Have we improved postoperative and long-term outcomes of liver surgery for colorectal cancer metastasis? Analysis of 1736 hepatectomies performed over 3 decades in a single center.

INTRODUCTION: Surgery is the only potentially curative treatment for colorectal cancer liver metastases (CRLM) and its indication and results have varied in the last 30 years. METHODS: All patients operated on for CRLM in our centre from 1990 to 2021 were prospectively collected, establishing 3 subgroups based on the year of the first surgery: group A 1990-1999, group B 2000-2010, group C 2011-2021. Clinical characteristics and the results of survival, recurrence and prognostic factors were compared. RESULTS: 1736 hepatectomies were included (Group A n = 208; Group B n = 770; Group C n = 758). Patients in group C had better survival at 5 and 10 years (A 40.5%/28.2%; B 45.9%/32.2%; C 51.6%/33.1%, p = 0.013), although there were no differences between groups in overall recurrence at 5 and 10 years (A 73%/75.7%; B 67.6%/69.2%, and C 63.9%/66%, p = 0.524), nor in liver recurrence (A 46.4%/48.2%; B 45.8%/48.2%; and C 44.4%/48.4%, p = 0.899). An improvement was observed in median survival after recurrence, being 19 months, 23 months, and 31 months (groups A, B and C respectively). Prognostic factors of long-term survival changed over the 3 study periods. The only ones that remained relevant in the last decade were the presence of >4 liver metastasis, extrahepatic disease at the time of hepatectomy, and intraoperative blood transfusion. CONCLUSIONS: Survival after surgery for CRLM has improved significantly, although this cannot be explained by a reduction in overall and hepatic recurrence, but rather by an improvement in post-recurrence survival. Involvement of the resection margin has lost prognostic value in the last decade.

Análisis retrospectivo de los resultados a largo plazo de la estrategia inversa en pacientes con cáncer colorrectal y enfermedad hepática metastásica sincrónica avanzada / Long-term results of liver-first approach strategy in patients with advanced synchronous liver metastases from colorectal cancer

Introducción: La estrategia inversa (EI) es un esquema indicado en pacientes con cáncer colorrectal (CCR) y metástasis hepáticas sincrónicas (MHS) avanzadas. Incluye quimioterapia neoadyuvante, seguido de resección hepática y, por último, resección del CCR. Material: Estudio descriptivo retrospectivo sobre una base de datos prospectiva de hepatectomías por metástasis hepáticas de CCR en 2 centros entre 2007 y 2019. Se incluyeron 88 pacientes con CCR y MHS. La enfermedad hepática fue bilobar en un 65,9%, el número y el tamaño medio de las lesiones fue de 5,5 y 42,7mm, respectivamente. La respuesta radiológica al tratamiento se evaluó mediante criterios RECIST. La supervivencia libre de progresión (SLP) y la supervivencia global (SG) media se estimaron mediante el método de Kaplan-Meier y regresión de Cox.Resultados: De los 88 pacientes, 75 completaron la EI (85,2%). La respuesta radiológica fue parcial en el 75,7% y la estabilización en el 22,8%. La tasa de morbilidad (Clavien-Dindo ≥IIIA) tras la cirugía hepática y colorrectal fue del 29,4 y 9,3%, respectivamente. No hubo mortalidad a los 90 días. La tasa de recurrencia fue del 76%. Se diagnosticaron 106 recurrencias en 56 pacientes. De estos, se realizó tratamiento quirúrgico asociado a quimioterapia en 34 (32,1%). La SLP fue de 8,5 meses y la SG a 5 años fue del 53%. Conclusiones: En pacientes con CCR y MHS la EI permite el control inicial de la enfermedad metastásica, seleccionar pacientes respondedores a la neoadyuvancia y optimizar las posibilidades de resección completa, influyendo en la supervivencia a largo plazo. (AU)

Background: The “liver-first” approach (LFA) is a strategy indicated for advanced synchronous liver metastases (ASLM) from colorectal cancer (CRC). Includes neoadjuvant chemotherapy, resection of the ASLM followed by CRC resection.Methods: Retrospective descriptive analysis from a prospective database of hepatectomies from liver metastases (LM) from CRC in two centers. Between 2007-2019, 88 patients with CRC-ASLM were included in a LFA scheme. Bilobar (LM) was present in 65.9%, the mean number of lesions was 5.5 and mean size 42.7mm. Response to treatment was assessed by RECIST criteria. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier survival curves. Results: Seventy-five of 88 patients (85.2%) completed the LFA. RECIST evaluation showed partial response in 75.7% and stable disease in 22.8%. Severe morbidity rate (Clavien–Dindo ≥ IIIA) after liver and colorectal surgery was present in 29.4% and 9.3%, respectively. There was no 90-day postoperative mortality in both liver and colorectal surgeries. Recurrence rate was 76%, being the liver the most frequent site, followed by the pulmonary. From the total number of recurrences (106) in 56 patients, surgical with chemotherapy rescue treatment was accomplished in 34 of them (32.1%). The mean PFS was 8.5 and 5-year OS was 53%. Conclusions: In patients with CRC-ASLM the LFA allows control of the liver disease beforehand and an assessment of the tumor response to neoadjuvant chemotherapy, optimising the chance of potentially curative liver resection, which influences long-term survival. (AU)

Long-term results of liver-first approach strategy in patients with advanced synchronous liver metastases from colorectal cancer.

