RESUMEN
LT has become the treatment of choice for children with end-stage liver disease. The scarcity of donors and the considerable mortality on waiting lists have propelled the related living-donor techniques, especially in small children. This population need smaller and good quality grafts and are usually candidates to receive a LLS from a related donor. Many times this grafts are still large and do not fit in the receptor's abdomen, so a further hyper-reduction may be required. Despite all advances in LT field, vascular complications still occur in a considerable proportion remaining as a significant cause of morbidity, graft loss, and mortality. Technical issues currently play an essential role in its genesis. The widely spread technique for biliary and vascular reconstruction in living donor LT (LDLT) nowadays implies removal of the portal vein (PV) clamp after the venous anastomosis, then the arterial reconstruction is done, followed by the biliary reconstruction. However, due to the posterior location of the LLS bile duct, for its reconstruction, a rotation of the liver is required risking a potential transient PV occlusion leading to thrombosis afterward. We describe a new technique that involves performing biliary reconstruction after the PV anastomosis and before removing the vascular clamp, thus allowing to freely rotate the liver with less risk of PV occlusion and thrombosis.
Asunto(s)
Conductos Biliares/cirugía , Sistema Biliar , Enfermedad Hepática en Estado Terminal/cirugía , Trasplante de Hígado/métodos , Trombosis/prevención & control , Anastomosis Quirúrgica , Peso Corporal , Preescolar , Supervivencia de Injerto , Hepatectomía/métodos , Humanos , Incidencia , Lactante , Hígado/cirugía , Donadores Vivos , Vena Porta/patología , Vena Porta/cirugía , Riesgo , Trombosis de la Vena/cirugíaRESUMEN
BACKGROUND: Percutaneous biliary balloon dilation (PBBD) stands as a safe, useful, and inexpensive treatment procedure performed on patients with benign anastomotic stricture of Roux-en-Y hepatojejunostomy (BASH). However, the optimal mode of application is still under discussion. METHODS: A retrospective cohort study was conducted including patients admitted between 2008 and 2015 with diagnosis of BASH. Patients were divided into 2 groups: group I (n = 22), included patients treated after the implementation of an institutional protocol of 3 PBBD sessions within a fixed time interval and group II (n = 24) consisted of our historical control of patients who underwent one or 2 dilation sessions. Patency at one-year post procedure was assessed with the classification proposed by Schweizer. Symptomatic response to treatment was analyzed using the Terblanche classification. RESULTS: Patients in group I exhibited more excellent/good results (90 vs. 50%, p = 0.003) and less poor results (5 vs. 42%, p = 0.005) according to the Schweizer classification and more grade I/excellent results according to Terblanche classification (p = 0.003). Additionally, group I showed lower serum total bilirubin (p = 0.001), direct bilirubin (p = 0.002), alkaline phosphatase (p = 0.322), aspartate aminotransferase (p = 0.029), and alanine aminotransferase (p = 0.006). CONCLUSION: A protocol of 3 consecutive PBBD sessions within a fixed time interval may yield a high rate of patency, with a positive clinical, biochemical, and radiological impact on patients with BASH.
Asunto(s)
Dilatación/métodos , Conducto Hepático Común/cirugía , Yeyuno/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Alanina Transaminasa/sangre , Fosfatasa Alcalina/sangre , Anastomosis Quirúrgica/efectos adversos , Aspartato Aminotransferasas/sangre , Bilirrubina/sangre , Protocolos de Ensayos Clínicos como Asunto , Constricción Patológica/sangre , Constricción Patológica/etiología , Constricción Patológica/terapia , Dilatación/efectos adversos , Femenino , Humanos , Yeyunostomía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
The treatment of biliary stenosis after pediatric LDLT is challenging. We describe an innovative technique of peripheral IHCJ for the treatment of patients with complex biliary stenosis after pediatric LDLT in whom percutaneous treatment failed. During surgery, the percutaneous biliary drainage is removed and a flexible metal stylet is introduced trough the tract. Subsequently, the most superficial aspect of the biliary tree is recognized by palpation of the stylet's round tip in the liver surface. The liver parenchyma is then transected until the bile duct is reached. A side-to-side anastomosis to the previous Roux-en-Y limb is performed over a silicone stent. Among 328 pediatric liver transplants performed between 1988 and 2015, 26 patients developed biliary stenosis. From nine patients requiring surgery, three patients who had received left lateral grafts from living-related donors due to biliary atresia were successfully treated with IHCJ. After a mean of 45.6 months, all patients are alive with normal liver morphological and function tests. The presented technique was a feasible and safe surgical option to treat selected pediatric recipients with complex biliary stenosis in whom percutaneous procedures or rehepaticojejunostomy were not possible, allowing complete resolution of cholestasis and thus avoiding liver retransplantation.
