Excluding Ascites From the GEMA-Na Score Does Not Impact Outcome Predictions in Liver Transplant Candidates Manuel Luis Rodríguez‐Perálvarez, Antonio Manuel Gómez‐Orellana, Avik Majumdar, Geoffrey W. McCaughan, María Kalafateli, Rhiannon Taylor, Gloria de la Rosa, María Victoria Aguilera, Mikel Gastaca, Carmen Cepeda‐Franco, María Luisa Ortiz, Jordi Colmenero, Alejandra Otero, Rocío González Grande, Alba Cachero, Esther Molina Pérez, Mónica Barreales, Rosa Martín Mateos, María Rodríguez‐Soler, Mario Romero, Cristina Dopazo, Carmen Alonso Martín, Elena Otón, Luisa González Diéguez, María Dolores Espinosa, Ana Arias Milla, Gerardo Blanco Fernández, Sara Lorente, Antonio Cuadrado Lavín, Miguel Sogbe, David Guijo‐Rubio, César Hervás Martínez, Emmanuel Tsochatzis Liver International, 2026 Background and Aims Although GEMA‐Na outperforms MELD 3.0 for liver allocation, concerns about the subjectivity of its ascites component persist. We compared the performance of a GEMA‐Na iteration that excludes ascites with other allocation scores. Approach and Results A multinational cohort study was conducted, including adult candidates for elective liver transplantation in the UK (2010–2020), Australia (1998–2020), and Spain (2016–2021). The primary outcome was mortality or delisting for sickness within 90 days. The prognostic impact of ascites was evaluated using multivariable Cox's regression. Discrimination was assessed using Harrell's c‐statistics (Hc). The study included 15 391 patients (28.5% women). The prevalence of the primary outcome was 5.8% in the UK, 5.3% in Australia, and 4.7% in Spain. The presence and severity of ascites was associated with an incremental risk of the primary outcome: 3.3% without ascites, 5.8% with mild ascites, and 7.7% with moderate–severe ascites ( p < 0.001). Removal of ascites from the GEMA‐Na score resulted in a one‐point reduction in 18% of patients (52.4% of patients with moderate–severe ascites). GEMA‐Na without ascites showed only a marginal decrease in discrimination (Hc = 0.755 vs. Hc = 0.753; p = 0.007) but still significantly outperformed MELD 3.0 (Hc = 0.734; p < 0.001) and MELD‐Na (Hc = 0.737; p < 0.001). In women, GEMA‐Na with and without ascites demonstrated comparable discrimination (Hc = 0.784 vs. Hc = 0.783; p = 0.61), both outperforming MELD 3.0 (Hc = 0.750; p < 0.001), and MELD‐Na (Hc = 0.749; p < 0.001). Conclusions Despite the prognostic impact of ascites among liver transplant candidates, GEMA‐Na without ascites outperformed other scores in predicting wait‐list outcomes and may be used wherever the inclusion of ascites is considered too subjective.
Assessing inter- and intra-rater agreement of four upper digestive endoscopy visibility scores Jorge Ruiz Rodríguez, Samuel Juan Fernández-Prada, Esteban Fuentes-Valenzuela, Miryam Moreta-Rodríguez, Alba Fernández Ozores, Carlos Maroto Martín, Carmen Alonso-Martín, Javier García-Alonso Revista Espanola De Enfermedades Digestivas, 2026 Although various upper digestive endoscopy visibility scores are available, no comparative studies have directly evaluated them to determine the most effective tool. A prospective study was conducted to evaluate the inter- and intra-rater agreement of four upper digestive endoscopy visibility scores. A dataset of 32 videos was randomly selected from a collection of complete endoscopy procedures. Eight videos were assessed twice to estimate the intra-rater reliability. Eleven evaluators, four of whom had over five years of experience, independently rated the videos using four different scoring systems: Elvas, Kuo, Bhandari, and Chen.