BACKGROUND: The "liver-first" approach (LFA) is a strategy indicated for advanced synchronous liver metastases (ASLM) from colorectal cancer (CRC). Includes neoadjuvant chemotherapy, resection of the ASLM followed by CRC resection. METHODS: Retrospective descriptive analysis from a prospective database of hepatectomies from liver metastases (LM) from CRC in two centers. Between 2007-2019, 88 patients with CRC-ASLM were included in a LFA scheme. Bilobar (LM) was present in 65.9%, the mean number of lesions was 5.5 and mean size 42.7 mm. Response to treatment was assessed by RECIST criteria. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier survival curves. RESULTS: Seventy-five of 88 patients (85.2%) completed the LFA. RECIST evaluation showed partial response in 75.7% and stable disease in 22.8%. Severe morbidity rate (Clavien-Dindo ≥ IIIA) after liver and colorectal surgery was present in 29.4% and 9.3%, respectively. There was no 90-day postoperative mortality in both liver and colorectal surgeries. Recurrence rate was 76%, being the liver the most frequent site, followed by the pulmonary. From the total number of recurrences (106) in 56 patients, surgical with chemotherapy rescue treatment was accomplished in 34 of them (32.1%). The mean PFS was 8.5 and 5-year OS was 53%. CONCLUSIONS: In patients with CRC-ASLM the LFA allows control of the liver disease beforehand and an assessment of the tumor response to neoadjuvant chemotherapy, optimising the chance of potentially curative liver resection, which influences long-term survival.

Cambios fisiopatológicos y complicaciones de las resecciones hepáticas / Physiopathological changes and complications of liver resections / Alterações fisiopatológicas e complicações das ressecções hepáticas

Las modernas técnicas quirúrgicas y anestésicas han permitido ampliar el número de intervenciones quirúrgicas a nivel hepático por diversas patologías. Logrando disminuir su moralidad pero manteniendo al día de hoy elevados niveles de morbilidad. Durante la cirugía hepática se producen cambios hemodinámicos vinculados a la movilización del hígado, a los clampeos y a las pérdidas sanguíneas independientemente de la vía de abordaje. En el postoperatorio las complicaciones o cambios fisiopatológicos derivan de las lesiones producidas por los fenómenos de isquemia y reperfusión; y aquellas producidas por la regeneración hepática. Dicha capacidad depende no solo de la cantidad de hígado remanente sino también de la posible hepatopatía preexistente. La insuficiencia hepática postoperatoria es la complicación más temida y se manifiesta con ictericia, ascitis, encefalopatía y alteraciones en la paraclínica como la hiperbilirrubinemia y descenso del tiempo de protrombina. Las complicaciones quirúrgicas dependen del procedimiento realizado y se dividen principalmente en biliares y vasculares. Las secuelas de las hepatectomías dependen de factores como el estado general del paciente, la presencia hepatopatía, el acto quirúrgico y la cantidad y calidad del hígado remanente.

Modern surgical and anesthetic techniques have made it possible to increase the number of liver surgeries for various pathologies. This has reduced morbidity but still maintains high levels of morbidity. During hepatic surgery, hemodynamic changes related to liver mobilization, clamping and blood loss occur independently of the approach route. In the postoperative period, complications or pathophysiological changes derive from the lesions produced by ischemia and reperfusion phenomena; and those produced by hepatic regeneration. This capacity depends not only on the amount of remaining liver but also on the possible pre-existing hepatopathy. Postoperative liver failure is the most feared complication and manifests with jaundice, ascites, encephalopathy and paraclinical alterations such as hyperbilirubinemia and decreased prothrombin time. Surgical complications depend on the procedure performed and are mainly divided into biliary and vascular. The sequelae of hepatectomies depend on factors such as the patient's general condition, the presence of liver disease, the surgical procedure and the quantity and quality of the remaining liver.