Asunto(s)
Conductos Biliares Intrahepáticos/cirugía , Procedimientos Quirúrgicos del Sistema Biliar/métodos , Colestasis Intrahepática/cirugía , Yeyuno/cirugía , Trasplante de Hígado , Donadores Vivos , Complicaciones Posoperatorias/cirugía , Anastomosis Quirúrgica/métodos , Preescolar , Colestasis Intrahepática/etiología , Femenino , Estudios de Seguimiento , Humanos , Lactante , Trasplante de Hígado/métodos , Masculino , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: We had previously described a left lateral segment hyper-reduction technique capable of sizing the graft according to the volume of the abdominal cavity of the recipient. AIM: The purpose of our study was to evaluate our 14-year live-donor liver transplantation experience with in situ graft hyper-reduction in children under 10 kg of weight. PATIENTS AND METHODS: Between January 1997 and May 2011, we performed 881 liver transplants. Two hundred and seventy-seven (n = 277) involved pediatric recipients, of which 102 (37 %) were from live donors. Thirty-five (n = 35) patients under 10 kg of weight underwent hyper-reduced living donor liver transplants. There were 21 females (60 %) and 14 males (40 %), with a median age of 12 months (range 3-23) and a median weight of 7.7 kg (range 5.6-10). RESULTS: Median operative time was 350 min (range 180-510). Median cold ischemia time was 180 min (range 60-300). Twenty-six (n = 26) patients required intraoperative transfusion of blood products. There were 49 postoperative complications involving 26 patients (74 % morbidity rate). One-, 3-, and 5-year survival rates were 87, 79, and 74 %, respectively. Twenty-eight patients are currently alive. CONCLUSIONS: Hyper-reduced grafts provide an alternative approach for low-weight pediatric recipients. The relatively high immediate postoperative morbidity could be related to the complexity of these patients.
Asunto(s)
Peso Corporal , Fallo Hepático/cirugía , Trasplante de Hígado/métodos , Hígado/patología , Argentina , Femenino , Humanos , Terapia de Inmunosupresión/métodos , Lactante , Fallo Hepático/congénito , Donadores Vivos , Masculino , Tamaño de los Órganos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Tasa de Supervivencia , Recolección de Tejidos y Órganos/métodos , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of benign disease and a few patients will develop end-stage liver disease (ESLD) requiring a liver transplant (LT). OBJECTIVE: Analyse the experience using LT as a definitive treatment of BDI in Argentina. PATIENTS AND METHODS: A national survey regarding the experience of LT for BDI. RESULTS: Sixteen out 18 centres reported a total of 19 patients. The percentage of LT for BDI from the total number of LT per period was: 1990-94 = 3.1%, 1995-99 = 1.6%, 2000-04 = 0.7% and 2005-09 = 0.2% (P < 0.001). The mean age was 45.7 ± 10.3 years (range 26-62) and 10 patients were female. The BDI occurred during cholecystectomy in 16 and 7 had vascular injuries. One patient presented with acute liver failure and the others with chronic ESLD. The median time between BDI and LT was 71 months (range 0.2-157). The mean follow-up was 8.3 years (10 months to 16.4 years). Survival at 1, 3, 5 and 10 years was 73%, 68%, 68% and 45%, respectively. CONCLUSIONS: The use of LT for the treatment of BDI declined over the review period. LT plays a role in selected cases in patients with acute liver failure and ESLD.
