 35 millions inhabitants (75% of spanish population). Mean number of beds per hospital was 740. 21 Units (35%) also perform liver transplantation. The mean number of surgeons per Unit is 5. Only 3 Units had a HPB fellowship program. 100% of the Units have intraoperative ultrasound for open approach and 50 (83.3%) have intraoperative ultrasound for laparoscopic approach. In 61.7% of the Units (37/60) the ultrasound was performed by the surgeon, radiologist 15% (9/60) and both 23.3% (14/60). 65% (39/60) of the Units have a 3D laparoscopic tower. 65% (39/60) have an ICG module. 95% (57/60) have the equipment to perform radiofrequency ablation of lesions. 40% has Portal flow measurement device (24/60). 100% can perform intraoperative cholangiography. The mean of liver resections per Unit during 2019 was: 20 major hepatectomies, 29 minor hepatectomies and 3 liver hydatidosis cases. Mean percentage of laparoscopic liver surgery was 20%. Preoperative nutritional assessment is carried out systematically by 43.3% Units (26/60), selectively 50% (30/60) and never 6.7% (4/60). Operative fragility is assessed in 45% of the Units (27/60), selectively in 50% and never in 6.7% (4/60). 86.7% Units (52/60) have a preoperative rehabilitation program, and it is systematically applied by 42.3% (22/52) and selectively by 57.7% (30/52). Answers about real-life practice in liver resections are in Table 1. Laparoscopic approach is more frequent in minor hepatectomies. Abdominal drain and hemostatics are more employed in major resections. In 2015-2018, 39 Units published 226 manuscripts. Mean impact factor/paper was 1,3. Conclusions: This survey provides updated information about the majority of the Units where liver surgery is performed in Spain, and could also serve as a starting point for prospective multicenter studies..EP011_Table IReal life approach comparing minor/major hepatectomiesMINORMAJORpApproach<0.001Laparoscopic50 (83.3%)16 (26.7%)Open10 (16.7%)44 (73.3%)Pringle Manouver0.060Never2 (3.33%)1 (1.67%)Selective41 (68.3%)30 (50.0%)Systematic17 (28.3%)29 (48.3%)Parenchyma Dissection1.000Ultrasonic bisturi55 (91.7%)54 (90.0%)Others5 (8.33%)6 (10.0%)Haemostasia0.798Aquamantis ®7 (11.7%)5 (8.33%)Energy (Caiman ®, Ligasure ®, etc…)4 (6.67%)2 (3.33%)Clips/sutures3 (5.00%)3 (5.00%)Mix of previous methods46 (76.7%)50 (83.3%)Abdominal Drain<0.001031 (51.7%)10 (16.7%)129 (48.3%)48 (80.0%)202 (3.33%)Hemostatics0.001Always15 (25.0%)35 (58.3%)Never3 (5.00%)2 (3.33%)Selective42 (70.0%)23 (38.3%)Eras Protocol0.713No25 (41.7%)28 (46.7%)Yes35 (58.3%)32 (53.3%) Open table in a new tab

INTRODUCTION:Awareness of organ donation among Spanish doctors and medical students is very positive. However, the emerging group of professionals of non-Spanish nationality studying in Spain has not been analyzed. OBJECTIVE:To analyze the differences in the attitudes toward the different types of donation among medical students, according to their nationality. METHODS:The population under study is medical students in Spanish universities using the database of the International Collaborative Donor Project, stratified by geographic area and academic year. Groups under study include students of non-Spanish nationality as group 1 (n = 1570) and students of Spanish nationality as Group 2 (n = 7705). Instruments are validated questionnaires of attitude toward donation "PCID-DTO-Ríos," "PCID-DVR-Ríos," "PCID-DVH-Ríos," and "PCID-XenoTx-Ríos." RESULTS:The attitude toward the donation of own organs after death is similar in both groups (P = .703). Non-Spaniards are 79.2% in favor compared to 79.6% of Spaniards. Living kidney donation, both unrelated (33.3% vs 29.3% in favor; P = .001) and related (91.2% vs 89, 6% in favor; P = .047), is more favorable among non-Spanish students. There are no differences regarding non-related living liver donation (29.7% vs 29.3% in favor; P = .063), but there are differences in the results for related living liver donation (94.1% vs 88%; P < .001). The attitude toward xenotransplantation of organs is similar (80.8% vs 80.8%; P = .999). CONCLUSIONS:Awareness of the donation of organs among Spanish medical students is similar to non-Spanish students studying in Spain, except the attitude toward living donation.