As modernas técnicas cirúrgicas e anestésicas tornaram possível aumentar o número de cirurgias hepáticas para várias patologias. Isto levou a uma diminuição da morbidade, mas ainda mantém altos níveis de morbidade. Durante a cirurgia hepática, ocorrem alterações hemodinâmicas ligadas à mobilização hepática, pinçamento e perda de sangue, independentemente da via de aproximação. No período pós-operatório, complicações ou alterações fisiopatológicas derivam de lesões causadas por fenômenos de isquemia e reperfusão, e aquelas causadas pela regeneração hepática. Esta capacidade depende não apenas da quantidade de fígado restante, mas também de uma possível doença hepática pré-existente. A insuficiência hepática pós-operatória é a complicação mais temida e se manifesta com icterícia, ascite, encefalopatia e alterações paraclínicas, tais como hiperbilirrubinemia e diminuição do tempo de protrombina. As complicações cirúrgicas dependem do procedimento realizado e são divididas principalmente em biliares e vasculares. As seqüelas de hepatectomias dependem de fatores como o estado geral do paciente, a presença de doença hepática, o procedimento cirúrgico e a quantidade e qualidade do fígado restante.

Aplicación de modelos 3D en cirugía hepática / Implementation of three-dimensional printed models in hepatic surgery

RESUMEN La impresión de modelos tridimensionales (M3D) implica obtener una estructura sólida y formada a partir de un modelo digital. Para la reconstrucción 3D se utilizó tomografía computarizada contrastada, realizándose impresión de modelos sobre la base de las principales estructuras anatómicas hepáticas. Se utilizaron M3D en dos pacientes con indicación quirúrgica, una mujer con trombocitopenia familiar y metástasis hepática de adenocarcinoma rectal, sin respuesta a quimioterapia, y un hombre con hepatopatía infecciosa crónica y diagnóstico de carcinoma hepatocelular. La aplicación de M3D resultó de gran utilidad, pues permitió un mejor entendimiento de la relación espacial de las estructuras anatómicas en ambos casos. En nuestra experiencia, la aplicación de M3D fue muy útil para planificar la cirugía y dar una aproximación más certera de los reparos anatómicos. El modelo se obtuvo en 7 días y costó 380 dólares, un valor elevado para nuestro medio.

ABSTRACT Three-dimensional (3D) printing is the construction of a solid structure from a digital model. 3D reconstruction was performed using contrast-enhanced computed tomography scan, and 3D-printed models were built based on the main anatomic structures of the liver. 3D-printed models were used in two patients with indication of surgery; one woman with inherited thrombocytopenia and liver metastases from colorectal adenocarcinoma with no response to chemotherapy, and one man with chronic liver infection and hepatocellular carcinoma. The implementation of 3D printing technology was very useful, as it facilitated the understanding of the spatial relationships among the anatomical structures in both cases. In our experience, the use of 3D-printed models was very useful for preoperative planning and for understanding the anatomic landmarks. The model was built in 7 days, with a cost of 380 dollars which is elevated in our environment.

Revisión del diagnóstico y manejo del quiste hidatídico hepático / Review of diagnosis and management of hydatid cyst of the liver

La hidatidosis es una zoonosis causada por el estado larvario de Echinococcus. Los seres humanos son huéspedes intermediarios accidentales, donde produce lesiones quísticas, principalmente en hígado y pulmón. Suele ser asintomática, por lo que se suele detectar de forma incidental. Los síntomas se deben a la expansión del quiste y/o a la reacción inflamatoria. El signo más frecuente es la hepatomegalia. No produce alteraciones analíticas específicas pero existeninmunodiagnósticos que pueden complementar su estudio, siendo la detección de anticuerpos el método de elección. Aunque la ecografía es la principal técnica para su diagnóstico, la tomografía brinda información más precisa respecto a sus características y relaciones anatómicas. Actualmente hay varias opciones terapéuticas. El tratamiento con albendazol, combinado o no con prazicuantel, es útil en los quistes pequeños (< 5 cm) sin complicaciones. Solo el 30 % de los quistes desaparecen con tratamiento médico exclusivo. La cirugía está indicada en los quistes hepáticos grandes (> 10 cm), con riesgo de ruptura y/o complicados; el abordaje laparoscópico está poco generalizado. La técnica radical (quistoperiquistectomía total) es preferible dado el menor riesgo postoperatorio de infecciones abdominales, fístulas biliares y morbilidad global. Las técnicas conservadoras son adecuadas en las áreas endémicas donde la cirugía la realizan cirujanos no especializados. La PAIR (punción-aspiración-inoculación-reaspiración) es una técnica innovadora que representa una alternativa a la cirugía. Está indicada en los pacientes inoperables y/o que rechazan la cirugía, en caso de recidiva tras la cirugía y cuando hay ausencia de respuesta al tratamiento médico. En los casos en que se demuestran quistes quiescentes o inactivos no complicados, se puede realizar una vigilancia activa sin tratamiento. (AU)

Programa de recuperación mejorada en cirugía hepática / Enhanced recovery program in liver surgery

RESUMEN Desde la aparición de un programa de Fast Track en cirugía colónica con resultados alentadores, muchos centros se abocaron a su aplicación y mejoramiento. El uso de estos programas en diferentes órganos trajo aparejados los mismos resultados que en cirugía colónica. Las resecciones hepáticas no quedaron excluidas de su uso. En ellas se logró una importante reducción de los días de estancia hospitalaria y de los costos. Entre los puntos que componen estos programas, una adecuada información al paciente y un compromiso de parte de este, la analgesia multimodal, la fluidoterapia y un inicio temprano de la alimentación parecen ser los más importantes.

