Biliary reconstruction before clamp removal to avoid portal vein thrombosis in pediatric living-donor liver transplantation using hyper-reduced left lateral segment grafts: A novel technical strategy.

LT has become the treatment of choice for children with end-stage liver disease. The scarcity of donors and the considerable mortality on waiting lists have propelled the related living-donor techniques, especially in small children. This population need smaller and good quality grafts and are usually candidates to receive a LLS from a related donor. Many times this grafts are still large and do not fit in the receptor's abdomen, so a further hyper-reduction may be required. Despite all advances in LT field, vascular complications still occur in a considerable proportion remaining as a significant cause of morbidity, graft loss, and mortality. Technical issues currently play an essential role in its genesis. The widely spread technique for biliary and vascular reconstruction in living donor LT (LDLT) nowadays implies removal of the portal vein (PV) clamp after the venous anastomosis, then the arterial reconstruction is done, followed by the biliary reconstruction. However, due to the posterior location of the LLS bile duct, for its reconstruction, a rotation of the liver is required risking a potential transient PV occlusion leading to thrombosis afterward. We describe a new technique that involves performing biliary reconstruction after the PV anastomosis and before removing the vascular clamp, thus allowing to freely rotate the liver with less risk of PV occlusion and thrombosis.

Short- and Long-Term Outcomes After Live-Donor Transplantation with Hyper-Reduced Liver Grafts in Low-Weight Pediatric Recipients.

OBJECTIVE: To evaluate short- and long-term outcomes after live-donor liver transplantation (LT) with hyper-reduced grafts in low-weight pediatric recipients. LT is an established curative therapy for children with end-stage chronic liver disease or acute liver failure. A major problem in pediatric LT has been the lack of size-matched donor organs. The disadvantage of the use of large-for-size grafts is the insufficient tissue oxygenation and graft compression, which result in poor outcomes. The shortage of suitable donors is most notable in children under 10 kg. To overcome such obstacle, in situ hyper-reduced live-donor liver grafts have been introduced. Available articles in the literature are based on small samples and are deficient in long-term follow-up. METHODS: A single-cohort, retrospective analysis was conducted including 59 pediatric patients under 10 kg who underwent hyper-reduced (in situ "a la carte" left lateral segment reduction) live-donor LT (LDLT) between February 1994 and February 2018. RESULTS: The most frequent cause of liver failure was biliary atresia (70%). Median recipient weight was 8 kg. Vascular complications were confirmed in 15% of the sample, while 45% presented biliary complications. Median follow-up time was 40.3 months. Ten-year overall survival rate was 74%. Pediatric end-stage liver disease score > 23 was associated with a higher risk of post-operative complications. CONCLUSION: LDLT can be undertaken in children with body weight < 10 kg achieving good results in high-volume centers by experienced surgeons.

Percutaneous Patency Recovery and Biodegradable Stent Placement in a Totally Occluded Hepaticojejunostomy After Paediatric Living Donor Liver Transplantation.

Biliary complications after living donor liver transplantation (LDLT) cause severe morbidity and mortality, with biliary anastomotic stricture being the most common form of presentation. Surgical revision is risky, and it is avoided whenever possible. When a Roux-en-Y hepaticojejunostomy (RYHJ) is used for bilioenteric reconstruction, endoscopic approach is more difficult, if not impracticable. Therefore, percutaneous approach remains as a first-line treatment in these patients. In this case presentation, a percutaneous approach was used to recover patency in an intractable, totally occluded RYHJ stricture in an LDLT paediatric recipient, using a Rösch-Uchida needle to access to the collapsed jejunal loop from the bile duct. Once recanalization of the RYHJ was achieved, a biodegradable stent was placed with middle-term patency at follow-up.

Percutaneous Biliary Balloon Dilation: Impact of an Institutional Three-Session Protocol on Patients with Benign Anastomotic Strictures of Hepatojejunostomy.

BACKGROUND: Percutaneous biliary balloon dilation (PBBD) stands as a safe, useful, and inexpensive treatment procedure performed on patients with benign anastomotic stricture of Roux-en-Y hepatojejunostomy (BASH). However, the optimal mode of application is still under discussion. METHODS: A retrospective cohort study was conducted including patients admitted between 2008 and 2015 with diagnosis of BASH. Patients were divided into 2 groups: group I (n = 22), included patients treated after the implementation of an institutional protocol of 3 PBBD sessions within a fixed time interval and group II (n = 24) consisted of our historical control of patients who underwent one or 2 dilation sessions. Patency at one-year post procedure was assessed with the classification proposed by Schweizer. Symptomatic response to treatment was analyzed using the Terblanche classification. RESULTS: Patients in group I exhibited more excellent/good results (90 vs. 50%, p = 0.003) and less poor results (5 vs. 42%, p = 0.005) according to the Schweizer classification and more grade I/excellent results according to Terblanche classification (p = 0.003). Additionally, group I showed lower serum total bilirubin (p = 0.001), direct bilirubin (p = 0.002), alkaline phosphatase (p = 0.322), aspartate aminotransferase (p = 0.029), and alanine aminotransferase (p = 0.006). CONCLUSION: A protocol of 3 consecutive PBBD sessions within a fixed time interval may yield a high rate of patency, with a positive clinical, biochemical, and radiological impact on patients with BASH.