Asunto(s)
Conductos Biliares/lesiones , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Enfermedad Hepática en Estado Terminal/cirugía , Fallo Hepático Agudo/cirugía , Trasplante de Hígado , Adulto , Argentina , Distribución de Chi-Cuadrado , Colecistectomía/efectos adversos , Procedimientos Quirúrgicos del Sistema Digestivo/mortalidad , Enfermedad Hepática en Estado Terminal/etiología , Enfermedad Hepática en Estado Terminal/mortalidad , Femenino , Encuestas de Atención de la Salud , Hepatectomía/efectos adversos , Humanos , Enfermedad Iatrogénica , Fallo Hepático Agudo/etiología , Fallo Hepático Agudo/mortalidad , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate short- and long-term outcomes after live-donor liver transplantation (LT) with hyper-reduced grafts in low-weight pediatric recipients. LT is an established curative therapy for children with end-stage chronic liver disease or acute liver failure. A major problem in pediatric LT has been the lack of size-matched donor organs. The disadvantage of the use of large-for-size grafts is the insufficient tissue oxygenation and graft compression, which result in poor outcomes. The shortage of suitable donors is most notable in children under 10 kg. To overcome such obstacle, in situ hyper-reduced live-donor liver grafts have been introduced. Available articles in the literature are based on small samples and are deficient in long-term follow-up. METHODS: A single-cohort, retrospective analysis was conducted including 59 pediatric patients under 10 kg who underwent hyper-reduced (in situ "a la carte" left lateral segment reduction) live-donor LT (LDLT) between February 1994 and February 2018. RESULTS: The most frequent cause of liver failure was biliary atresia (70%). Median recipient weight was 8 kg. Vascular complications were confirmed in 15% of the sample, while 45% presented biliary complications. Median follow-up time was 40.3 months. Ten-year overall survival rate was 74%. Pediatric end-stage liver disease score > 23 was associated with a higher risk of post-operative complications. CONCLUSION: LDLT can be undertaken in children with body weight < 10 kg achieving good results in high-volume centers by experienced surgeons.
Asunto(s)
Enfermedad Hepática en Estado Terminal/complicaciones , Enfermedad Hepática en Estado Terminal/cirugía , Trasplante de Hígado/efectos adversos , Donadores Vivos , Complicaciones Posoperatorias/epidemiología , Delgadez/complicaciones , Peso Corporal , Enfermedad Hepática en Estado Terminal/mortalidad , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
Biliary complications after living donor liver transplantation (LDLT) cause severe morbidity and mortality, with biliary anastomotic stricture being the most common form of presentation. Surgical revision is risky, and it is avoided whenever possible. When a Roux-en-Y hepaticojejunostomy (RYHJ) is used for bilioenteric reconstruction, endoscopic approach is more difficult, if not impracticable. Therefore, percutaneous approach remains as a first-line treatment in these patients. In this case presentation, a percutaneous approach was used to recover patency in an intractable, totally occluded RYHJ stricture in an LDLT paediatric recipient, using a Rösch-Uchida needle to access to the collapsed jejunal loop from the bile duct. Once recanalization of the RYHJ was achieved, a biodegradable stent was placed with middle-term patency at follow-up.
Asunto(s)
Implantes Absorbibles , Procedimientos Endovasculares/métodos , Yeyunostomía , Trasplante de Hígado , Complicaciones Posoperatorias/cirugía , Stents , Grado de Desobstrucción Vascular/fisiología , Conductos Biliares/diagnóstico por imagen , Conductos Biliares/fisiopatología , Conductos Biliares/cirugía , Niño , Pancreatocolangiografía por Resonancia Magnética , Constricción Patológica , Femenino , Humanos , Hígado/cirugía , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/fisiopatología , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
UNLABELLED: Primary sclerosing cholangitis is frequently associated with inflammatory bowel disease. OBJECTIVE: to evaluate the evolution of IBD in patients transplanted for PSC and the incidence of severe dysplasia/carcinoma. PATIENTS AND METHODS: we included 32 patients transplanted between 1988 and 2006 for PSC. Median follow-up: 8.7 years (1-20 y). All patients were evaluated pre-OLT with colonoscopy and multiple intestinal biopsies. Post-OLT surveillance colonoscopies were performed every 12 months. RESULTS: of 32 patients included, 26 had inflammatory bowel disease pre-OLT (ulcerative colitis 25, Crohn's disease 1). 12 patients had active intestinal disease pre-OLT and 2 patients had moderate dysplasia but were not surgically treated due to the severity of their liver disease. Among the 26 patients with IBD pre-OLT, 2 died in the postoperative period due to complications related to the transplantation procedure. Among the other 24 patients, 16 had a quiescent colonic disease post-OLT. Among them, 12 had quiescent disease pre-OLT and 4 showed improvement in their colonic symptoms after transplantation. Eight patients were symptomatic pre-OLT and had a transitory improvement in their symptoms post-OLT, with worsening of their intestinal disease by 5.7 +/- 2.8 months after transplantation. Three patients developed severe dysplasia or colonic cancer. CONCLUSIONS: over half of patients transplanted for PSC presented with quiescent intestinal disease. Yet, there was a group of patients that worsened their colonic symptoms and had a high incidence of dysplasia/carcinoma. It is necessary to maintain an adequate colonic surveillance even in the absence of colonic symptoms or active disease.