ABSTRACT Since the development of fast-track programs in colorectal surgery with promising results, many centers started with these programs, and improved them. These programs were applied to different organs with the same results observed in colorectal surgery. Liver resections were not excluded from enhanced recovery programs, with a significant reduction in length of hospital stay and costs. Adequate patient information and commitment, multimodal analgesia, fluid therapy and early oral intake are the most important items of these programs.

Caprio, Mérola y los orígenes de la cirugía hepática en el Uruguay / Caprio & Mérola: the origins of liver surgery in Uruguay / Caprio, Mérola e os origens da cirurgia hepática no Uruguai

En la historia de la cirugía hepática los pioneros latinoamericanos han sido escasamente mencionados en la literatura anglosajona. Tal vez una excepción sea el trabajo del cirujano uruguayo Gerardo Caprio, que publicó su informe sobre una resección del lóbulo izquierdo del hígado, en 1931, en un período oscuro de las ideas sobre esta técnica quirúrgica, luego del fuerte impulso que tuviera en los últimos 25 años del siglo XIX. Los conceptos anatómicos y de la movilización hepática utilizados por Caprio fueron desarrollados por Mérola en comunicaciones que realizadas entre 1916 y 1920, las cuales incluso muestran fundadas discrepancias con los grandes anatomistas de la época. El presente trabajo analiza el perfil académico de Mérola y Caprio a través de un análisis de sus publicaciones, en cuanto a las bases de conocimiento y experiencia que impulsaron a Caprio a realizar esa hepatectomia y describir los principios quirúrgicos aplicados en la misma, que se consolidarían en el mundo recién 20 años después.

Regarding the history of liver surgery, Latin American pioneers have only occasionally been mentioned in Anglo-Saxon literature. One of such rare cases was Uruguayan surgeon Gerardo Caprio, who in 1931 published a report about a resection of the left lobe of the liver. This was done during an uneventful period in the development of ideas on this surgical technique, following the remarkable advances made in the last quarter of the 19th Century. The anatomic and liver manipulation concepts used by Caprio had been developed by Mérola in reports dating back to 1916 and 1920, which revealed well-grounded disagreements with the most renowned anatomists of the time. This paper discusses Mérola and Caprio's academic profile by analyzing their publications, the knowledge base and experience that led the latter to perform such liver resection, and the surgical principles applied to it, which would only be formally adopted worldwide twenty years later.

Na história da cirurgia hepática, os pioneiros latino-americanos pouco foram mencionados na literatura anglo-saxônica. Tal vez uma exceção seja o trabalho do cirurgião uruguaio Gerardo Caprio, que publicou uma ressecção do lobo esquerdo do fígado em 1931, em um período sombrio de as idéias sobre esta técnica cirúrgica, após o forte impulso que teve nos últimos 25 anos do século XIX. Os conceitos anatômicos e a mobilização hepática utilizada pelo Caprio foram desenvolvidos por Mérola em comunicações que datam de 1916 a 1920, que até mesmo mostre desentendimentos claros com os grandes anatomistas da época. Este artigo analisa o perfil acadêmico de Mérola e Caprio através de uma análise de suas publicações, em termos de bases de conhecimento e experiência que levaram a esta hepatectomia e aos princípios cirúrgicos aplicados nele, que seria consolidado em o mundo apenas 20 anos depois.

Factores asociados a reingreso hospitalario precoz posterior a resecciones hepáticas y pancreáticas / Hospital readmission rates after hepatic and pancreatic resections

Resumen Objetivo: Determinar la frecuencia de reingreso hospitalario y sus factores asociados en pacientes sometidos a resecciones hepáticas o pancreáticas en nuestro centro. Metodología: Se revisaron registros de pacientes sometidos a resecciones hepáticas o pancreáticas entre 2012 y 2014. Se registraron variables biodemográficas, quirúrgicas y reingresos hasta 30 días posalta. Se excluyó la cirugía de urgencia, pacientes fallecidos durante la hospitalización, pacientes sometidos a resecciones hepáticas menores a dos segmentos, cirugías no anatómicas o cirugía no resectiva. El análisis estadístico univariable se realizó con prueba χ2 para variables categóricas y T Student/Mann Whitney para variables continuas. El análisis multivariable se realizó con regresión logística. Resultados: Se incluyeron 116 pacientes, 50,9% mujeres. La estadía promedio fue de 14 días. El adenocarcinoma pancreático fue el diagnóstico más frecuente (25,9%) y 40,5% de los procedimientos quirúrgicos fueron pancreatoduodenectomías. La tasa de reingreso global fue 18,1%, mayor en pancreatectomías respecto a hepatectomías (23,7 vs 12,2% respectivamente p < 0,05). Los factores asociados a reingreso fueron: resección de páncreas, leucocitos preoperatorios, complicaciones posoperatorias y tiempo de estadía hospitalaria. Tras el análisis multivariable, sólo el tiempo hospitalario se asocia de forma independiente al reingreso precoz [OR 1,2 IC 95% 1,1-1,5 (p = 0,001)]. Conclusión: La estadía hospitalaria prolongada es un factor de riesgo consistente en la literatura para la rehospitalización posterior a resecciones hepáticas o pancreáticas. La tasa de reingreso posterior a resecciones hepáticas o pancreáticas es elevada, incluso en centros de alto volumen. Recomendamos el uso de este parámetro como un nuevo instrumento de medición de calidad en los resultados quirúrgicos en nuestro país.

Aim: To determine readmission rates and its associated factors in patients undergoing pancreatic and hepatic resections at our center. Matherial and Methods: Perioperative variables of patients undergoing pancreatic and hepatic resections between 2012-2014 were reviewed. Demographic and perioepartive data, as well as up —to postoperative day 30— readmisson rates were analyzed. Emergency cases, postoperative mortality and/or patients undergoing less extensive surgery (less than 2 Couinaud's segments, non-anatomical resections and non resective cases such as bilioenteric anastomoses) were excluded. Readmission associated factors were identified using both univariate (χ2 for categorical and t-student's/Mann-Whitney for continuous variables) and multivariate (logistic regression) analysis. Results: 116 cases were included, 50.9 % female. Mean postoperative stay was 14 days. Pancreatic adenocarcinoma was the most frequent diagnosis (25.9%), and the 40.5% of surgical procedures were pancreaticoduodenectomy. Overall 30-day readmission rate was 18.1%, with a 23.7% for pancreatic resections and 12.2% for hepatic resections. According to univariate analysis; readmission associated factors were: pancreatic resection, preoperative White cell count, the development of postoperative complications and postoperative length of stay. On Multivariate analysis only postoperative stay was the only significant associate factor [OR 1,2 CI 95% 1.1- 1.5 (p = 0.001)]. Conclussion: Readmission rates after pancreatic and hepatic resections are elevated, even in high-volume centers. Postoperative length of stay is a consistent risk factor for readmission after these type of surgeries. We highly recommend including this parameter as a quality marker of our surgical results in our country.

Anatomía quirúrgica y radiológica del hígado: fundamentos para las resecciones hepáticas / Radiological and surgical anatomy of the liver and fundamentals of the various options liver resections

RESUMEN: El hígado es un órgano sólido, de gran relevancia para la fisiología. Es asiento potencial de lesiones tumorales quísticas y sólidas; benignas y malignas (primarias y secundarias); razón por la cual, conocer su anatomía radiológica y quirúrgica es muy relevante. Los antecedentes históricos comienzan con Berta en 1716, quien fue el primero en realizar una resección hepática; en 1888, Lagenbuch fue el primero el realizar una resección hepática programada. En 1889, Keen realizó la primera lobectomía hepática izquierda, seguido de Webde, en 1910, quien ejecutó la primera lobectomía hepática derecha. Más tarde, Couinaud, en 1957, realizó ua descripción completa de la anatomía segmentaria del hígado, dando una mejor comprensión quirúrgica de la morfología hepática, para su abordaje en distintas patologías. Un hito fundamental en el desarrollo del estudio del hígado, fue el establecimiento de la "Clasificación de Brisbane", por parte del Comité Científico de la Asociación Internacional Hepatobilio-Pancreática, poniendo fin a la confusión terminológica establecida entre los términos franceses y anglosajones. Y desde el ámbito anatómico, se destaca la aparición de Terminologia Anatomica, por parte del Programa Federativo Internacional de Terminologia Anatomica (FIPAT) dependiente de la Federación Internacional de Asociaciones de Anatomistas (IFAA), quienes dentro de la misma, establecieron los términos anatómicos correspondientes al hígado. El objetivo de este manuscrito, es entregar un resumen esquemático de la anatomía quirúrgica y radiológica del hígado, que fundamentan las diferentes opciones de resecciones hepáticas.