Endoscopic Management of Recurrent Anastomotic Biliary Stricture Following Deceased Orthotopic Liver Transplantation Esteban Fuentes-Valenzuela, Marina De Benito Sanz, Irene Peñas-Herrero, Félix García-Pajares, Carmen Alonso-Martín, Carolina Almohalla Álvarez, Antonio Martínez-Ortega, Ramon Sanchez-Ocana, Carlos de la Serna-Higuera, Gloria Sánchez-Antolín, Manuel Perez-Miranda Journal of Clinical Medicine, 2025 Background/Objectives: Data on the natural history and endoscopic treatment outcomes of recurrent anastomotic biliary stricture (RABS) after orthotopic liver transplantation (OLT) are limited. This study aimed to evaluate the incidence and outcomes of RABS after OLT. Methods: A retrospective single-center study on OLT patients who underwent successful endoscopic treatment of ABS was conducted. The incidence of RABS, risk factors for recurrence, and outcomes of repeat endoscopic therapy were recorded. Results: A total of 131 OLT patients with ABS underwent endoscopic treatment, of which 119 successfully completed an endoscopic treatment course. After a median follow-up of 51.5 months (IQR 18.5–86.25) from ABS resolution, 26/119 patients (22.7%) developed RABS. All patients with RABS underwent a second endoscopic treatment course; 24 patients received self-expandable metal stents and 2 received plastic stents. Re-treatment was successful in 21 patients (80.8%) after a median of 8.5 months (IQR 5.25–14.50) and a total of 62 ERCPs. Adverse events occurred in two patients (7.4%)—one bacteremia and one suprastenotic biliary stricture. After a median follow-up of 65.5 months (IQR 20.75–125.5) from stent removal, only one patient had a second recurrence, which was treated with a Roux-en-Y hepaticojejunostomy. Multivariate analysis showed that older age at ABS diagnosis (OR 1.1; 95% CI: 1.1–1.2 p = 0.04) was the only independent risk factor for recurrence. Conclusions: RABS affects more than 20% of patients after successful endoscopic treatment. A second endoscopic therapy with covered self-expandable metal stents is a safe and effective option and should be considered before more invasive options.
GEMA-Na and MELD 3.0 severity scores to address sex disparities for accessing liver transplantation: a nationwide retrospective cohort study Manuel Rodríguez‐Perálvarez, Gloria de la Rosa, Antonio M. Gómez-Orellana, Maria Aguilera, Teresa Vicente, et al. Eclinicalmedicine, 2024 Background: The Gender-Equity Model for liver Allocation corrected by serum sodium (GEMA-Na) and the Model for End-stage Liver Disease 3.0 (MELD 3.0) could amend sex disparities for accessing liver transplantation (LT). We aimed to assess these inequities in Spain and to compare the performance of GEMA-Na and MELD 3.0. Methods: Nationwide cohort study including adult patients listed for a first elective LT (January 2016-December 2021). The primary outcome was mortality or delisting for sickness within the first 90 days. Independent predictors of the primary outcome were evaluated using multivariate Cox's regression with adjusted relative risks (RR) and 95% confidence intervals (95% CI). The discrimination of GEMA-Na and MELD 3.0was assessed using Harrell c-statistics (Hc). Findings: The study included 6071 patients (4697 men and 1374 women). Mortality or delisting for clinical deterioration occurred in 286 patients at 90 days (4.7%). Women had reduced access to LT (83.7% vs. 85.9%; p = 0.037) and increased risk of mortality or delisting for sickness at 90 days (adjusted RR = 1.57 [95% CI 1.09-2.28]; p = 0.017). Female sex remained as an independent risk factor when using MELD or MELD-Na but lost its significance in the presence of GEMA-Na or MELD 3.0. Among patients included for reasons other than tumours (n = 3606; 59.4%), GEMA-Na had Hc = 0.753 (95% CI 0.715-0.792), which was higher than MELD 3.0 (Hc = 0.726 [95% CI 0.686-0.767; p = 0.001), showing both models adequate calibration. Interpretation: GEMA-Na and MELD 3.0 might correct sex disparities for accessing LT, but GEMA-Na provides more accurate predictions of waiting list outcomes and could be considered the standard of care for waiting list prioritization. Funding: Instituto de Salud Carlos III, Agencia Estatal de Investigación (Spain), and European Union.
