Early laparoscopic cholecystectomy in acute mild gallstone pancreatitis. Is there a role for routine admission contrast-enhanced CT Scan?

PURPOSE: This study aims to evaluate the efficacy of admission contrast-enhanced CT scans in formulating strategies for performing early laparoscopic cholecystectomy in cases of acute gallstone pancreatitis. METHODS: Patients diagnosed with acute gallstone pancreatitis underwent a CT scan upon admission (after at least 24 h from symptom onset) to confirm diagnosis and assess peripancreatic fluid, collections, gallstones, and common bile duct stones. Patients with mild acute gallstone pancreatitis, following the Atlanta classification and Baltazar score A or B, were identified as candidates for early cholecystectomy (within 72 h of admission). RESULTS: Within the analyzed period, 272 patients were diagnosed with mild acute gallstone pancreatitis according to the Atlanta Guidelines. A total of 33 patients (12.1%) were excluded: 17 (6.25%) due to SIRS, 10 (3.6%) due to local complications identified in CT (Balthazar D/E), and 6 (2.2%) due to severe comorbidities. Enhanced CT scans accurately detected gallstones, common bile duct stones, pancreatic enlargement, inflammation, pancreatic collections, and peripancreatic fluid. Among the cohort, 239 patients were selected for early laparoscopic cholecystectomy. Routine intraoperative cholangiogram was conducted in all cases, and where choledocholithiasis was present, successful treatment occurred through common bile duct exploration. Only one case required conversion from laparoscopic to open surgery. There were no observed severe complications or mortality. CONCLUSION: Admission CT scans are instrumental in identifying clinically stable patients with local tomographic complications that contraindicate early surgery. Patients meeting the criteria for mild acute gallstone pancreatitis, as per Atlanta guidelines, without SIRS or local complications (Baltazar D/E), can safely undergo early cholecystectomy within the initial 72 h of admission.

The building of an institutional liver transplant registry: opportunities and challenges.

To improve current data systems for institutional decision-making, the Adult Liver Transplant Registry was established at the Hospital Italiano de Buenos Aires, Argentina. This article describes its design and implementation and reports on the outcomes for patients transplanted since its January 2020 launch. A multidisciplinary team designed the registry by identifying key variables from a literature review while considering balance between data depth and feasibility. Rigorous quality control measures were enforced, including monthly audits and staff training. Benchmark indicators for post-transplant outcomes were established. As of November 2023, the registry included 136 transplants. Its implementation and maintenance were straightforward, with no significant difficulties encountered. Cirrhosis was the predominant indication (77%) for transplant. Only one living donor transplantation was performed. Post-transplant results generally aligned with benchmarks, but rates of biliary complications slightly exceeded the recommended thresholds. The one-year post-transplant survival rate was 87%. The successful registry implementation provides a robust framework for research, treatment management, and patient care enhancement within a liver transplant unit.

Harmonizing Definitions and Perspectives in Extreme Liver Surgery: A Delphi Experts Consensus.

OBJECTIVE: To propose to our community a common language about extreme liver surgery. BACKGROUND: The lack of a clear definition of extreme liver surgery prevents convincing comparisons of results among centers. METHODS: We used a two-round Delphi methodology to quantify consensus among liver surgery experts. For inclusion in the final recommendations, we established a consensus when the positive responses (agree and totally agree) exceeded 70%. The study steering group summarized and reported the recommendations. In general, a five-point Likert scale with a neutral central value was used, and in a few cases multiple choices. Results are displayed as numbers and percentages. RESULTS: A two-round Delphi study was completed by 38 expert surgeons in complex hepatobiliary surgery. The surgeon´s median age was 58 years old (52-63) and the median years of experience was 25 years (20-31). For the proposed definitions of total vascular occlusion, hepatic flow occlusion and inferior vein occlusion, the degree of agreement was 97%, 81% and 84%, respectively. In situ approach (64%) was the preferred, followed by ante situ (22%) and ex situ (14%). Autologous or cadaveric graft for hepatic artery or hepatic vein repair were the most recommended (89%). The use of veno-venous bypass or portocaval shunt revealed the divergence depending on the case. Overall, 75% of the experts agreed with the proposed definition for extreme liver surgery. CONCLUSION: Obtaining a consensus on the definition of extreme liver surgery is essential to guarantee the correct management of patients with highly complex hepatobiliary oncological disease. The management of candidates for extreme liver surgery involves comprehensive care ranging from adequate patient selection to the appropriate surgical strategy.

Adjuvant chemotherapy is associated with better oncological outcomes after ALPPS for colorectal liver metastases.

ALPPS enables complete tumor resection in a shorter interval and a larger number of patients than classic two-stage hepatectomies. However, there is little evidence regarding long-term outcomes in patients with colorectal liver metastases (CLM). This study aims to evaluate the short and long-term outcomes of ALPPS in patients with CRM. Single-cohort, prospective, observational study. Patients with unresectable CLM due to insufficient liver remnant who underwent ALPPS between June 2011 and June 2021 were included. Of 32 patients treated, 21 were male (66%) and the median age was 56 years (range = 29-81). Both stages were completed in 30 patients (93.7%), with an R0 rate of 75% (24/32). Major morbidity was 37.5% and the mortality nil. Median overall survival (OS) and recurrence-free survival (RFS) were 28.1 and 8.8 months, respectively. The 1-3, and 5-year OS was 86%, 45%, and 21%, and RFS was 42%, 14%, and 14%, respectively. The only independent risk factor associated with poor RFS (5.7 vs 11.6 months; p = 0.038) and OS (15 vs 37 months; p = 0.009) was not receiving adjuvant chemotherapy. KRAS mutation was associated with worse OS from disease diagnosis (24.3 vs. 38.9 months; p = 0.025). ALPPS is associated with favorable oncological outcomes, comparable to traditional strategies to increase resectability in patients with CLM and high tumor burden. Our results suggest for the first time that adjuvant chemotherapy is independently associated with better short- and long-term outcomes after ALPPS. Selection of patients with KRAS mutations should be performed with caution, as this could affect oncological outcomes.

Enhancing ACLF prediction by integrating sarcopenia assessment and frailty in liver transplant candidates on the waiting list.

Background & Aims: Malnutrition, sarcopenia, and frailty are prevalent in cirrhosis. We aimed to assess the correlation between assessment tools for malnutrition, sarcopenia, and frailty in patients on the liver transplant (LT) waiting list (WL), and to identify a predictive model for acute-on-chronic liver failure (ACLF) development. Methods: This prospective single-center study enrolled consecutive patients with cirrhosis on the WL for LT (May 2019-November 2021). Assessments included subjective global assessment, CT body composition, skeletal muscle index (SMI), ultrasound thigh muscle thickness, sarcopenia HIBA score, liver frailty index (LFI), hand grip strength, and 6-minute walk test at enrollment. Correlations were analyzed using Pearson's correlation. Competing risk regression analysis was used to assess the predictive ability of the liver- and functional physiological reserve-related variables for ACLF. Results: A total of 132 patients, predominantly with decompensated cirrhosis (87%), were included. Our study revealed a high prevalence of malnutrition (61%), sarcopenia (61%), visceral obesity (20%), sarcopenic visceral obesity (17%), and frailty (10%) among participants. Correlations between the assessment tools for sarcopenia and frailty were poor. Sarcopenia by SMI remained prevalent when frailty assessments were not usable. After a median follow-up of 10 months, 39% of the patients developed ACLF on WL, while 28% experienced dropouts without ACLF. Multivariate analysis identified MELD-Na, SMI, and LFI as independent predictors of ACLF on the WL. The predictive model MELD-Na-sarcopenia-LFI had a C-statistic of 0.85. Conclusions: The poor correlation between sarcopenia assessment tools and frailty underscores the importance of a comprehensive evaluation. The SMI, LFI, and MELD-Na independently predicted ACLF development in WL. These findings enhance our understanding of the relationship between sarcopenia, frailty, and ACLF in patients awaiting LT, emphasizing the need for early detection and intervention to improve WL outcomes. Impact and implications: The relationship between sarcopenia and frailty assessment tools, as well as their ability to predict acute-on-chronic liver failure (ACLF) in patients on the liver transplant (LT) waiting list (WL), remains poorly understood. Existing objective frailty screening tests have limitations when applied to critically ill patients. The correlation between sarcopenia and frailty assessment tools was weak, suggesting that they may capture different phenotypes. Sarcopenia assessed by skeletal muscle index, frailty evaluated using the liver frailty index, and the model for end-stage liver disease-Na score independently predicted the development of ACLF in patients on the WL. Our findings support the integration of liver frailty index and skeletal muscle index assessments at the time of inclusion on the WL for LT. This combined approach allows for the identification of a specific patient subgroup with an increased susceptibility to ACLF, underscoring the importance of early implementation of targeted treatment strategies to improve outcomes for patients awaiting LT.

Resecciones hepáticas laparoscópicas: ¿qué hemos aprendido luego de más de 20 años de experiencia? / Laparoscopic liver resections: What have we learned after more than 20 years of experience?

Introducción: El objetivo de este estudio es describir nuestra experiencia en los últimos 8años de resecciones hepáticas laparoscópicas (RHL) por tumores benignos y malignos, para evaluar indicaciones y resultados, y comparar los resultados con nuestra experiencia previa y con otros centros de referencia a nivel mundial. Métodos: A partir de una base de datos prospectiva de la Unidad de Cirugía Hepatopancreatobiliar y Trasplante Hepático del Hospital Italiano de Buenos Aires se analizaron de forma retrospectiva los pacientes que fueron sometidos a RHL entre septiembre de 2014 y junio de 2022 (períodoB) y se compararon los resultados con nuestra propia experiencia de RHL realizadas entre los años 2000 y 2014, publicada previamente (períodoA). Resultados: La indicación quirúrgica más frecuente fue por metástasis de cáncer colorrectal (26,4%). El 15,7% de las resecciones fueron hepatectomías mayores y el procedimiento más frecuentemente realizado fueron hepatectomías típicas y atípicas (58,4%), seguido por la hepatectomía lateral izquierda (20,3%). La tasa de complicaciones mayores fue del 10,1%. La mortalidad en los primeros 90días postoperatorios fue del 1%. La mediana de estancia postoperatoria fue de 4 (IQR: 3-6) días. La sobrevida global al año, a los 3 y a los 5años fue del 94%, del 84% y del 70%, respectivamente, con una media de seguimiento de 22,9meses. Conclusiones: Las resecciones hepáticas por vía laparoscópica en manos de cirujanos entrenados continúan creciendo de manera segura, y hemos visto un aumento en la indicación de RHL para patologías malignas y resecciones mayores, tendencia que acompaña al resto de los grandes centros del mundo y se ha convertido en el método de elección para el tratamiento quirúrgico de la mayoría de los tumores hepáticos. (AU)

Introduction: The aim of this study is to describe our experience in the last 8years of laparoscopic liver resections (LLR) for benign and malignant tumors, to evaluate indications and results, and to compare the results with our previous experience and with other reference centers worldwide. Methods: Based on a prospective database of the Hepatopancreatobiliary Surgery and Liver Transplantation Unit of the Hospital Italiano de Buenos Aires, patients who underwent LLR between September 2014 and June 2022 were retrospectively analyzed (periodB) and where compared to our own experience from 2000-2014 previously published (periodA). Results: Colorectal liver metastasis was the main indication for surgery (26.4%). Major hepatectomies accounted for 15.7% of resections and the most frequently performed procedure was typical and atypical hepatectomies (58.4%) followed by left lateral hepatectomy (20.3%). The total postoperative major complications rate was 10.1% and the 90-day postoperative mortality was 1%. The median postoperative stay was four (IQR: 3-6) days. The overall survival rate estimated at 1, 3 and 5 years was 94%, 84% and 70%, respectively, with a median follow-up of 22.9months. Conclusions: LLRs in the hands of trained surgeons continue to grow safely, and we have seen an increase in the indication of LLR for malignant pathologies and major resections, a trend that follows the rest of the major centers in the world and has become the method of choice for surgical treatment of most liver tumors. (AU)

Epidemiología de pacientes con hepatocarcinoma en un hospital Universitario / Epidemiology of patients with hepatocellular carcinoma in a University hospital

Resumen El carcinoma hepatocelular (HCC) es el tumor primario más frecuente del hígado, con 905 677 casos diagnosticados en 2020, en todo el mundo, y 830 180 muertes. Es responsable de la novena causa de muerte por cáncer en los hombres y la décima en mujeres en Argentina. A diferencia de otros tumo res de alta prevalencia, la evidencia científica acerca del HCC se limita principalmente a pequeñas cohortes y estudios retrospectivos. El objetivo de este estudio fue describir epidemiológicamente a aquellos pacientes con diagnóstico de HCC en el Hospital Italiano de Buenos Aires en un periodo de 12 años. La supervivencia global para nuestra cohorte fue de 58, 46 y 36% a 1, 3 y 5 años respectivamente. El promedio de supervivencia en pacientes con tratamiento paliativo fue de 5 meses, 23 para aquellos que recibieron tratamientos no curativos y 75 meses para los que recibieron tratamientos curativos. El porcentaje de pacientes libres de enfermedad a 1, 3 y 5 años fue de 89%, 76% y 61% respectivamente. Se realizó un estudio minucioso de la etiología, factores de riesgo, incidencia, mortalidad y tratamientos realizados. Su importancia yace en su tamaño muestral, calidad y cantidad de información disponible.

Abstract Hepatocellular carcinoma is the most common primary liver tumor, with 905 677 diagnosed cases and 830 180 deaths, in 2020 worldwide. In Argentina, it accounts for the 9th cause of death for cancer in men and the 10th in women. Unlike other highly-prevalent tumors, scientific evidence for most therapeutic options is limited mainly to small cohorts and retrospective studies. The aim of this study is to characterize and describe epidemiologically patients with diagnosis of hepatocellular carcinoma in the Italian Hospital of Buenos Aires during a 12-year period. Overall survival for our cohort was 58%, 46%, and 36% at 1, 3 and 5 years respectively. Average survival for patients receiving palliative treatment was 5 months, while for those who received either non-curative or curative treatment was 23 and 75 months respectively. Recurrence-free survival for those patients who under went a curative treatment was 89%, 76% y 61% at 1, 3 and 5 years. A thorough analysis of etiology, risk factors, incidence, mortality and treatment was made. The study's importance lies in its large sample size, quantity and quality of data, and will most certainly stimulate the development of local studies in hepatocellular carcinoma.

Supervivencia a largo plazo luego de pancreatectomía por cáncer de páncreas / Long-term survival after pancreatic cancer surgery

Resumen El adenocarcinoma ductal de páncreas es una enfermedad agresiva asociada con pobres resultados de supervivencia a largo plazo. La resección quirúrgica y los nuevos tratamientos oncológicos pe rioperatorios han logrado mejorar la supervivencia de estos pacientes en la experiencia internacional. En este estudio retrospectivo se analiza la supervivencia global y la libre de enfermedad de todos los pacientes operados por cáncer de páncreas en el Hospital Italiano de Buenos Aires de enero 2010 a enero 2020. Se identificaron 242 pacientes con resecciones pancreáticas por adenocarcinoma de páncreas o carcinoma indiferenciado. La supervivencia global mediana fue de 22.8 meses (IC 95%: 19.5-29) y la tasa de supervivencia global a 1, 3 y 5 años fue de 72%, 32.5% y 20.8% respectivamente. La supervivencia libre de enfermedad mediana fue de 13.8 meses (IC 95%: 12-17.6) y la tasa de supervivencia libre de enfermedad a 1, 3 y 5 años fueron de 56.1%, 21.8% y 19.4% respectivamente. El grupo de pacientes que logró completar el tratamiento adyuvante mostró una mayor supervivencia global (p<0.0001).

Abstract Pancreatic cancer is an aggressive disease associated with poor results regarding long term survival. Surgical treatment along with new onco logic treatments have improved the survival of these patients in international experience reports. The aim of this study was to describe overall survival and disease-free survival after pancreatectomy for pancreatic ductal adenocarcinoma. A retrospective study of consecutive patients undergoing pancreatic resection due to PDAC or undifferentiated carcinoma from January 2010 to January 2020 in a single tertiary center was performed. Overall, 242 patients underwent complete pancreatic resections for pancreatic ductal adenocarcinoma or undifferentiated carcinoma. Median overall survival was 22.8 months (95% CI: 19.5-29) and survival at 1, 3 and 5 years were 72%, 32.5% and 20.8% respectively. The median disease-free survival was 13.8 months (95% CI: 12-17.6) and 1, 3- and 5-years disease-free survival were 56.1%, 21.8% and 19.4% respectively. The groups of patients that completed adjuvant treatment showed a better overall survival (p < 0.0001).

Percepciones de los médicos en formación en Cirugía General en la fase inicial de la pandemia por COVID-19 / Perceptions of general surgeons in training in the initial phase of COVID-19 pandemic

RESUMEN Objetivo: describir las percepciones de los cirujanos en formación durante la fase inicial de la pandemia por COVID-19. Material y métodos: se realizó el análisis transversal de una encuesta de 51 preguntas a médicos en formación de un Servicio de Cirugía General en un hospital de la Argentina. Se abarcaron 5 ámbitos: institucional, asistencial, académico, doméstico y emocional. Resultados: en total 55 médicos completaron la encuesta (91,7%): 35 residentes y 20 becarios de perfeccionamiento; 56,4% eran hombres. El 98,1% consideró suficiente la información brindada por el hospital y el servicio sobre las medidas tomadas con respecto al COVID-19. Si bien el 98,1% consideró satisfactorios los instructivos sobre los equipos de protección personal, el 38% informó inconvenientes en su utilización. El 92,5% de los residentes estuvo de acuerdo con el esquema de guardias implementado. El 94,5% incrementó el tiempo dedicado a actividades académicas. El 75% consideró útil el cronograma de clases virtuales implementado. El 72,7% de los encuestados consideró que contaba con espacios donde manifestar sus preocupaciones. El 60% consideró adecuada la supervisión. El 81,81% manifestó preocupación por perder habilidad manual. El 53% dijo sentirse frustrado y el 54% manifestó temor de contagiar a su familia/pareja. Conclusión: conocer las percepciones de los cirujanos en formación en la fase inicial de la pandemia por COVID-19 permitió detectar oportunidades de mejora e incorporar nuevas estrategias educativas para afrontar las fases siguientes, asegurando el aprendizaje y priorizando su bienestar físico y psicosocial.

ABSTRACT Objective: The aim of this study is to describe the perceptions of surgeons in training during the initial phase of the COVID-19 pandemic. Material and methods: A 51-question survey was conducted among physicians in training from a department of surgery in an Argentine hospital. Five domains were explored: institutional, healthcare, academic, domestic and emotional. Results: The survey was completed by 55 physicians (91.7%): 35 residents and 20 fellows. Among the respondents, 98.1% considered the information provided by the hospital and the department about the measures implemented in the COVID-19 stetting was sufficient. 98.1% considered that the instructions about personal protective equipment were satisfactory, but 38% reported difficulties to use them. 92.5% of the residents agreed with the system implemented for on-call shifts, 94.5% increased the time dedicated to academic activities, 75% considered the virtual class schedule implemented as very useful and 72.72% perceived that they had spaces to express their concerns. The supervision was considered adequate by 60%; 81.81% were worried to lose manual dexterity; 53% felt frustrated and 54% were afraid of infecting their family/partner. Conclusion: Understanding the perceptions of surgeons in training in the initial phase of the COVID-19 pandemic made it possible to detect opportunities for improvement and incorporate modifications to address the following phases, ensuring learning and prioritizing their physical and psychosocial well-being.

Impacto de la pandemia por COVID-19 sobre el trasplante hepático en la argentina. Otro daño colateral / Impact of COVID-19 pandemic in liver transplantation in Argentina. Other collateral damage

Resumen La pandemia COVID-19 declarada en marzo del 2020, ha generado preocupación mundial por su efecto en la salud de la población y el potencial colapso sanitario. La estrategia de "aplanar la curva" mediante el distanciamiento social permitió adaptar los recursos del sistema de salud a pacientes con COVID-19, pero no se pudo prever su repercusión en otras áreas de la salud. El objetivo de este trabajo fue analizar las consecuencias de la pandemia sobre el trasplante hepático en general y por hepatocarcinoma (HCC). Fueron realizados los siguientes estudios: a) un análisis retrospectivo utilizando datos del CRESI/INCUCAI para comparar ingreso en lista de espera, mortalidad en lista, donación y trasplante hepático desde 20/03 a 15/08, 2019 e igual periodo de 2020, y b) una encuesta a los centros de trasplante de mayor actividad trasplantológica para valorar el efecto de las medidas tomadas en diferentes situaciones institucionales y regionales. El primer análisis evidenció una disminución del 55% de los trasplantes hepáticos, con una reducción similar en la donación y en el ingreso a lista de espera hepática; mientras que el trasplante por HCC ascendió de 10% en 2019 a 22% en 2020. El segundo análisis, mostró que la tasa de ocupación de camas por pacientes COVID-19/semana fue variable: de 0.4% al 42.0%. El número de cirugías, hepato-bilio-pancreática, resección de HCC y trasplante hepático, se redujeron en 47%, 49%, 31% y 36% respectivamente. La reducción de la actividad trasplantológica afectó mayormente los centros con alta ocupación por COVID-19. El impacto final a largo plazo deberá evaluarse.

Abstract The COVID-19 pandemic declared in March 2020, has generated worldwide concern due to its effect on the health of the population and the potential health collapse. The strategy of "flattening the curve" through social distancing made it possible to adapt the resources of the health system to patients with COVID-19, but results in other areas of health could not be predicted. The objective of this work was to analyze the consequences of the pandemic on liver transplantation in general and for hepatocarcinoma (HCC). The following studies were carried out: a) a retrospective analysis using data from the CRESI / INCUCAI to compare admission to the waiting list, mortality on the list, donation and liver transplantation from 03/20 to 08/15, 2019 and the same period in 2020, and b) a survey of the transplant centers with the highest transplant activity to assess the effect of the measures taken in different institutional and regional situations. The first analysis showed a 55% decrease in liver transplants, with a similar reduction in donation and admission to the liver waiting list; while HCC transplantation rose from 10% in 2019 to 22% in 2020. The second analysis showed that the occupancy rate of beds by COVID-19 patients / week was variable: from 0.4% to 42.0%. The number of surgeries, hepato-bilio-pancreatic, resection of HCC and liver transplantation, were reduced by 47%, 49%, 31% and 36% respectively. The reduction in transplant activity mainly affected centers with high occupancy due to COVID-19. The final long-term outcome will need to be assessed.

Controversias en lesiones quirúrgicas de la vía biliar. Rol de la video laparoscopia en el manejo de lesiones quirúrgicas de la vía biliar / Controversies in iatrogenic bile duct injuries. Role of video-assisted laparoscopy in the management of iatrogenic bile duct injuries

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Cambios en el Programa de Formación Quirúrgica en la era COVID-19 / Changes in the Surgical Training Program in the COVID-19 era

La aparición de esta nueva enfermedad por coronavirus 2019 (COVID-19) ha generado un gran impacto dentro de los equipos de salud, obligando a realizar cambios profundos en la actividad diaria. Estas modificaciones están orientadas a promover un ambiente de trabajo seguro para el personal médico y no médico. Sin embargo, algunos de esos cambios pueden tener consecuencias sobre el proceso de aprendizaje de los médicos en formación. El desafío que enfrenta un Servicio de Cirugía de un Hospital Universitario es mantener la continuidad de los programas formativos asegurando a la vez la seguridad de los médicos residentes. En este comunicado se describen los cambios realizados en el Programa de la Residencia de Cirugía General en un Hospital Universitario, orientados a brindar la misma calidad educativa, en un entorno seguro durante el transcurso de esta pandemia.

The appearance of this new coronavirus 2019 disease (COVID-19) has generated a great impact within health teams, forcing profound changes in the daily activity. These modifications are aimed at promoting a safe work environment for medical and non-medical personnel. However, some of these changes may have consequences on the learning process of doctors in training. The challenge faced by a Surgery Service of a University Hospital is to maintain the continuity of the training programs while ensuring the safety of Residents. This report describes the changes made to the General Surgery Residency Program at a university hospital, aimed at providing the same educational quality, in a safe environment during the course of this pandemic.

COVID-19: Reestructuración de emergencia e impacto de la pandemia en una Sección de Cirugía Mininvasiva Guiada por Imágenes / Emergency restructuring and impact of the pandemic in an Image-Guided Minimally Invasive Surgery Section

Antecedentes: La enfermedad por coronavirus-19 (COVID-19) ha forzado cambios en todas las facetas de los sistemas de salud. En este artículo se describen las modificaciones realizadas en la Sección de Cirugía Miniinvasiva Guiada por Imágenes (CIGIM) del Hospital Italiano de Buenos Aires, para promover la seguridad y el bienestar del personal manteniendo la capacidad de respuesta a la demanda asistencial y académica. Material y métodos: Las medidas incluyeron la reorganización del personal, el manejo de los procedimientos electivos y de urgencia, las consultas ambulatorias, así como la actividad docente y de investigación. También se analizó comparativamente la variación interanual (2019-2020) de los pacientes atendidos (procedimientos percutáneos y consultas ambulatorias) entre el 20 de marzo y el 10 de mayo de cada año. Resultados: La Sección CIGIM fue reorganizada en rotaciones semanales de 3 actividades, con distanciamiento estricto entre sus miembros, y hasta el momento ninguno resultó afectado. Los pacientes operados y las consultas realizadas durante el período estudiado 2019 vs. 2020 disminuyeron significativamente: 136 vs. 57 operados y 102 vs. 39 consultas; p < 0,0001. Las plataformas virtuales se utilizaron con éxito para mantener la actividad de pregrado, incluyendo cursadas de alumnos de grado de Medicina de dos universidades, el programa de residencia de Cirugía General y reuniones científicas; en dicho período se produjeron 3 trabajos científicos para publicación. Conclusiones: La disminución de la demanda asistencial, la reorganización de los grupos de trabajo y las plataformas virtuales pueden resultar estrategias y herramientas valiosas para afrontar la pandemia por COVID-19.

Background: Coronavirus-19 disease (COVID-19) has forced changes in all facets of health systems. This article describes the modifications made in the Image-Guided Minimally Invasive Surgery Section (CIGIM) of the Hospital Italiano de Buenos Aires, to promote the safety and well being of personnel while maintaining the ability to respond to academic and healthcare demand. Material and methods: Measures included reorganization of staff, management of elective and emergency procedures, outpatient consultations, as well as teaching and research activity. The inter-annual variation (2019-2020) of the patients attended (percutaneous procedures and outpatient consultations) between March 20 and May 10 of each year was also analyzed comparatively. Results: The CIGIM Section was reorganized into weekly rotations of 3 activities, with strict distancing among its members, and so far none have been affected. The operated patients and the consultations made during the analyzed period of 2019 vs. 2020 decreased significantly: 136 vs. 57 operated and 102 vs. 39 consultations; p <0.0001. Virtual platforms were successfully used to maintain undergraduate activity, including courses taken by medical students from two universities, the General Surgery residency program and scientific meetings; In this period, 3 scientific papers were written for publication. Conclusions: Dealing with healthcare demand, reorganizing working groups and virtual platforms can be valuable strategies and tools to confront the COVID-19 pandemic.

Tratamiento quirúrgico de las metástasis pancreáticas de cáncer renal de células claras en una institución de la Argentina / Surgical treatment of pancreatic metastases from renal clear cell carcinoma

Isolated pancreatic metastases of clear cell renal carcinoma are rare. Clear cell renal carcinoma (CCRC) is responsible for approximately 20-30 % of cases that present metastases at diagnosis. Despite that pancreatic involvement is inusual, this is an organ were particularly and frequently place as the only dissemination site. The aim of this report was to evaluate the surgical and oncological results of patients submitted to pancreatectomy consecutively to a CCRC. Patients with pancreatectomy because of metastases were selected in a 10 -year period. Clear cell renal carcinoma spreads both by direct perinephric extension and by hematogenous and lymphatic routed. The treatment of localized CCRC is surgical. For patients with metastatic CCRC, no efficacious agent has ever been identified, and there is no standard or accepted therapy. The results of this study are presented and discussed

Síndrome de hipoglucemia por hiperinsulinismo endógeno: tratamiento quirúrgico / Endogenous hyperinsulinemic hypoglycemia syndrome: Surgical treatment

INTRODUCCIÓN: El síndrome hipoglucémico por hiperinsulinismo endógeno (SHHE) puede estar originado por un insulinoma o, menos frecuentemente, por la nesidioblastosis en niños, conocida en la población adulta con el nombre de síndrome hipoglucémico pancreático no insulinoma (SHPNI). El objetivo de este trabajo es mostrar la estrategia para el tratamiento quirúrgico del SHHE. MATERIAL Y MÉTODO: Se incluyó a un total de 19 pacientes con diagnóstico final de insulinoma o SHPNI que fueron tratados quirúrgicamente desde enero del 2007 hasta junio del 2012. Se describió la forma de presentación clínica y estudios preoperatorios. Se hizo hincapié en la técnica quirúrgica, las complicaciones y el seguimiento a largo plazo de los pacientes. RESULTADOS: Todos los pacientes en estudio tuvieron un test de ayuno positivo. Las lesiones que originaron el SHHE pudieron ser localizadas preoperatoriamente en el 89,4% de los casos. La cirugía más frecuente fue la pancreatectomía distal con preservación de bazo (9 casos). Tres pacientes con diagnóstico de insulinoma se presentaron con metástasis sincrónicas, que fueron tratadas con cirugía simultánea. No tuvimos mortalidad perioperatoria y la morbilidad fue del 52,6%. El análisis histológico reveló que 13 pacientes (68,4%) presentaban insulinoma benigno, 3 insulinoma maligno con metástasis hepáticas y 3 con diagnóstico final de SHPNI. La mediana de seguimiento fue de 20 meses. Todos los pacientes con diagnóstico de insulinoma benigno o SHPNI resolvieron el síndrome de SHHE. CONCLUSIÓN: El tratamiento quirúrgico del SHHE logra excelentes resultados a largo plazo en el control de los síntomas de hipoglucemia

BACKGROUND: The endogenous hyperinsulinemic hypoglicemia syndrome (EHHS) can be caused by an insulinoma, or less frequently, by nesidioblastosis in the pediatric population, also known as non insulinoma pancreatic hypoglycemic syndrome (NIPHS) in adults. The aim of this paper is to show the strategy for the surgical treatment of EHHS. MATERIAL AND METHODS: A total of 19 patients with a final diagnosis of insulinoma or NIPHS who were treated surgically from January 2007 until June 2012 were included. We describe the clinical presentation and preoperative work-up. Emphasis is placed on the surgical technique, complications and long-term follow-up. RESULTS: All patients had a positive fasting plasma glucose test. Preoperative localization of the lesions was possible in 89.4% of cases. The most frequent surgery was distal pancreatectomy with spleen preservation (9 cases). Three patients with insulinoma presented with synchronous metastases, which were treated with simultaneous surgery. There was no perioperative mortality and morbidity was 52.6%. Histological analysis revealed that 13 patients (68.4%) had benign insulinoma, 3 malignant insulinoma with liver metastases and 3 with a final diagnosis of SHPNI. Median follow-up was 20 months. All patients diagnosed with benign insulinoma or NIPHS had symptom resolution. CONCLUSION: The surgical treatment of EHHS achieves excellent long-term results in the control of hypoglucemic symptoms

Enucleación laparoscópica de una neoplasia intraductal papilar mucinosa de ramos periféricos localizada en la cabeza del páncreas. Una nueva alternativa / Laparoscopic enucleation of a peripheral branch intraductal papillary mucinous neoplasm situated in the pancreatic head. A new alternative

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