SUMMARY: The liver is a solid organ which is most relevant for physiology. It is a potential site for cystic and solid (primary and secondary) benign and malignant tumor lesions. Therefore, thorough knowledge of its radiological and surgical anatomy is important. Historical background of liver resections began with Berta in 1716, who was the first to carry out the procedure. In 1888, Lagenbuch performed the first programmed liver resection and subsequently, in 1889 Keen performed the very first left hepatic lobectomy, followed by Webde in 1910, who performed the first right hepatic lobectomy. Later in 1957, Couinaud recorded a complete description of the segmental anatomy of the liver, providing a greater surgical understanding of the hepatic morphology, for approach in various pathologies. A fundamental milestone in the development of the liver study was the establishment of the "Brisbane Classification" by the Scientific Committee of the International Hepatobiliary-Pancreatic Association, which ended previous confusion between the French and Anglo-Saxon terminology. Furthermore, within the scope of anatomy, the introduction of Terminología Anatómica, by the International Federative Program of Anatomical Terminology (FIPAT) which depends on the International Federation of Associations of Anatomists ( IFAA), established the anatomical terms for the liver The objective of this manuscript is to provide a schematic summary of the surgical and radiological anatomy of the liver, on which the different options for liver resections are based.

Cirugía hepática: algunas consideraciones más allá de la técnica quirúrgica / Liver surgery: Considerations beyond the surgical technique

La mortalidad de la cirugía resectiva hepática es de 1-2%. Mejorar esto requerirá optimizar detalles que involucran a todos los encargados del cuidado de estos pacientes. El primero de estos puntos es la evaluación de la función hepática postoperatoria. Diversos métodos han sido utilizados para tratar de estimarla, sin resultados concluyentes respecto a cuál es el más adecuado. Estudios que evalúan la cantidad de parénquima residual y su relación con el desarrollo de falla hepática postoperatoria recomiendan que en presencia de un hígado sano debería quedar 20-25% del volumen hepático, 30-60% en casos de condiciones que deterioran la funcionalidad, y 40-70% en casos de cirrosis. El aporte de volumen y su relación con la morbilidad, el sangrado y el desarrollo de insuficiencia renal han sido muy estudiados. La restricción del volumen y el mantenimiento de presiones venosas bajas aparecen como estrategias recomendadas, pero no deben comprometer la perfusión sistémica. A diferencia de lo observado en pacientes críticos, especialmente sépticos, el uso de almidones aparece como una alternativa segura en pacientes sanos sometidos a procedimientos resectivos o trasplante hepático. Las alteraciones de exámenes de coagulación deben ser evaluadas y corregidas cuando corresponda, idealmente a través de métodos que permitan identificar la causa. El tromboelastograma aparece como una alternativa adecuada. La administración profiláctica de hemocomponentes no está indicada, pudiendo ser origen de morbilidad. La analgesia debe ser optimizada, siendo la peridural una buena alternativa en presencia de hígado sano y en procedimientos no mayores de una lobectomía.

The mortality of liver resection surgery is 1-2%. Improve this will require optimizing details involving all caregivers of these patients. The first of these points is the evaluation of postoperative liver function. Various methods have been used to estimate it, without conclusive results regarding what is the most appropriate. Several studies evaluating the amount of residual parenchyma and its relationship to the development of postoperative liver failure recommend that in the presence of a healthy liver should be 20-25% of liver volume, 30-60% in cases of conditions that impair the functionality and 40-70% in cases of cirrhosis. The contribution of fluids administration and its relationship with morbidity, bleeding and development of renal failure have been studied. The volume restriction, maintenance of low central venous pressures appear as recommended strategies but must not compromise systemic perfusion that can determine organ dysfunction. Unlike what was observed in critically ill patients, the use of starches appears as a safe alternative in healthy patients and those undergoing liver transplantation. Alterations in coagulation tests should be evaluated, ideally through methods that allow to identify the cause. The thromboelastography appears as a suitable alternative. Prophylactic administration of blood components is not indicated and can be a source of morbidity. Analgesia should be optimized, being epidural analgesia a good alternative in the presence of healthy liver and procedures involving no more than a lobectomy.

Liver resection morbidity, mortality, and risk factors at the departments of hepatobiliary surgery in Veracruz, Mexico. / Morbilidad, mortalidad y factores de riesgo de la cirugía hepática en los departamentos de cirugía hepatobiliar de Veracruz, México.

INTRODUCTION: Liver resection has been associated with high morbidity and mortality, and the most serious complication is liver failure. Patient evaluation is limited to risk scales. The 50-50 criteria and bilirubin peak>7mg/dl have been used as mortality predictors. AIM: The aim of this study was to determine the risk factors associated with morbidity and mortality for liver resection in our population. MATERIAL AND METHODS: A retrospective study was carried out on 51 patients that underwent liver resection. Sociodemographic variables, pathology, and the surgical act were analyzed, together with morbidity and mortality and their associated factors. RESULTS: Fifty-one patients, 23 men and 28 women, were analyzed. They had a mean age of 51.4±19.13 years, 64.7% had concomitant disease, and their mean MELD score was 7.49±1.79. The mean size of the resected lesions was 7.34±3.47cm, 51% were malignant, and 34 minor resections were performed. The Pringle maneuver was used in 64.7% of the cases and the mean blood loss was 1,090±121.76ml. Morbidity of 25.5% was associated with viral hepatitis infection, greater blood loss, transfusion requirement, the Pringle maneuver, lower hemoglobin and PTT values, and higher MELD, INR, bilirubin, and glucose values. A total 3.9% mortality was associated with hyperbilirubinemia, hyperglycemia, and greater blood loss and transfusions. CONCLUSIONS: The main risk factors associated with the morbidity and mortality of liver resection in our population were those related to the preoperative biochemical parameters of the patient and the factors that occurred during the surgical act.

Surgical alternatives used in the treatment of liver hydatid cyst: a systematized approach based on evidence (an overview) / Alternativas quirúrgicas utilizadas en el tratamiento del quiste hidatídico hepático: revisión global de la evidencia

Echinococcosis is an endemic zoonosis in the south of Chile; we therefore have occasion to treat a large number of patients, particularly in the liver. Hepatic echinococcosis (HE) has its own morbidity and mortality due to evolutionary complications, to which the risk of complications related to the surgical procedures is added, the morbidity which has been reported up to 80 %. This is associated with a history of previous surgeries for HE, evolutionary complications of the cyst, the need for additional procedures such as the treatment of the disease in other simultaneous locations, etc. Moreover, reported mortality is up to 10 %, a situation that remains unchanged despite technological and therapeutic advances. The surgical treatment of HE can be divided into four phases: isolation of the surgical area, evacuation of the cyst, treatment of the complications of the cyst and treatment of the residual cavity. HE surgical procedures can be classified as conservative (marsupialization, cystostomy, Posadas technique and cystojejunostomy) and radical (pericystectomy and hepatic resections). Finally, the role of laparoscopic surgery, which is still under evaluation, is also worthy of note. The aim of this article is to present a general evidence-based overview of some surgical aspects of interest in the treatment of HE. In this article issues of the different surgical options utilized for HE treatment and their results are discussed, based on published evidence.

La equinococosis es una zoonosis endémica en el sur de Chile; por lo tanto, tenemos la oportunidad de tratar un gran número de pacientes, particularmente en el hígado. La equinococosis hepática (EH) tiene su propia morbilidad y mortalidad debido a complicaciones evolutivas, a lo que se añade el riesgo de complicaciones relacionadas con los procedimientos quirúrgicos. Se ha informado una morbilidad hasta del 80 %. Esto se asocia con antecedentes de cirugías previas para EH, complicaciones evolutivas del quiste, la necesidad de procedimientos adicionales, tales como el tratamiento de la enfermedad en otros lugares en forma simultánea, etc. Por otra parte, la mortalidad reportada alcanza el 10 %, una situación que se mantiene sin cambios a pesar de los avances tecnológicos y terapéuticos. El tratamiento quirúrgico de la EH se puede dividir en cuatro fases: aislamiento de la zona quirúrgica, evacuación del quiste, tratamiento de las complicaciones del quiste y tratamiento de la cavidad residual. Los procedimientos quirúrgicos de la EH se pueden clasificar en conservador (marsupialización, cistostomía, técnica y cistoyeyunostomía de Posadas) y radical (periquistectomía y resecciones hepáticas). Por último, el papel de la cirugía laparoscópica, que todavía está en proceso de evaluación, también es digno de mención. El objetivo de este artículo es presentar una visión general basada en la evidencia de algunos aspectos quirúrgicos de interés en el tratamiento de la EH. Se discuten los temas desde las diferentes opciones quirúrgicas utilizadas para el tratamiento de la EH y sus resultados, sobre la base de la evidencia publicada.

Tumor fibroso solitario del lóbulo caudado del hígado / Solitary fibrous tumor of the liver caudate lobe

Introduction: Solitary fibrous tumor of the liver (SFTL) constitutes such a rare finding that it has been published only as case reports and to the present date there are only 45 cases published in English medical literature. This article describes the case of a patient treated at our institution with SFTL. Case report: A male 59-years-old patient was diagnosed with a SFTL incidentally found in a computed abdominal tomography taken by another causes, tumor was originating from the caudate lobe. The patient was asymptomatic. At surgery, the tumor was observed originating directly from the caudate lobe through a pedicle measuring approximately 3 cm. The tumor was resected sectioning its implantation pedicle and ligating all arterial, venous and biliary vessels. The SFTL was well encapsulated, measured 15 x 9 x 6 cm and weighted 794 g. The histological diagnosis was a SFTL and was confirmed by immunohistochemistry with monoclonal antibodies that reacted positively to CD34 and vimentin and negatively to CD117, S100, smooth-muscle α-actin and desmin. Conclusions: SFTL is an uncommon tumor. The present case is the first reported in Chilean medical literature and presented all the habitually described radiologic, surgical and pathological characteristics.

Introducción: El tumor fibroso solitario del hígado (TFSH) constituye un hallazgo tan raro que se ha publicado únicamente como reportes de caso y hasta el presente se encontraron sólo 45 casos publicados en la literatura inglesa. El presente artículo describe el caso de un paciente que fue tratado en nuestra institución por un TFSH. Reporte de caso: Paciente masculino de 59 años de edad al que, en una tomografía abdominal computarizada que se tomó por otras causas, se encontró en forma incidental un gran tumor hepático localizado en el lóbulo caudado del hígado. El paciente no refería síntomas relacionados con el tumor. En la cirugía se observó que el tumor se originaba directamente del lóbulo caudado al cual lo unía un pedículo de aproximadamente 3 cm de diámetro transverso. Se seccionó el tumor desde su base de implantación en el hígado ligándose los vasos arteriales y venosos así como los conductos biliares que se encontraron. Este medía 15 x 9 x 6 cm y pesaba 794 g, se encontraba bien encapsulado. El diagnóstico histológico fue el de un TFSH, el cual se confirmó mediante inmunohistoquímica con anticuerpos monoclonales que resultaron positivos para CD34 y vimentina en las células tumorales y negativos para CD117, S100, α-actina de músculo liso y desmina. Conclusiones: El TFSH es un tumor raro. El presente caso de un TFSH es el primero reportado en la literatura médica chilena y presentó las características radiológicas, quirúrgicas y patológicas habitualmente descritas en estos casos.

Single-port laparoscopic approach of the left liver: initial experience.

INTRODUCTION: New technological advances have enabled the development of single-port laparoscopic surgery. This approach began with cholecystectomy and subsequently with other abdominal surgeries. However, few publications on laparoscopic liver surgery have described the use of complete single-port access. We present our initial experience of a single-port laparoscopic hepatectomy. MATERIAL AND METHODS: Between May 2012 and December 2013, 5 single-port laparoscopic hepatectomies were performed: one for benign disease and four for colorectal liver metastases. The lesions were approached through a 3-5 cm right supraumbilical incision using a single-port access device. All the lesions were located in hepatic segments II or III. Four left lateral sectorectomies and one left hepatectomy were performed. RESULTS: Median operative time was 135 min. No cases were converted to conventional laparoscopic or open surgery. The oral intake began at 18 h. There were no postoperative complications and no patients required blood transfusion. The median hospital stay was 3 days. The degree of satisfaction was very good in 4 cases and good in one. Patients resumed their normal daily activities at 8 days. DISCUSSION: Single-port laparoscopic hepatectomy is safe and feasible in selected cases and may reduce surgical aggression and offer better cosmetic results. Comparative studies are needed to determine the real advantages of this approach.

[Laparoscopic liver resection: lessons learned after 132 resections]. / Resección hepática por laparoscopia: lecciones aprendidas tras 132 resecciones.

INTRODUCTION: After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc. AIM: To report our experience in laparoscopic liver resections (LLRs). PATIENTS AND METHOD: Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS. SURGICAL TECHNIQUE: 6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections. RESULTS: There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively. CONCLUSION: LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery.

[Results after laparoscopic liver resection: an appropriate option in malignant disease]. / Resultados tras resección hepática laparoscópica: una opción adecuada en patología maligna.

INTRODUCTION: The laparoscopic approach is not yet widely used in liver surgery, but has proven to be safe and feasible in selected patients even in malignant disease. The experience and results of a hepato-pancreato-biliary (HPB) surgery unit in the treatment of malignant liver disease by laparoscopic approach is presented. MATERIAL AND METHODS: Between February 2002 and May 2011, 71 laparoscopic liver resections were performed, 43 for malignant disease (only patients with more than one year of follow-up were included). Mean age was 63 years old and 58% of the patients were male. Forty-nine per cent of the lesions were located in segments ii-iii. Thirty segmentectomies were performed, 7 limited resections and 6 major hepatectomies. RESULTS: The median operative time was 163 min. There were 3 conversions. Five cases (11%) required blood transfusion. The oral intake began at 32 h and the median hospital stay was 6.7 days. There were no reoperations and there was one case of mortality. Nine patients (21%) had postoperative complications. The mean number of resected lesions was 1.2, with an average size of 3.5 cm. All resections were R0. The median survival after resection of colorectal liver metastases (CLM) was 69% and 43.5% at 36 and 60 months, respectively, and 89% and 68% at 36 and 60 months, respectively, in hepatocellular carcinoma (HCC). CONCLUSION: The laparoscopic liver resection in malignant disease is feasible and safe in selected patients. The same oncological rules as for open surgery should be followed. In selected patients it offers similar long-term oncological results as open surgery.