Introduction. Health professionals are asked to promote health, especially organ transplantation; however, they do not always have specific training. Objective. To analyze information about donation and organ transplantation among Spanish medical students. Method. The population under study is medical students in Spanish universities using the database of the International Donor Collaborative Project, stratified by geographic area and academic year (n = 9275). The instrument used is the attitude questionnaire for organ donation for "PCID-DTO-Rios" transplantation, validated with an explained variance of 63.203% and alpha = 0.834. The Student t test was applied together with the chi(2) test, complemented by an analysis of the remainders, and Fisher's exact test was applied. Results. Of the students, 74% indicate that they have received information from university professors about organ transplant. Concerning specific issues with the donation, it is notable that only 66.7% (n = 6190) know and accept the concept of brain death as the death of a person. However, only 22% consider themselves as having good information, and 35.3% indicate that their information is scarce or void. Students indicate having received information about transplant from other extra-university sources, such as television and Internet (80.9%), books and magazines (73.2%), and the press (66.9%). From the information obtained in the sociofamilial field, 60.7% have obtained information from the family and 58.1% from friends. Of this information, 9% has been negative from friends, 7.5% from family, 6% from the Internet and television, and 4% from university professors. Conclusion. Spanish medical students believe they have little information about organ transplantation and have received negative information.

Background: Total pancreatectomy (TP), pancreatoduodenectomy (PD) and distal pancreatectomy (DP) with celiac axis resection (CAR) are performed in patients with locally advanced pancreatic cancer. The morbidity and mortality rates of these procedures are very high and the real benefit in a better survival rates is not fully confirmed. Objective: measuring morbidity and mortality at 90 days, hospital stay and survival rates in patients in which we performed TP/PD and DP + CAR and comparing both groups Methods: Observational retrospective multicentre study. Inclusion criteria: patient operated from a pancreatic cancer performing TP, PD or DP plus CAR in Spanish Surgical Departments. Data collection was closed 31 March 2018. Several preoperative, intraoperative and postoperative data were studied (Table 1). Complications were measured with Clavien classification at 90 days. Specific pancreatic complications were measured using ISGPS classifications. Chi-square or Student's t tests were used to compare categorical or continuous variables, respectively. Kaplan–Meier estimator was used to calculate overall survival and survival differences were compared with the log-rank test. Data were analyzed using R version 3.1.3 (http://www.r-project.org). Level of significance was set at 0.05. Results: Table 1 shows the Results of the whole series (62 patients), the PD+TP (17) and DP group (45). Both groups were homogeneous. Operative time was longer in TP/PD group. Series morbidity was 84,9%, major morbidity (>IIIA) was 45.2 % and mortality 17.7%. Comparing morbidity and mortality of both groups, we did not find statistical differences. Series survival at 2 years is 40% but disease free survival is 0%. No statistical difference related to survival between both groups was found. Conclusion: CAR combined with pancreatectomy is a surgical procedure with high morbidity and mortality. In our series, 2-year survival is 40% but disease free survival is 0% Type of pancreatectomy is not related with survival, morbidity and mortality.Tabled 1Table 1.