Asunto(s)
Colangitis Esclerosante/cirugía , Enfermedades Inflamatorias del Intestino/etiología , Trasplante de Hígado/efectos adversos , Adulto , Colangitis Esclerosante/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Enfermedades Inflamatorias del Intestino/epidemiología , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Análisis de Supervivencia , Adulto JovenRESUMEN
BACKGROUND: Surgical treatment indications in benign and malignant hepatic tumors changed in last 20 years. Total number of hepatic resections increased in reference centers. OBJECTIVE: To evaluate complications after hepatic resections in a specific center, during a 12 months period. METHODS: Between January 2001 and January 2002, 80 patients with hepatic resection were analyzed. Mean age 55 years (r:14-79). Female: 55%. We analyze: tumor specifications, hepatic resection performed, transfusions, vascular clamping, operative time, associated procedures, length of hospital stage, postoperative complications and mortality. RESULTS: 61 patients (76.2%) were treated because of malignant pathology and 19 for benign. In 30 patients (37.5%) was made major resections and minor in 50 (62.5%). 16 patients (20%) required blood transfusions. Vascular intermittent clamping was used in 66 patients (82.5%). Associated procedures were made in 46 patients (58%). Mean operative time was 200'. Mean hospital stage: 6 days (r:3-12). Morbidity: 15 patients (18.7%). Complications were significantly higher in patients with: major hepatic resections (p: 0.002); primary hepatic tumors (p: 0.01); mean operative time more than 200' (p: 0.00007). Mortality associated with the procedure: 0%. CONCLUSIONS: 1-Hepatic resections performed in high volume centers have a low complication risk and almost with no mortality. 2-Major hepatic resection, primary malignant tumors and mean operative time more than 200', were risk factors associated with postoperative complications.
Asunto(s)
Hepatectomía/efectos adversos , Neoplasias Hepáticas/cirugía , Complicaciones Posoperatorias/epidemiología , Adolescente , Adulto , Anciano , Argentina/epidemiología , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morbilidad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients. OBJECTIVE: To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival. MATERIAL AND METHODS: Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival. RESULTS: Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis. CONCLUSIONS: Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Hepatectomía , Neoplasias Hepáticas/cirugía , Adolescente , Adulto , Anciano , Carcinoma Hepatocelular/mortalidad , Niño , Femenino , Humanos , Neoplasias Hepáticas/mortalidad , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Pronóstico , Tasa de Supervivencia , Adulto JovenRESUMEN
BACKGROUND: Although data about the incidence and management of biliary complications after deceased-donor liver transplantation (DDLT) are well defined, those pertaining to adult living-donor liver transplantation (LDLT) are conflicting. METHODS: We retrospectively compared endoscopic retrograde cholangio-pancreatography (ERCP) findings in 30 LDLT vs. 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction. LDLT and DDLT recipients were followed up for median durations of 30.5 and 36.0 months after the last ERCP, respectively. RESULTS: Postoperative biliary complications were more frequently identified at ERCP after LDLT versus DDLT (10/30 [33.3%] vs. 34/357 [9.5%]; P<0.001). Complications mainly consisted of anastomotic biliary strictures (10/30 [33.3%] vs. 27/357 [7.6%]; LDLT vs. DDLT recipients, respectively; P<0.001) and biliary leaks (4/30 [13.3%] vs. 6/357 [1.7%]; LDLT vs. DDLT recipients, respectively; P=0.005; some patients had both complications). Stricture dilation was successful in 4/10 (40%) LDLT vs. 27/27 (100%) DDLT recipients (P<0.001), and bile ducts remained patent up to the end of follow-up without further intervention in 2/10 (20.0%) vs. 21/27 (77.8%) patients, respectively (P=0.002). Endoscopic treatment of bile leaks was successful in 3/4 (75.0%) vs. 5/6 (83.3%) LDLT versus DDLT recipients, respectively (NS). CONCLUSIONS: Biliary complications were more frequent after LDLT compared with DDLT. Endoscopic treatment of anastomotic biliary strictures was successful in a minority of patients after LDLT, in contrast with DDLT. Most biliary leaks were successfully treated at endoscopy after LDLT or DDLT.
