[Quality standards in liver surgery: influence of multidisciplinary team work and patient centralization]. / Indicadores de calidad en cirugía hepatica: influencia del trabajo en equipo multidisciplinario y del "efecto centro".

BACKGROUND: Multidisciplinary team work and centralization of health care in specialized teams, improves outcomes and quality of assistance in medical practice. OBJECTIVES: To describe the evolution of surgical and anesthetic practice and outcomes during a period of improving team work and centralization of liver surgery. METHODS: A retrospective descriptive study of the type of surgery, anesthesia practice, outcomes and hospitalization was performed in 68 patients that underwent major hepatic surgery in our service, between Febriary 2004 and December 2007. RESULTS: Fifty-one patients (75%) had hydatid liver disease. Ten surgeries (15%) were categorized as major; 20 (29%) as minor and 38 (56%) as hydatidic cystectomy. The number of surgeries tends to increase by year: 2004 (n = 13); 2005 (n = 14); 2006 (n = 18); 2007 (n = 23). An 87% of the anesthetics techniques were combined: epidural-general (n = 49; 72%) and spinal-general (n = 10O; 15%). The use of thoracic epidural was 0% in 2004 and 59% in 2007. A 62% of the cases bled less than 500 mL and 28% of the patients were transfused. The transfused volume in those patients (1,120 +/- 618mL) was 12% of the mean volume documented in 1998 in the same surgical service. There were no re-interventions or mortality. An 85% of the patients were admitted to the intensive care unit (ICU) for postoperative care in 2004 compared with only 22% in 2007. An 80% of the patients were discharged fom the hospital in the first 8 days after surgery (the majority by the fourth day). CONCLUSIONS: Our multidisciplinary approach and teamwork may have positively influenced quality standards in liver surgery by diminishing transfusions of blood products and utilization of ICU resources.

Hepatectomía derecha de urgencia por necrosis hepática infectada secundaria a colangiografía endoscópica / Urgent right hepatectomy for infected hepatic necrosis secondary to endoscopic cholangiography

RESUMEN El hematoma subcapsular hepático es una complicación infrecuente pero potencialmente grave de la colangiografía retrógrada endoscópica. Por otra parte, las complicaciones derivadas del hematoma pueden ser su rotura, con el consiguiente sangrado masivo, y/o la trombosis portal por compresión que evolucione hacia la necrosis, la cual es susceptible de infecciones generalmente graves que requieren un manejo más enérgico. Presentamos el caso de una paciente a quien se le realizó una colangiografía endoscópica retrógrada por una colangitis aguda, y presentó en la evolución un hematoma subcapsular, que progresó a la necrosis hepática por compresión del pedículo portal, y una infección de esa necrosis, por lo que requirió una hepatectomía derecha de urgencia.

ABSTRACT Hepatic subcapsular hematoma is a rare but potentially lethal complication of endoscopic retrograde cholangiography. On the other hand, complications derived from the hematoma can be its rupture with the consequent massive bleeding, and/or portal thrombosis due to compression that evolves towards necrosis, which is susceptible to generally serious infections that require more aggressive management. We present the case of a patient treated in our department who underwent retrograde endoscopic cholangiography as treatment for her acute cholangitis, presenting in the evolution a subcapsular hematoma that progressed to hepatic necrosis due to compression of the portal pedicle and later an infection of that necrosis. requiring an emergency right hepatectomy as surgical treatment.

Quiste epidermoide de bazo / Splenic epidermoid cyst

Los quistes de bazo, entre ellos los quistes epidermoides, son una patología infrecuente, la cual ha aumentado su incidencia en los últimos años por el desarrollo de la imagenología. Las indicaciones y la táctica quirúrgica para seguir son motivo de controversia. La indicación de cirugía habitualmente se da por el tamaño, debido al potencial riesgo de infección, la rotura por traumatismos, el sangrado intraquístico, o en caso de presentarse el posible diagnóstico de quiste hidático esplénico. Presentamos el caso clínico de una paciente tratada en nuestro Servicio, quien fue sometida a una esplenectomía laparoscópica por un quiste esplénico, que se sospechaba fuera hidático. Sin embargo, del análisis patológico surgió que era un quiste epidermoide.