Background: Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical procedure with high morbidity and mortality performed in patients with locally advanced pancreatic cancer. Preoperative embolization of hepatic artery (PHAE) has been postulated as a technical option to decrease morbidity and mortality. Objective: comparison of morbidity and mortality at 90 days, operative time, hospital stay and survival between patients that performed DP-CAR with and without PHAE Methods: Observational retrospective multicentre study. Inclusion criteria: patient operated in Spanish Centres from a pancreatic cancer performing DP-CAR until 31 March 2018. Several preoperative, intraoperative and postoperative data were studied (Table 1). Complications were measured with Clavien classification at 90 days. Specific pancreatic complications were measured using ISGPS classifications. Resection margins were classified using Royal College of Pathologists. Chi-square or Student's t tests were used to compare categorical or continuous variables, respectively. Kaplan–Meier estimator was used to calculate overall survival and survival differences were compared with the log-rank test. Data were analyzed using R version 3.1.3 (http://www.r-project.org) and the appropiate packages. Level of significance was set at 0.05. Results: 41 patients were studied. 26 patients were not embolized (NO-PHAE group) and 15 patients received PHAE (36.5%). Only preoperative BMI and percentage of neoadjuvant chemotherapy were the only preoperative variables different between both groups. Operative time was shorter in PHAE group. Morbidity and mortality at 90 days and hospital stay were higher in the PHAE group. No statistical difference in overall survival was observed between both groups (p=0.14). Conclusion: Our study showed that PHAE is not related with less postoperative morbidity or better survival. Even more major morbidity (Clavien III-IV) and mortality was higher in PHAE group. The only benefit of PHAE was shorter operative time. A randomized clinical trial is needed to confirm real benefit of PHAE in DP-CARTabled 1Table 1.

INTRODUCTION:Despite sensitization of medical students toward the donation of organs, a non-negligible percentage of students are not in favor of donation. OBJECTIVE:To analyze the reasons of Spanish medical students who do not have a favorable attitude toward the donation of their own organs after death. METHOD:The population under study is medical students in Spanish universities, using the database of the International Donor Collaborative Project, stratified by geographic area and academic year. The questionnaire completion was anonymous and self-administered. The study group is medical students with an unfavorable attitude toward organ donation. The assessment instrument used is a validated questionnaire of attitude toward the donation of organs for transplant, "PCID-DTO-Ríos." The reasons against the donation are valued in the questionnaire through a question. RESULTS:Of the participants included in the PCID, students who are not in favor of organ donation were selected (n = 1899). Of them, 8.1% (n = 154) are against and 91.1% (n = 1745) are doubtful. The main reasons indicated are the fear of apparent death in 11.4% of respondents, fear of possible mutilation after donation in 11.1%, and religious reasons in 2.6%. Of those, 6.9% indicate other reasons but do not clearly specify the reasons, using words such as "fear" (2.5%) or "doubts about the process" (4.1%); 66.2% (n = 1257) indicated an "assertive refusal" ("I don't want to express my reasons"). CONCLUSION:Twenty percent of Spanish medical students are not in favor of donating their organs and are not in favor of showing their reasons.

The awareness of organ donation among health professionals is important at the time of transplant promotion. In this sense, the training and awareness of the professionals in training is fundamental. Objective. To analyze the differences in the attitude toward organ donation and the factors that condition it among medical students of regions with donation rates >50 donors per million population (pmp) with respect to those with rates <40 donor pmp. Method. Population under study: medical students in Spanish universities. Database of the Collaborative International Donor Project, stratified by geographic area and academic course. The completion was anonymous and self-administered. Groups under study: Group 1 (n = 1136): students in universities of regions with >50 donors pmp. Group 2 (n = 2018): university students in regions with <40 donors pmp. Assessment instrument: attitude questionnaire for organ donation for transplant PCID-DTO-Rios. Results. The attitude toward organ donation for transplantation is similar among students from the autonomous communities with >50 donors pmp and with <40 donors pmp. In group 1, 79% (n = 897) of students are in favor compared with 81% (n = 1625) of group 2 (P=.29). The psychosocial profile toward donation is similar in both groups relating to the following variables (P < .05): sex, having discussed transplantation with family and as a couple, considering the possibility of needing a transplant, involvement in prosocial activities, attitude toward the manipulation of corpses, knowledge of the brain death concept, and religion. Conclusions. The awareness of organ donation in Spanish medical students is quite homogeneous and is not related to the local donation rates of each region.