Asunto(s)
Enfermedades de las Vías Biliares/cirugía , Colangiopancreatografia Retrógrada Endoscópica , Trasplante de Hígado/efectos adversos , Donadores Vivos , Adolescente , Adulto , Anciano , Fístula Biliar/etiología , Fístula Biliar/cirugía , Enfermedades de las Vías Biliares/diagnóstico por imagen , Enfermedades de las Vías Biliares/etiología , Enfermedades de las Vías Biliares/mortalidad , Cateterismo , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Colangiopancreatografia Retrógrada Endoscópica/instrumentación , Femenino , Humanos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Stents , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI. METHODS: Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan-Meier test. RESULTS: Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24-152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively. CONCLUSION: Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.
Asunto(s)
Conductos Biliares/lesiones , Conductos Biliares/cirugía , Trasplante de Hígado , Adulto , Femenino , Humanos , Enfermedad Iatrogénica , Pruebas de Función Hepática , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Introducción La presentación, el tratamiento y el pronóstico del hepatocarcinoma dependen de la presencia o la ausencia de cirrosis. Existen pocos estudios de hepatocarcinoma en pacientes sin cirrosis. Objetivo Analizar una serie consecutiva de pacientes operados por hepatocarcinoma en hígado no cirrótico e identificar los factores de pronóstico de la recidiva y la supervivencia. Material y método Se operó a 51 pacientes entre 1990 y 2006. Se organizó una base de datos retrospectiva hasta el año 2001 y prospectiva desde esa fecha. Se evaluaron los resultados de la cirugía. Se realizaron análisis univariado y multivariado para identificar los factores asociados con la supervivencia y el tiempo libre de enfermedad. Resultados Treinta y tres pacientes eran de sexo masculino (mediana de edad de 49,8 años). Al 72,5% se le realizó una hepatectomía mayor. La mortalidad intrahospitalaria fue del 0% y la morbilidad del 43%. El tiempo de supervivencia fue del 90, el 75 y el 67% a uno, a 2 y a 3 años. El tiempo libre de enfermedad fue del 65, el 41 y el 37% a uno, a 2 y a 3 años. En el análisis univariado, la invasión vascular y la infiltración ganglionar fueron estadísticamente significativas para la supervivencia, pero ninguno de éstas fue significativa en el estudio multivariado. Conclusiones La resección hepática mayor es un tratamiento seguro para el tratamiento del hepatocarcinoma en el hígado no cirrótico. Tanto la presencia de invasión vascular como la infiltración ganglionar están estadísticamente relacionadas con la supervivencia, pero no se identificaron como factores pronósticos independientes de ésta (AU)
Background Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients. Objective To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival. Material and methods Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival. Results Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis. Conclusions Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable (AU)
Asunto(s)
Humanos , Masculino , Femenino , Niño , Adolescente , Adulto , Persona de Mediana Edad , Anciano , Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Carcinoma Hepatocelular/mortalidad , Neoplasias Hepáticas/mortalidad , Recurrencia Local de Neoplasia/epidemiología , Pronóstico , Tasa de SupervivenciaAsunto(s)
Hígado/cirugía , Trasplante de Hígado/tendencias , Argentina , Cooperación Internacional , FranciaRESUMEN