The impact of obesity on postoperative complications and short-term survival after liver transplantation Javier Tejedor-Tejada, Felix Garcia-Pajares, Rifaat Safadi, Violeta Mauriz-Barreiro, Esther Molina, Laura Juan-Casamayor, Samuel Fernández-Prada, Abdelaleem Helal, Esteban Fuentes-Valenzuela, Carmen Alonso-Martin, Carolina Almohalla-Alvarez European Journal of Gastroenterology and Hepatology, 2023 BACKGROUND AND AIMS Obesity is considered a risk factor for perioperative complications, but its effect on patients undergoing liver transplantation (LT) remains unclear. This study was conducted to analyze the impact of obesity on early morbidity and mortality risk following LT. METHODS A multicenter study of outcomes in patients submitted to LT between 2009 and 2019 was conducted. Recipients were stratified into obese (BMI ≥ 30 kg/m2) and nonobese patients (BMI < 30 kg/m2). Early postoperative complications were compared and 30-day and 1-year patient and graft survival were assessed by Kaplan-Meier method. Primary graft nonfunction (PGNF) was defined as the presence of total bilirubin > 10 mg/dl, INR > 1.6 or ALT > 2000 U/l within the first week after LT. RESULTS A total of 1608 patients were included after applying exclusion criteria, nonobese (1149, 71.46%) and obese patients (459, 28.54%). There were no significant differences in age, sex, Model for End-stage Liver Disease, Charlson comorbidity score, ethnicity, waiting list time and ischemia time. There were significantly higher rates of vascular (17.58% vs 23.53%, P = 0.021) and biliary complications (27.68% vs 35.73%, P = 0.006) and PGNF (11.40% vs 12.20%, P = 0.021) in obese patients. There was a significantly increased risk for long-term graft failure; however, there was no significant difference in patient survival after LT. CONCLUSION Obese patients have significantly increased morbidity in terms of vascular and biliary complications and PGNF after LT. They have a higher risk for worse 1-year graft survival in comparison to controls.
Esophageal necrosis secondary to thoracic aortic aneurysm Laura Juan Casamayor, Cristina Martínez Cuevas, Esteban Fuentes-Valenzuela, Carmen Alonso-Martín Revista Espanola De Enfermedades Digestivas, 2023 We present the case of a 78-year-old man with dyslipidemia with ongoing treatment with statins. He was admitted for a history of 3-month dysphagia and weight loss. The physical exam was unremarkable. Blood tests revealed anemia (hemoglobin 11,5 g/dL). Gastroscopy showed a partially stenotic bulging ulcer in the middle esophagus, with a fibrinous base and residual clot Histopathology ruled out any malignancy and confirmed the presence of transmural necrosis with infiltration of inflammatory cells. Computed tomography (CT) revealed a 11x11x12 cm thoracic aortic aneurysm, with an intramural 4 cm thrombus in the anterolateral wall. The patient was referred for urgent Vascular Surgery, but unfortunately, he presented massive hematemesis with cardiorespiratory arrest, and despite cardiopulmonary resuscitation, he died.
DRESS syndrome secondary to carbamazepine Miryam Moreta Rodríguez, Félix García-Pajares, Carolina Almohalla-Álvarez, Carmen Alonso-Martín, Antonio González López, José Pablo Miramontes-González, Javier Miguel Martín Guerra, Begoña Morejón Huerta Revista Espanola De Enfermedades Digestivas, 2023 DRESS syndrome is a multisystem disorder that appears in the context of an adverse drug reaction, characterized by fever, rash and peripheral eosinophilia with involvement of other organs such as the liver. The typical liver involvement is acute toxic hepatitis (DILI), showing improvement and a tendency to resolution when corticotherapy is started. We must not forget this manifestation in the clinical context of a DRESS syndrome.