The involvement of health professionals from their training period is important for the promotion of living liver donation. There are data that indicate that the awareness of living donation is lower in areas with high rates of deceased donation. Objective. To analyze the attitude toward living liver donation among Spanish medical students, according to donation rates of their regions. Method. Population under study: Medical students in Spanish universities. Database of the Collaborative International Donor Project, stratified by geographic area and academic course. The completion was anonymous and self-administered. Groups under study: group 1 (n = 1136): students in universities of regions with >50 donors per million population (pmp); group 2 (n = 2018): students in region universities with <40 donors pmp. Assessment instrument: the attitude questionnaire for living liver donation Proyecto Colaborativo Internacional Donante sobre Donacion de Vivo Hepatico-Rios (PCID-DVH Rios). Results. The attitude toward related liver donation is more favorable among the students of regions with <40 donors pmp than among those of >50 donors pmp. Thus, in group 1, a total of 88% (n = 1002) of students are in favor compared with 91% (n = 1831) of group 2 (P=.02). The psychosocial profile of each study group about their attitude toward living related liver donation is analyzed. There is a similar profile between the 2 groups, although there are differences in some variables such as age, a belief that one might need a transplant, family discussion about donation and transplantation, discussion with friends about donation and transplantation, and knowing about a donor. Conclusions. The awareness of living related donation among Spanish medical students is greater among the regions with lower organ donation rates.

While there is increasing interest in its use, definitive evidence demonstrating superiority of normothermic regional perfusion in controlled donation after circulatory death liver transplantation has not been presented. Unlike the rest of the Western world, where use of NRP has been anecdotal, 25% of all cDCD donors that have been performed in Spain since 2012 have included post-mortem NRP. Aim Analyze the first years of the Spanish experience with cDCD liver transplantation, in particular regarding the impact post-mortem NRP has had on organ utilization rates and transplant outcomes. Methods Data was collected regarding potential cDCD liver donors and transplants that resulted between 2012 and 2016. All transplants had at least 6 mos of follow-up. Each donor hospital determined the process by which organs were recovered: NRP with pre-mortem cannulation, NRP with post-mortem cannulation, or super rapid recovery. Results From 2012 to 2016, 370 potential cDCD liver donors were evaluated: 152 with NRP and 218 with SRR. Ultimately, rates of liver transplantation were 64% NRP and 57% SRR (P=0.102). Among livers that were transplanted, median donor age was 57 (46-65 IQR). While there were no differences in terms of relevant donor or recipient characteristics when analyzed according to recovery method, the functional warm ischemia time was shorter when NRP was applied – 12 (10-16) NRP vs. 15 (11-20) SRR – given that in most cases femoral cannulae were placed prior to withdrawal of care. While rates of early allograft dysfunction (22% NRP vs. 29% SRR) and PNF (2% NRP vs. 4% SRR) did not vary, rates of overall biliary complications (9% NRP vs. 24% SRR, P=0.006) and ITBL (2% NRP vs. 12% SRR, P=0.01) were significantly improved among recipients of livers recovered with NRP. One-year graft survival was 87% NRP vs. 78% SRR (P=0.110). On multivariate analysis analyzing risk factors for ITBL (including fWIT), the only significant factor was the organ recovery method used. Conclusions This is the first large series describing the application of NRP in cDCD liver transplantation. While results with SRR were acceptable, results using NRP were superior and comparable to those achieved using standard-quality livers, even in spite of advanced donor age.

Objective: To analyze the level of understanding of the brain death concept among medical students in universities in Spain. Methods: This cross-sectional sociological, interdisciplinary, and multicenter study was performed on 9598 medical students in Spain. The sample was stratified by geographical area and academic year. A previously validated self-reported measure of brain death knowledge (questionnaire Proyecto Colaborativo Internacional Donante sobre la Donación y Transplante de Organos) was completed anonymously by students. Results: Respondents completed 9275 surveys for a completion rate of 95.7%. Of those, 67% (n = 6190) of the respondents understood the brain death concept. Of the rest, 28% (n = 2652) did not know what it meant, and the remaining 5% (n = 433) believed that it did not mean that the patient was dead. The variables related to a correct understanding of the concept were: (1) being older (P < .001), (2) studying at a public university (P < .001), (3) year of medical school (P < .001), (4) studying at one of the universities in the south of Spain (P = .003), (5) having discussed donation and transplantation with the family (P < .001), (6) having spoken to friends about the matter (P < .001), (7) a partner’s favorable attitude toward donation and transplantation (P < .001), and (8) religious beliefs (P < .001). Conclusions: Sixty-seven percent of medical students know the concept of brain death, and knowledge improved as they advanced in their degree.