Splenic cysts, including epidermoid cysts, are rare disease; its incidence has increased in recent years as a result of the development of diagnostic imaging. The indications and surgical approach are controversial. Surgery is usually indicated on the basis of the size, due to the potential risk of infection, rupture due to trauma, intracystic bleeding, or possible diagnosis of splenic hydatid cyst. We report the clinical case of a female patient treated in our Service, who underwent laparoscopic splenectomy to remove a splenic cyst suspected to be hydatid. However, the pathological analysis revealed an epidermoid cyst.

Fístula hepatobronquial: una rara complicación de un absceso hepático / Hepatobronchial fistula: A rare complication of liver abscess

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Cistoadenocarcinoma primario: excepcional etiología de un tumor quístico retroperitoneal. Primera comunicación nacional / Primary cystoadenocarcinoma exceptional etiology of a cystic retroperitoneal tumor

El cistoadenocarcinoma primario retroperitoneal es una enfermedad excepcional, siendo este el primer caso publicado en la literatura nacional. Su diagnóstico, en la totalidad de los casoscomunicados, es anatomopatológico luego del estudio definitivo de la pieza. Es debatida la extensión de la resección quirúrgica en caso de no existir compromiso de estructuras vecinas. Eltratamiento adyuvante se justifica cuando se produce la rotura de la tumoración o existe compromiso locorregional. Se presenta el caso clínico de una paciente de 29 años que consultó por dolor en flanco derecho,en la cual se constató una tumoración a dicho nivel. Tomográficamente se confirmó la existencia de un proceso quístico, al cual se le realizó la excéresis quirúrgica completa junto a un sector depared abdominal. El informe de anatomía patológica confirmó un cistoadenocarcinoma primario retroperitoneal. No se realizó tratamiento adyuvante, presentando buena evolución a 11 meses de la cirugía, sin evidencias de enfermedad.

Primary retroperitoneal cystoadenocarcinoma is an exceptionaldisease, being this the first case Publisher in the national literature.Diagnosis, in all of the cases reported is anatomopathological, anatomopathological, subsequent to the final study of the sample. Surgicalresection extension is debated if there is no compromise of neighboring structures. Adjuvant treatment is justified when the tumor is broken or there is locoregional compromise.We present the clinical case of a 29 year old patient who consulted for right lank pain, where a tumor was identified.Ultrasound confirmed the existence of a cystic process, and complete surgical abscission/exeresis was performednext to an area in the in the abdominal wall. Anatomopathological report confirmed a primaruy retroperitonealcistoadenocarcinoma. No adjuvant treatment was applied, evolution was good 11 months after surgery, no evidence of the disease.

O cistoadenocarcinoma primário retroperitoneal é uma doença rara, sendo este o primeiro caso publicado na literatura nacional. Em todos os casos publicados seu diagnóstico foi realizado por anatomia patológica do examedefinitivo do material. A extensão da resecção cirúrgica quando não se observa compromisso das estruturas próximas é motivo de debate. O tratamento adjuvante é justificadoquando há ruptura do tumor ou se registra compromisso regional.Descreve-se o caso clínico de uma paciente de 29 anos que consultou por dor no flanco direito onde se constatoua presença de uma tumoração. Uma tomografia computada confirmou a existência de um processo cístico, que foi ressecado completamentejuntamente com um setor da parede abdominal. O exame de anatomia patológica confirmou um cistoadenocarcinoma primário retroperitoneal. A paciente não recebeu tratamento adjuvante apresentadoboa evolução 11 meses depois da cirurgia, sem evidências de patologia.