Antecedentes: La ecografía intraoperatoria (EIO) es una herramienta fundamental que asiste al cirujano en la toma de decisiones con respecto a la resecabilidad de los tumores periampulares y para la detección y guía terapéutica de los tumores neuroendocrinos del páncreas. Objetivo: Evaluar la utilidad de la ecografía intraoperatoria en patología pancreática. Lugar de aplicación: Hospital Privado de Comunidad. Diseño: Serie de casos. Retrospectivo. Material y método: En el período junio 1996 a diciembre 1999, se realizaron 64 ecografías intraoperatorias en 64 pacientes operados de páncreas. La edad promedio de la población fue de 58 años. Las patologías tratadas fueron 46 carcinomas periampulares (5 de ellos con diagnóstico preoperatorio de irresecabilidad por tomografías computadas), 12 tumores quísticos, 4 pancreatitis crónicas y 2 tumores neuroendocrinos. Resultados: EIO modificó la estrategia intraoperatoria en 44 pacientes (67,2 por ciento). En carcinomas periampulares, la EIO fue útil para comprobar la invasión portal en 37 pacientes (80,4 por ciento) 8 de ellos también presentaron metástasis hepáticas (17,4 por ciento). En tumores quísticos, en 6 pacientes se encontró criterios ecográficos de malignidad (50 por ciento). En un paciente con insulinoma pancreático la EIO demostró enfermedad multicéntrica siendo necesario realizar pancretectomía total. En pancreatitis crónica la EIO fue útil para realizar punción biopsia de ganglios paraaórticos y también para elegir el lugar apropiado para realizar quisto-gastro anastomosis. Conclusiones: EIO en patología pancreática cambió la estrategia quirúrgica en 67,2 por ciento de los pacientes. En carcinoma periampular la visión de la invasión portal fue útil para no realizar una exploración quirúrgica agresiva y para evitar maniobras riesgosas. En tumores quísticos fue útil para diferenciar lesiones benignas de lesiones maliganas. Pequeños tumores neuroendocrinos fueron localizados con este método. En pseudoquistes pancreáticos el espesor de la pared y el lugar correcto para la anastomosis pudieron ser evaluados
Asunto(s)
Humanos , Masculino , Adulto , Persona de Mediana Edad , Femenino , Neoplasias Quísticas, Mucinosas y Serosas , Tumores Neuroendocrinos , Neoplasias Pancreáticas , Pancreatitis , Seudoquiste Pancreático , Enfermedad Crónica , Cuidados Intraoperatorios , Neoplasias Quísticas, Mucinosas y Serosas , Tumores Neuroendocrinos , Páncreas , Neoplasias Pancreáticas , Pancreatitis , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Estudios Retrospectivos , Seudoquiste Pancreático/cirugía , UltrasonografíaRESUMEN
Se relata una experiencia en la ecografía peroperatoria y su utilidad en la cirugía hepatobiliar que permite una exploración directa y topográfica. Es el único método para efectuar subsegmentectomías, que son más economizadoras de parénquima hepático sin dejar de ser cancerológicamente satisfactorias. Permite de esta forma realizar exéresis en enfermos en quienes la función hepática es precaria como en los cirróticos o los portadores de una colestasis importante. Asismismo la detección ecográfica de metástasis hepáticas en la cirugía cancerológica es muy útil por sus implicancias pronósticas y terapéuticas
Asunto(s)
Humanos , Conductos Biliares/cirugía , Hígado/cirugía , Cuidados Intraoperatorios , Ultrasonografía , Neoplasias de los Conductos Biliares/diagnóstico , Colelitiasis/diagnóstico , Hipertensión Portal/diagnóstico , Neoplasias Hepáticas/diagnósticoRESUMEN
Los autores comunican las ventajas y desventajas de las distintas vias de acceso a las glandulas suprarrenales y hacen consideraciones anatomicas basadas en su experiencia que comprende el periodo 1956 a 1979
Asunto(s)
Glándulas Suprarrenales , AdrenalectomíaRESUMEN
En una serie de 112 neumonectomias por distintas lesiones, la ampliacion de la reseccion habitual se efectuo en 69 (60 por cancer del pulmon). Se considera que la via intrapericardica para la ligadura de los vasos esta indicada para subsanar accidentes operatorios o cuando la situacion anatomica (tumor o inflamacion) hace imposible o riesgosa la ligadura extrapericardica.Se describen las maniobras quirurgicas seguidas con ambas tecnicas.Las complicaciones intra o postoperatorias imputables a la via (alteraciones del ritmo, hemorragia) y los resultados obtenidos. En los ultimos 14 casos solo 1 enfermo fallecio, a pesar de que en todos se efetuaron amplias resecciones. Los autores consideran que se trata de un excelente recurso tecnico que debe ser conocido u dominado por el cirujano toracico
Asunto(s)
Neumonectomía , Neoplasias PulmonaresRESUMEN
Se presentan 7 casos de Síndrome de Budd Chiari tratados quirúrgicamente. En tres casos agudos se realizaron anastomosis meso cava latero lateral, una forma subaguda y dos crónicas fueron tratadas con trasplante hepático, y una crónica con obstrucción de vena cava se resolvió con anastomosis meso atrial. La insuficiencia hepática severa y la cirrosis fueron los indicadores del trasplante hepático como tratamiento electivo. La hipertensión portal asociada a una función hepática adecuada fue resuelta con derivaciones porto sistémicas descompresivas. La anastomosis meso cava L-L con interposición de vena fue la más utilizada. En los pacientes con coagulopatía subyacente, se asoció tratamiento anticoagulante permanente
Asunto(s)
Humanos , Masculino , Femenino , Preescolar , Adolescente , Adulto , Síndrome de Budd-Chiari/cirugía , Síndrome de Budd-Chiari/diagnóstico , Hipertensión Portal/cirugía , Insuficiencia Hepática/cirugía , Insuficiencia Hepática/etiologíaRESUMEN
Antecedentes: Los tumores benignos sólidos del hígado (TBSH) constituyen una patología poco común. La mayoría de ellos son asintomáticos y de diagnóstico accidental. Un pequeño número de pacientes sufre complicaciones entre las que se encuentran la hemorragia y la transformación maligna. Objetivo: Describir las complicaciones observadas en los pacientes operados por TBSH y analizar la conducta terapéutica y la evolución postoperatoria de este grupo de enfermos. Diseño: Estudio clínico restrospectivo. Población: De los 99 pacientes portadores de TBSH que fueron operados, 18 (18,1 por ciento) estaban complicados. En este grupo se incluyen: 6/49 (12,2 por ciento) hemangiomas, 8/21 (38,1 por ciento) adenomas, 2/16 (12,5 por ciento) hiperplasias nodulares focales, 1 hamartoma y 1 pseudotumor inflamatorio. La complicación más frecuente fue la hemorrágica (66,6 por ciento) en 3 casos por biopsias preoperatorias. Todos los pacientes con adenomas asociados a hemorragia presentaban antecedentes de ingesta de anticonceptivos orales. Además se describen 3 transformaciones malignas, 1 necrosis infectada, 1 síndrome de Kasabach Merrit y 1 síndrome de Budd Chiari. Método: Con excepción de un caso, todos los pacientes fueron resecados requiriendo de trasplante hepático en 2 oportunidades. El paciente no resecado fue sometido a laparotomía exploradora y biopsia por un hemangioma con comportamiento agresivo. El seguimiento se realizó mediante evaluación clínica y estudios por imágenes. Resultados: La morbilidad postoperatoria en los TBSH complicados fue de 4/18 (22,2 por ciento). No hubo mortalidad postoperatoria en este grupo, siendo la global de la serie de 1 por ciento (1 hemorragia cerebral por ruptura de una malformación vascular). El seguimiento alcanzó un promedio de 3,2 años (rango 1 mes-12 años). Todos los pacientes resecados se hallan libres del tumor. El paciente con el hemangioma invasivo falleció a los 26 meses del postoperatorio. Conclusiones: 1. La ingesta de anticonceptivos orales podría ser un factor importante en la parición de complicaciones hemorrágicas en pacientes con adenomas hepáticos. 2. La malignización es una complicación a tener en cuenta en los adenomas y las hiperplasias nodulares focales. 3. Deben sospecharse patologías cerebrales asociadas en pacientes con tumores hepáticos benignos. 4. Debe evitarse la biopsia hepática que no modifica la conducta terapéutica, ya que puede precipitar una complicación...