Introduction. Religious factors have conditioned the attitude toward organ donation and transplantation (ODT) since the beginning of transplantation, despite the fact that most religions are in favor of transplantation. Objective. To assess the impact of religious beliefs of medical students on their attitude toward ODT. Method. Population under study: Medical students in Spanish universities. Study sample: Stratified by geographical area and academic course. Assessment instrument: Attitude ODT questionnaire PCID-DTO-Rios, anonymous and self-administered. Results. Of all students, 42% (n = 3907) declare themselves atheists or agnostics. The remaining 58% (n = 5368) declare themselves to be religious, the majority being Catholic (55%, n = 5102). Of the rest, 0.2% are Muslims (n = 8), 0.1% Protestants (n = 1), and the remaining 2.7% (n = 257) indicate other religious doctrines but do not want to specify it. Regarding their attitude toward ODT, those who consider themselves atheists or agnostics have a more favorable attitude than those who consider themselves religious (84% versus 76%; P < .001). Among those who follow some kind of religion, Catholics are more in favor of ODT than non-Catholics (77% vs 64%, P < .001). Note that among the religious, only 57% (n = 3050) know which religion is in favor of transplantation, while 22% (n = 1,152) consider that it has not been pronounced on the matter, 13% (n = 723) think the religion is against donation, and the remaining 8% (n = 443) do not know. Conclusion. The religion professed by medical students conditions their attitude toward donation, with the atheists and agnostics being more in favor of donation.

ABSTRACT Introduction: Medical students represent a new generation of medical thought, and if they have a favourable attitude towards organ donation this will greatly encourage its promotion. Objective: To analyse the attitude of medical students in Spanish universities towards the donation of their own organs and to determine the factors affecting this attitude. Material and Methods: Type of study: A sociological, interdisciplinary, multicentre, and observational study in Spain. Study population: Students studying a degree in medicine enrolled in Spain (n = 34,000). Sample size: A sample of 9598 students (confidence of 99% and precision of ±1%), stratified by geographical area and academic year. Instrument of measurement: A validated questionnaire of attitude towards organ donation and transplantation (PCID-DTO RIOS) was self-administered and completed anonymously. Results: The questionnaire completion rate was 95.7% (n = 9.275). 80% were in favour of donation, 2% against and 18% were undecided. The following main variables were related to a favourable attitude: being of the female sex (Odds Ratio = 1.739); being in the sixth year of the degree (OR = 2.506); knowing a donor (OR = 1.346); having spoken about the subject with one’s family (OR = 2.132) and friends (OR = 1.333); having a family circle that is in favour, more specifically, having a father (OR = 1.841), mother (OR = 2.538) or partner in favour (OR = 2.192); being a blood donor (OR = 2.824); acceptance of the mutilation of the body if it were necessary (OR = 2.958); and being an atheist or an agnostic (OR = 1.766). Conclusions: Spanish medical students generally have a favourable attitude towards organ donation, although 20% are not in favour.

A retrospective cohort multicenter study was conducted to analyze the risk factors for tumor recurrence after liver transplantation (LT) in cirrhotic patients found to have an intrahepatic cholangiocarcinoma (iCCA) on pathology examination. We also aimed to ascertain whether there existed a subgroup of patients with single tumors ≤2 cm ("very early") in which results after LT can be acceptable. Twenty-nine patients comprised the study group, eight of whom had a "very early" iCCA (four of them incidentals). The risk of tumor recurrence was significantly associated with larger tumor size as well as larger tumor volume, microscopic vascular invasion and poor degree of differentiation. None of the patients in the "very early" iCCA subgroup presented tumor recurrence compared to 36.4% of those with single tumors >2 cm or multinodular tumors, p = 0.02. The 1-, 3- and 5-year actuarial survival of those in the "very early" iCCA subgroup was 100%, 73% and 73%, respectively. The present is the first multicenter attempt to ascertain the risk factors for tumor recurrence in cirrhotic patients found to have an iCCA on pathology examination. Cirrhotic patients with iCCA ≤2 cm achieved excellent 5-year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs.