Pathophysiology of ascites: The importance of the intestine. A surgical contribution to the understanding of a medical problem.

The understanding of the mechanisms for the development of ascites has evolved over the years, involving the liver, peritoneum, heart, and kidneys as key responsible for its formation. In this article, we review the pathophysiology of ascites formation, introducing the role of the intestine as a major responsible for ascites production through "a game changer" case.

Serie de casos de sangrado intraluminal postoperatorio en colectomía izquierda / Case series of postoperative intraluminal bleeding in left colectomy

Introducción: El sangrado digestivo intraluminal postoperatorio es una entidad poco frecuente y su manifestación clínica no difiere de la hemorragia digestiva baja de otra etiología. A pesar de que su presentación más habitual es la hematoquecia autolimitada en la primera deposición, en un discreto porcentaje puede requerir transfusiones, tratamiento endoscópico, hemodinámico, o incluso cirugía. Objetivo: Analizar los pacientes con sangrado digestivo intraluminal postoperatorio tratados en un centro de alta complejidad y realizar una revisión bibliográfica del tema. Diseño: Estudio retrospectivo, descriptivo. Material y métodos: Pacientes con sangrado anastomótico durante el post operatorio inmediato de una colectomía izquierda, operados en el Servicio de Cirugía General y Coloproctología desde enero del 2017 a diciembre del 2021. Las variables estudiadas fueron edad, sexo, anticoagulación y su causa, descenso de hemoglobina, cirugía realizada y su indicación, vía de abordaje, configuración de la anastomosis, electividad de la cirugía, complicaciones, días de internación y manejo terapéutico. Resultados: Se incluyeron 4 pacientes con una edad media de 72 (rango 54-87) años y una distribución por sexo de 1:1. En todos la colectomía izquierda fue programada y en 3 el abordaje fue laparoscópico. La anastomosis fue termino-terminal con sutura mecánica circular. Todos los pacientes presentaron sangrado en las primeras 24 horas postoperatorias. El tratamiento fue decidido de acuerdo a la condición hemodinámica: en los 2 pacientes con estabilidad hemodinámica fue suficiente el tratamiento conservador con reanimación y transfusiones. Los otros 2 que presentaron inestabilidad hemodinámica requirieron manejo intervencionista con endoscopía rígida, videocolonoscopía y cirugía. Conclusión: El sangrado intraluminal es una complicación poco frecuente de la anastomosis colorrectal que requiere manejo intervencionista solo en los pacientes que presentan inestabilidad hemodinámica. (AU)

Introduction: Postoperative intraluminal gastrointestinal bleeding is a rare entity and its clinical manifestation does not differ from lower gastro-intestinal bleeding of another etiology. Despite the fact that its most common presentation is self-limited hematochezia at the first stool, in a small percentage it may require transfusions, endoscopic or hemodynamic management, or even surgery. Aim: To analyze the patients with postoperative intraluminal gastrointestinal bleeding treated in a tertiary center and to carry out a bibliographic review of the subject. Design: Retrospective descriptive study. Material and methods: Patients with immediate postoperative anastomotic bleeding from a left colectomy, operated on at the General Surgery and Coloproctology Service from January 2017 to December 2021 were included. The variables recorded were age, sex, anticoagulation and its cause, decrease in hemoglobin, procedure performed and its indication, surgical approach, type of anastomosis, electiveness of surgery, complications, hospital stay and management. Results: Four patients with a mean age of 72 (range 54-87) years and a 1:1 gender distribution were included. All procedures were elective and 3 laparoscopic. All anastomoses were performed end-to-end with a circular stapler. All patients presented bleeding in the first 24 postoperative hours. The treatment was decided according to the hemodynamic condition; patients with hemodynamic stability (2) received medical treatment while those with hemodynamic instability (2) required interventional management with rigid endoscopy, colonoscopy and surgery. Conclusion: Intraluminal bleeding is a rare complication of colorectal anastomosis that requires interventional management only in patients with hemodynamic instability. (AU)

Resección hepática laparoscópica versus hepatectomía abierta para lesiones benignas: estudio comparativo con propensity score matching / Laparoscopic liver resection versus open liver resection for benign lesions: a comparative study with propensity score matching

RESUMEN Antecedentes : las ventajas de la hepatectomía videolaparoscópica (HVL) hicieron que gane cada vez más campo para el tratamiento de los tumores hepáticos benignos (THB). Objetivo : comparar los resultados perioperatorios de pacientes sometidos a HVL con los de los operados con hepatectomía abierta (HA) por THB, emparejados con propensity score matching (PSM). Material y métodos : estudio descriptivo, retrospectivo y comparativo de HA y HVL por THB entre agosto de 2010 y junio de 2021. Se analizaron variables demográficas, preoperatorias, intraoperatorias y posoperatorias. Para evitar sesgos de las distintas covariables entre los grupos se realizó un PSM 1:1. Resultados : de 403 hepatectomías, se analizaron 82 por THB. De ellas 36 (44%) fueron HA y 46 (56%) HVL. Edad media 45 ±14 años, 65% mujeres. Tras realizar el PSM, quedaron dos grupos de 28 pacientes cada uno. En HA, 5 (18%) pacientes requirieron transfusiones y ninguno en HVL (p = 0,01). Las complicaciones mayores se presentaron en 4 (14%) pacientes en HA, y ninguna en HVL (p = 0,03). Se reoperaron 4 (14%) pacientes con HA y ningún paciente con HVL (p = 0,03). La estadía hospitalaria total fue significativamente mayor en las HA (p = 0,04). No se registraron muertes a los 90 días en ninguno de los dos grupos. Conclusión : la HVL por THB es una técnica segura y eficaz, ya que los pacientes presentaron menor requerimiento transfusional, número de reoperaciones, de complicaciones mayores y de estadía hospitalaria que con HA. Por las ventajas encontradas, la HVL podría ser considerada la técnica de elección en cirugía por THB.

ABSTRACT Background : The advantages of laparoscopic liver resection (LLR) have increased its use for the treatment of benign liver tumors (BLTs). Objective : The aim of this study was to compare the perioperative outcomes of patients undergoing LLR with those operated on with open liver resection (OLR) for BLTs using propensity score matching (PSM). Material and methods : We conducted a descriptive and retrospective study comparing OLRs with LLRs performed between August 2010 and June 2021. The demographic, perioperative, intraoperative and postoperative variables were analyzed. We used PSM with 1:1 matching to avoid biases of the different covariates between the groups. Results : Of 303 liver resections, 82 corresponded to BLTs and were included in the analysis; 36 (44%) were OLRs and 46 (56%) were LLRs. Mean age was 45 ±14 years and 65% were women. After PSM, two groups of 28 patients each were constituted. Five patients (18%) in the OLR group and none in the LLR required transfusions (p = 0.01). Major complications, occurred in 4 (14%) patients in the OLR group and in no cases in the LLR group (p = 0.03). Four (14%) undergoing OLR required reoperation versus no patients with LLR (p = 0.03). Total length of hospital stay was significantly longer in OLR (p = 0.04). There were no deaths in any of the groups within 90 days. Conclusion : LLR for BLTs is a safe and effective technique, with lower requirement for transfusions, fewer reoperations and major complications and shorter length of hospital stay than OLR, Therefore, LLR could be considered the surgical technique of choice for BLTs.

Induction Versus Maintenance Immunosuppression After Intestinal Transplant: Determining Which Treatment Most Impacts Long-Term Patient And Graft Survival.

OBJECTIVES: Immunosuppressive strategies for intestinal transplant have changed over time. However, specific intestinal transplant-oriented protocols and reports on long-term maintenance regimens are scarce. Our objective was to evaluate the impact of 2 different initial immunosuppressive protocols based on thymoglobulin (group A) and basiliximab (anti-interleukin 2 antibody) (group B) and of changes to maintenance immunosuppression over long-term follow-up in intestinal transplant recipients. MATERIALS AND METHODS: We performed a retrospective analysis of a prospectively established protocol for intestinal transplant immunosuppression, conducted between May 2006 and December 2020. We analyzed 51 intestinal transplant recipients, with 6 patients excluded because of early death or graft loss. Acute cellular rejection frequency and grade, number of acute cellular rejection episodes, time to the first acute cellular rejection episode, response to treatment, number of patients who progressed to chronic allograft rejection, kidney function, infections, incidence of posttransplant lymphoproliferative disorder and graft-versus-host disease, and patient and graft survival were analyzed. RESULTS: In the study groups, there were 87 acute cellular rejection episodes in 45 patients (33 in group A and 54 in group B). We found degree of acute cellular rejection to be mild in 45 patients, moderate in 18, and severe in 24 (not significant between groups). Our comparison of induction therapy (thymoglobulin [group A] vs interleukin 2 antibody [group B]) did not show any statistical difference during clinical followup. Long-term review showed that all patients were on tacrolimus. Five-year patient and graft survival rates were 62% and 45% for group A and 54% and 46% for group B, respectively (not significant). CONCLUSIONS: Long-term patient and graft outcomes reflected the use of an individualized follow-up with adjustments and changes in immunosuppressive medications according to the patient's clinical course and complications rather than based on the induction immunosuppressive protocol used.

Non-conventional vascular accesses for the management of superior vena cava syndrome in patients with Intestinal Failure. Case series and systematic review.

BACKGROUND: Type III Intestinal Failure (IF) is a devastating clinical condition.characterized by the inability of the gut to absorb necessary macronutrients, and/or water and electrolytes, requiring Parenteral Nutrition (PN) as chronic therapy. Long-term PN may lead to life-threatening complications; the loss of central venous access (LCVA) is the most frequent and challenging. To date, few studies in the literature have reported the relevance of Non-conventional Vascular Accesses (NCVA) in the management IF as part of the comprehensive multidisciplinary care. METHODS: A retrospective analysis of a database collected from January 2006 to December 2019 was performed using SPSS v25.0 for statistical analysis, followed by a systematic review, using the PRISMA.methodology RESULTS: From January 2006 to December 2019, 184 NCVA were placed in 71 patients with LCVA as IF-related complication; 173 were placed in 61 patients by interventional radiology (IR) and 11 NCVA were placed in 10 patients by the surgical team during the intestinal transplant (ITx) operation. From the 173 IR procedures 166 (95.9%) were successful with 3 ± 2.7 procedures/patient; average catheter permanence rate was 738.68 ± 997 days; complications related to the procedures occurred in 18/173 (10.4%), including two deaths. On the other hand, among the 11 NCVA implanted by the surgical team, 7 (64%) were successful and were safely withdrawn 30 days after ITx when were no longer needed; 2 (18%) catheters malfunctioned during the first week and could not be further used, and 1 was accidently removed; average catheter permanence rate was 26 ± 4 days. There was one complication (9%) requiring laparotomy; there was no mortality associated the procedure in this group. A systematic review was conducted to evaluate the success and safety of NCVA as part of the treatment of HPN-related complications; from 337,542 papers, 14 studies were included. A total of 28 HPN-patients with LCVA received NCVA; 34 procedures were successfully performed, while procedure-related complications were reported in 11.7%, as well as one death. CONCLUSIONS: The data analyzed show that NCVAs may be successfully placed by expert teams, allowing to sustain long-term PN, as well as increasing the Intestinal Transplantation applicability for candidates in the extreme need of vascular access.

Experiencia inicial en hepatectomías videolaparoscópicas / Initial experience in laparoscopic liver resections

RESUMEN Antecedentes: La cirugía hepática videolaparoscópica ha experimentado un importante desarrollo; sin embargo, la mayoría de las hepatectomías continúan haciéndose por vía convencional. Objetivo: presentar la experiencia y aplicabilidad de hepatectomías videolaparoscópicas. Material y métodos: análisis retrospectivo de pacientes sometidos a una hepatectomía entre agosto de 2010 y diciembre de 2019. Analizamos variables preoperatorias, intraoperatorias y posoperatorias. Para evaluar la aplicabilidad, se dividió la muestra en: Etapa 1: agosto de 2010 a diciembre de 2013; Etapa 2: enero de 2014 a diciembre de 2016, Etapa 3: enero de 2017 a diciembre de 2019. Resultados: de 385 hepatectomías realizadas, 119 fueron videolaparoscópicas: 53 (44%) fueron to talmente laparoscópicas, 64 (54%) mano-asistidas y 2 híbridas. La aplicabilidad global fue 31%. En la etapa 1: 23% , en la 2: 30% y en la 3: 44% (p < 0,05). Fueron patología maligna en la etapa 1: 36%, en la 2: 67% y en la 3: 72% (p < 0,05). Hepatectomías mayores: 13%, 31% y 32% en etapas 1, 2, y 3, respectivamente (p < 0,05). El índice de conversión fue 12%, 0% y 11%, respectivamente (p NS). Se utilizó clampeo pedicular en: 6%, 5% y 45%; (p < 0,05). Las complicaciones en la etapa 1 fueron 30%, en la 2: 28% y en la 3: 17%, siendo complicaciones Dindo-Clavien III o más, el 6%, 13% y 5%, respectivamente, p NS. Conclusiones: Aa pesar de su complejidad, las hepatectomías videolaparoscópicas son técnicamente reproducibles. Adquiriendo experiencia, podemos aumentar la aplicabilidad, a favor de la patología oncológica y complejidad, sin comprometer la seguridad del paciente.

ABSTRACT Background: Despite laparoscopic liver resection has significantly evolved, most hepatectomies are performed by the conventional approach. Objective: The aim of this study is to present the initial experience and applicability of laparoscopic liver resections. Material and methods: We conducted a retrospective analysis of patients undergoing liver resection between August 2010 and December 2019. Perioperative, intraoperative and postoperative variables were analyzed. To evaluate applicability, the sample was divided into 3 stages: stage 1, from August 2010 to December 2013; stage 2, from January 2014 to December 2016; and stage 3, from January 2017 to December 2019. Results: Of 385 liver resections performed, 119 were laparoscopic procedures: 53 (44%) were pure laparoscopic procedures, 64 (54%) were hand-assisted (64 patients) and 2 corresponded to hybrid procedures. Global applicability was 31%. In stage 1 1: 23%, in 2: 30% and in 3: 44% (p < 0.05). Malignant lesions: stage 1: 36%, stage 2: 67% and stage 3: 72% (p < 0.05). Major liver resections: 13%, 31% and 32% in stages 1, 2, and 3, respectively (p < 0.05). Conversion rate was 12%, 0% and 11%, respectively (p NS). Hepatic pedicle clamping was used in 6%, 5% and 45%; (p < 0.05). Complications in stage 1 were 30%, in stage 2: 28% and in stage 3: 17%, and Clavien-Dindo complications grade 3 or greater were 6%, 13% and 5%, respectively, p NS. Conclusions: Laparoscopic liver resections are complex procedures but technically reproducible. Applicability increases with the acquisition of experience, not only in malignant lesions but also in complex lesions ensuring safety for the patient.

Neoplasia papilomucinosa intraductal de páncreas: experiencia a 10 años, en un único centro / Intraductal papillary mucinous neoplasm of the pancreas: A 10-year experience at a single center

RESUMEN Antecedentes: Debido a la mejoría de los métodos diagnósticos, la incidencia de la neoplasia papilar mucinosa intraductal del páncreas (NPMI) ha aumentado en los últimos años. Objetivo: Presentar la experiencia en el manejo alejado de pacientes con NPMI en un centro de referencia. Material y métodos : Se realizó análisis retrospectivo de pacientes que consultaron al Servicio de Ci rugía General y HPB del Hospital Universitario Fundación Favaloro, por patología pancreática tumo ral entre enero de 2010 y diciembre de 2019. Los pacientes se clasificaron en 2 grupos: A) aquellos con diagnóstico en consultorio de NPMI y B) aquellos en los que la NPMI fue un hallazgo en la pieza quirúrgica (B). Resultados: Ochenta y seis pacientes fueron analizados: 79 (90%) se incluyeron en el grupo A y 7 en el grupo B. De los pacientes del grupo A, en 57 casos (66%) se decidió conducta expectante y seguimiento (AS). De los 22 pacientes restantes, 18 fueron operados (29%) (AC) y 4 tienen la cirugía pendiente. Para el grupo A, la supervivencia a los 5 años fue de 89% para el grupo AS, de 86% en grupo AC, y del 43% para el grupo B (Breslow 0,001, Log-Rank 0,001 vs. grupo A). Conclusión: El diagnóstico y manejo de la NPMI está hoy estandarizado, en las tipo I y III está indicada cirugía, la tipo II debe seguirse por riesgo de malignización; cuando se le indica cirugía, la supervivencia a largo plazo debe ser similar a la del grupo en seguimiento.

ABSTRACT Background: The incidence of intraductal papillary mucinous neoplasm (IPMN) of the pancreas has increased over the past years along with the development of diagnostic imaging tests. Objective: The aim of this study is to describe our experience on long-term management of patients with IPMNs in a reference center. Material and methods: We conducted a retrospective and descriptive analysis of patients with pancreatic neoplasms followed-up at the Department of General Surgery and Hepato-Biliary Surgery, Hospital Universitario Fundación Favaloro, between January 2010 and December 2019. The patients were classified into 2 groups: group A (diagnosis of IPMN made in the outpatient clinic), and group B (diagnosis of IPMN in the pathological examination). Results: Eighty-six patients were analyzed: 79 (90%) in group A and 7 in group B. In group A, a watchful waiting with monitoring (AM) was decided in 57 cases (66%). Of the remaining 22 patients, 18 (29%) patients underwent surgery (AS) and 4 are waiting for surgery. Survival at 5 years was 89% in group AM, 86% in group AS and 43% in group B (Breslow 0.001, log-rank test 0,001 vs. group A). Conclusion : The diagnosis and management of IPMNs is currently standardized. Surgery is indicated in MD-IPMN and mixed type IPMN. Patients with BD-IPMN type should be monitored due to the risk of malignant transformation. When surgery is indicated, long-term survival should be similar to that of the surveillance group.

A Novel Surgical Technique to Assure Donor and Recipient Safety: Pyloric to Segment 4 Arterial Reconstruction.

BACKGROUND: Strategies to extend the pool of organs include and promote the use of segmental liver grafts. While performing a living donor left lateral segment (LLS) liver transplant and in split procedures, the hepatic artery´s division becomes critical when a dominant segment 4 artery (S4A) emerges from the left hepatic artery (LHA). We aim to describe a novel technique that consists of performing microsurgical reconstruction from the pyloric artery (PA) to S4A. CASE REPORTS: A 45-y-old living donor was evaluated to use his LLS as a graft for a pediatric recipient. During the procedure, a dominant S4A born from the LHA was dissected. To obtain an appropriate LHA length and diameter for the recipient, it was necessary to transect it. An extended right lobe split graft was used in a 61-y-old patient. The S4A born from LHA had to be sectioned during the split procedure. In both cases, segment 4 remained incompletely perfused. The PA was dissected with enough length to be rotated, to perform a microsurgical anastomosis to the S4A, recovering parenchyma's color and Doppler signal while vascular permeability was demonstrated using CT scan. There was no biliary or cut surface complication. CONCLUSIONS: PA to S4A reconstruction is a simple and novel technique that can be used for LLS and extended right lobe split graft and might contribute to increase donor selection and reduce living donor and recipient S4A-related complications.

Tumor papilar sólido-quístico pancreático / Solid pseudopapillary tumor of the pancreas

RESUMEN Antecedentes: la neoplasia sólida pseudopapilar del páncreas es una entidad rara, que típicamente se presenta en mujeres jóvenes. Suele presentar síntomas abdominales inespecíficos. Es un tumor maligno de bajo grado de malignidad. Objetivos : el objetivo del siguiente informe de serie de casos es presentar 9 casos tratados en un cen tro y realizar una revisión bibliográfica del tema. Material y métodos: estudio retrospectivo descriptivo de los casos con diagnóstico anatomopatoló gico de neoplasia sólida pseudopapilar en el Servicio de Cirugía General, desde febrero de 2013 hasta septiembre de 2019. Se contemplaron como variables: edad, sexo, localización del tumor, tratamiento quirúrgico realizado, tiempo operatorio, complicaciones, estancia hospitalaria y seguimiento alejado. Resultados: fueron 9 casos, todos de sexo femenino con media de edad de 30 años (rango 20 a 70 años). La localización más frecuente fue en cola de páncreas en 4 casos (45%). Todas las pacientes fueron sometidas a cirugía, con abordaje laparoscópico en el 60% de los casos (n = 5); la resección pancreática distal con preservación esplénica fue la conducta más utilizada (n = 6). Se constataron tres complicaciones, de las cuales dos fueron colecciones abdominales como consecuencia de una fístula pancreática que se abordaron por vía percutánea, y la restante fue un retardo del vaciamiento gástrico por lo cual la paciente requirió internación prolongada. Conclusión: la neoplasia sólida pseudopapilar pancreática es una enfermedad poco frecuente, ma ligna pero con bajo riesgo de malignidad. Presenta buena sobrevida cuando se somete a cirugía de carácter curativo; la laparoscopia es la vía de abordaje de elección en centros con experiencia.

ABSTRACT Background: Solid pseudopapillary tumor of the pancreas is a rare condition that affects young women. The most common symptom is unspecific abdominal pain. It is a malignant tumor of low malignant potential. Objective: The aim of this study is to report a case series of patients treated in a single center and perform a bibliographic review. Material and methods: We conducted a retrospective study of the cases with pathological diagnosis of solid pseudopapillary tumor of the pancreas treated in the Department of General Surgery between February 2013 and September 2019. The following variables were analyzed; age, sex, tumor location, surgical treatment, operative time, complications, length of hospital stay and long-term follow-up. Results: Nine patients were included; all of them were women with mean age of 30 years (range: 20 - 70 years). The most common location of the tumor was the tail of the pancreas (n = 4; 45%). Surgery was performed in all the cases; five cases underwent video-assisted laparoscopy and spleen-preserving distal pancreatectomy was the technique more commonly used (n = 6). Three complications were recorded: two abdominal collections due to biliary leaks were trated by percutaneous approach and the other patient presented delayed gastric emptying and required prolonged hospitalization. Conclusion: Solid pseudopapillary tumor pf the pancreas is a rare low-grade malignant neoplasm. The prognosis is favorable after surgery and laparoscopy is the preferred approach in centers with experience.

Results of Surgical and Medical Rehabilitation for Adult Patients With Type III Intestinal Failure in a Comprehensive Unit Today: Building a New Model to Predict Parenteral Nutrition Independency.

BACKGROUND: Short-bowel syndrome remains the primary cause of intestinal failure (IF) in adult patients. We aim to report the long-term results of medical and surgical rehabilitation in a cohort of patients with type III IF (III-IF) and develop a formula to predict parenteral nutrition (PN) independency. METHODS: We used a retrospective analysis of a prospective database for III-IF patients undergoing autologous gastrointestinal reconstruction surgery (AGIRS) from March 2006 to August 2018. Analyzed variables included demographic data, postsurgical intestinal length (PSIL), postsurgical anatomy, teduglutide (TED) treatment, and PN volume reduction. Univariate analysis, Cox regression, logistic regression forward stepwise models, and receiver operating characteristic (ROC) curve were done using SPSS v20. RESULTS: AGIRS was performed in 88 patients. The most frequent anatomy at first visit was type 1. Prevailing anatomy after surgery was type 3. Eight patients started TED; 6 achieved freedom from PN. At a mean follow-up time of 1606.1 ± 1190.25 days, freedom from PN survival was achieved in 83%. Variables identified at the logistic regression analysis led to a novel formula to predict intestinal rehabilitation, including PSIL, presence of ileocecal valve, and use of TED as part of postsurgical treatment. CONCLUSIONS: AGIRS in this group of patients enabled intestinal length increase and also intestinal anatomy conversion into a more favorable type for intestinal rehabilitation. TED treatment was useful to discontinue PN in patients with classical negative anatomical predictors. The novel predicting formula has an ROC area under the curve = 0.82. Further studies are necessary to validate this formula.

Factibilidad de la bipartición hepática derecha-izquierda in situ en el trasplante Hepático / Feasibility of in situ full-right full-left split liver transplantation

Debido a la falta de órganos para trasplantes se han desarrollado diferentes alternativas quirúrgicas, como la bipartición hepática (BH) y los trasplantes hepáticos con donantes vivos. En la BH clásica, de la división de un hígado de donante cadavérico se obtienen dos injertos, uno correspondiente a los segmentos 2-3 y otro a los segmentos 1, 4-8. Para poder utilizar los injertos de una BH, en pacientes adultos, se puede realizar una BH derecha/izquierda típica, donde se obtienen un injerto derecho (segmentos 5-8) y otro izquierdo (segmentos 1-4). La BH se puede realizar en el momento de la ablación (BH in situ) o en la cirugía de banco (BH ex situ). En este trabajo informamos el primer caso de BH in situ derecha/izquierda típica de la Argentina, resaltando los detalles de la cirugía del donante y del receptor.

Due to the shortage of organs for transplantation, different surgical alternatives have been developed, as split liver transplantation (SLT) and living-donor liver transplantation. In classical SLT, the liver of a cadaveric donor is divided and two allografts are obtained, one corresponding to segments 2-3 and the other to segments 1, 4-8. In order to produce two grafts from one liver for two adult recipients, splitting of the liver can create a right graft including segments 5-8 and a left graft with segments 1-4. Splitting of the liver can be performed during procurement (in situ) or on the bench (ex situ). The aim of our study is to describe the first case of in situ full-right full-left split liver transplantation, with focus on donor and recipient surgery.

Unusual spontaneous porto-systemic shunt: The importance of diagnosing non-anatomical porto-systemic shunts to improve portal flow in pediatric living-related liver transplantation. Case report.

Collateral circulation secondary to liver cirrhosis may cause the development of large PSSs that may steal flow from the main portal circulation. It is important to identify these shunts prior to, or during the transplant surgery because they might cause an insufficient portal flow to the implanted graft. There are few reports of "steal flow syndrome" cases in pediatrics, even in biliary atresia patients that may have portal hypoplasia as an associated malformation. We present a 12-month-old female who received an uneventful LDLT from her mother, and the GRWR was 4.8. During the early post-operative period, she became hemodynamically unstable, developed ascites, and altered LFT. The post-operative ultrasound identified reversed portal flow, finding a non-anatomical PSS. A 3D CT scan confirmed the presence of a mesocaval shunt through the territory of the right gonadal vein, draining into the right iliac vein, with no portal inflow into the liver. The patient was re-operated, and the shunt was ligated. An intraoperative Doppler ultrasound showed adequate portal inflow after the procedure; the patient evolved satisfactorily and was discharged home on day number 49. The aim was to report a case of post-operative steal syndrome in a pediatric recipient due to a mesocaval shunt not diagnosed during the pretransplant evaluation.

Avances en Gastroenterología Trasplante intestinal desde la clínica a la investigación traslacional: contribuciones de una unidad integral de insuficiencia intestinal, rehabilitación y trasplante. Seguimiento biomédico del proceso de trasplante intestinal y su correlación con los distintos eventos fisiopatológicos que atraviesa el paciente.

One of the greatest achievements in gastroenterology and surgery of the last 50 years has been the capability to transplant different abdominal organs of the digestive system separately or as a whole. The complexity of the intestinal transplantation demands a multidisciplinary team engaged in the management of patients with intestinal failure responsible for defining the need for nutritional support, rehabilitation, or intestinal transplantation. This team should include a basic research area to provide answers to unresolved clinical problems. The aim of this work is to update the current status of intestinal transplantation, and to show the progress and results of our center; emphasizing our achievements in the clinical area, and the contributions of the translational research and mucosal immunology studies as part of the integral unit of intestinal failure, rehabilitation and transplantation. The data reported here demonstrate that the intestinal transplantation has been established as a therapeutic option in our country and Latin America, with long term results that have ranked our service at the level of the best centers in the world positioning us as referent in the specialty.

[Impact of ishemia-reperfusion injury on long survival rate in intestinal transplantation in rats]. / Impacto de las lesiones por isquemia-reperfusión en la supervivencia alejada de ratas con trasplante intestinal.

INTRODUCTION: The intestine is a highly sensitive tissue to ischemia-reperfusion (IR) injury that will early respond increasing its permeability. Later this response is translated in morphologic and histological changes that reveal the degree of damage. The heterotopic intestinal transplantation model in rats allows to evaluate the evolution of intestinal tissue injury after ischemia-reperfusion without affecting the long survival rate. OBJECTIVE: The aim of this paper is to establish a relationship between the ischemic reperfusion injury with the long-term survival METHODS: Ten intestinal transplants were analyzed in adult, Wistar, inbred, male rats. Light microscopical examination was performed on intestine graft: 1) immediately post-dissection, 2) at the end of cold isquemia, 3) 30 min, 4) 48hs and 5) 5 days post-transplant procedure, respectively. Biopsies were reported according to Park's classification and extension of staining using immunohistochemestry to malondialdehyde (MDA) products. RESULTS: The Park's classification indexes reported in samples were 1) 0,57 +/- 1,13 (N=10); 2) 2,71 +/- 1,25 (N=10); 3) 4,14 +/- 0,89 (N=10); 4) 1,0 +/- 0,81 (N=7); 5) 0 (N=7). The highest levels of immunohistochemical detection of MDA were observed thirty minutes post-reperfusion (extension of staining between 51% to 75%). Three animals died when they were sampled at 48 hours, and the biopsies had Park's classification > or = 4 at 30 minutes post-reperfusion and endotoxemic signology. CONCLUSIONS: The highest degree of mucosal damage was observed immediately post-reperfusion. At 48hs the graft tended to be normalized Failure to repair the immediately I-R injury signficantly affects the long term survival.

[Partial external biliary diversion: a therapeutic alternative for Alagille syndrome. First case in Argentina]. / Derivación biliar externa parcial: alternativa terapéutica en el síndrome de Alagille. Primer caso en la Argentina.

BACKGROUND: Alagille 's syndrome is the main syndromic chronic intrahepatic cholestasis characterized by hypoplasia of the intrahepatic bile ducts. It is a multisystem disorder of autosomal dominant inheritance with involvement of multiple organs. Usually it becomes apparent in the neonatal period, presenting as subclinical cases or severe degrees of the disease with the consequent development of liver cirrhosis and subsequent liver failure associated with multiple abnormalities: defects in the vertebral arches, typical facies, pulmonary stenosis, mental retardation and hypogonadism. OBJECTIVE: To present the first case of partial external biliary diversion in Argentina, showing the surgical technique and the improvement in the quality of life, as an alternative to be considered in patients with Alagille's syndrome before the development of cirrhosis. RESULTS: It has been shown that partial external biliary diversion can stop the process of liver fibrogenesis, halting the progression of the disease and avoiding the need for transplantation in some types of intrahepatic cholestasis when cirrhosis has not been established. DISCUSSION: This surgical technique can improve the quality of life and morbidity associated with hypercholesterolemia in patients with Alagille's syndrome, delaying and maybe avoiding the need for liver transplantation.

Fístulas enterocutáneas: manejo clínico y tratamiento sistema de vacío y compactación / Cutaneous Fistula: clinical management and treatment of compaction by vacuum

Antecedentes: las fístulas enterocutáneas se definen como una comunicación patológica entre la luz de una víscera y la piel, existiendo generalmente un trayecto fistulosode longitud variable. 1Entre el 75% y 85% de las fístulas digestivas adquiridas, son postoperatorias. 2El objetivo final en el tratamiento de esta patología es restablecer el tránsito intestinal. 2.4Objetivos: demostrar la aplicabilidad del sistema y analizar los resultados obtenidos con nuestra experiencia.Lugar de aplicación: Hospital público de alta complejidad.Diseño: Retrospectivo, descriptivo.Material y Método: 10 pacientes con fístulas enterocutáneas postoperatorias tratados con Sistema de Vacío y Compactación (SIVACO)Resultados: Todos los pacientes disminuyeron el débito luego de implementar el SIVACO, el 80% toleró satisfactoriamente la ingesta oral y mostró un incremento significativo en la curva de albuminemia, y el 100% de las lesiones dérmicas curaron. Todos lograron la movilización activa, y el 40% pudo completar la deambulación.Conclusiones: El SIVACO se asocia con una rápida reepitelización, aceleración del desarrollo del tejido de granulación, temprana curación de lesiones dérmicas perifístulosas y disminución del débito fístuloso entre otras cosas, situación que optimiza el estado general del paciente y lo prepara para la cirugía, u otorga confort y mejor calidad de vida a pacientes terminales. 3.5.