Intrahepatic cholangiojejunostomy for complex biliary stenosis after pediatric living-donor liver transplantation.

The treatment of biliary stenosis after pediatric LDLT is challenging. We describe an innovative technique of peripheral IHCJ for the treatment of patients with complex biliary stenosis after pediatric LDLT in whom percutaneous treatment failed. During surgery, the percutaneous biliary drainage is removed and a flexible metal stylet is introduced trough the tract. Subsequently, the most superficial aspect of the biliary tree is recognized by palpation of the stylet's round tip in the liver surface. The liver parenchyma is then transected until the bile duct is reached. A side-to-side anastomosis to the previous Roux-en-Y limb is performed over a silicone stent. Among 328 pediatric liver transplants performed between 1988 and 2015, 26 patients developed biliary stenosis. From nine patients requiring surgery, three patients who had received left lateral grafts from living-related donors due to biliary atresia were successfully treated with IHCJ. After a mean of 45.6 months, all patients are alive with normal liver morphological and function tests. The presented technique was a feasible and safe surgical option to treat selected pediatric recipients with complex biliary stenosis in whom percutaneous procedures or rehepaticojejunostomy were not possible, allowing complete resolution of cholestasis and thus avoiding liver retransplantation.

Transplantation with hyper-reduced liver grafts in children under 10 kg of weight.

BACKGROUND: We had previously described a left lateral segment hyper-reduction technique capable of sizing the graft according to the volume of the abdominal cavity of the recipient. AIM: The purpose of our study was to evaluate our 14-year live-donor liver transplantation experience with in situ graft hyper-reduction in children under 10 kg of weight. PATIENTS AND METHODS: Between January 1997 and May 2011, we performed 881 liver transplants. Two hundred and seventy-seven (n = 277) involved pediatric recipients, of which 102 (37 %) were from live donors. Thirty-five (n = 35) patients under 10 kg of weight underwent hyper-reduced living donor liver transplants. There were 21 females (60 %) and 14 males (40 %), with a median age of 12 months (range 3-23) and a median weight of 7.7 kg (range 5.6-10). RESULTS: Median operative time was 350 min (range 180-510). Median cold ischemia time was 180 min (range 60-300). Twenty-six (n = 26) patients required intraoperative transfusion of blood products. There were 49 postoperative complications involving 26 patients (74 % morbidity rate). One-, 3-, and 5-year survival rates were 87, 79, and 74 %, respectively. Twenty-eight patients are currently alive. CONCLUSIONS: Hyper-reduced grafts provide an alternative approach for low-weight pediatric recipients. The relatively high immediate postoperative morbidity could be related to the complexity of these patients.

Experience using liver transplantation for the treatment of severe bile duct injuries over 20 years in Argentina: results from a National Survey.

BACKGROUND: Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of benign disease and a few patients will develop end-stage liver disease (ESLD) requiring a liver transplant (LT). OBJECTIVE: Analyse the experience using LT as a definitive treatment of BDI in Argentina. PATIENTS AND METHODS: A national survey regarding the experience of LT for BDI. RESULTS: Sixteen out 18 centres reported a total of 19 patients. The percentage of LT for BDI from the total number of LT per period was: 1990-94 = 3.1%, 1995-99 = 1.6%, 2000-04 = 0.7% and 2005-09 = 0.2% (P < 0.001). The mean age was 45.7 ± 10.3 years (range 26-62) and 10 patients were female. The BDI occurred during cholecystectomy in 16 and 7 had vascular injuries. One patient presented with acute liver failure and the others with chronic ESLD. The median time between BDI and LT was 71 months (range 0.2-157). The mean follow-up was 8.3 years (10 months to 16.4 years). Survival at 1, 3, 5 and 10 years was 73%, 68%, 68% and 45%, respectively. CONCLUSIONS: The use of LT for the treatment of BDI declined over the review period. LT plays a role in selected cases in patients with acute liver failure and ESLD.

Factores pronósticos del hepatocarcinoma en el hígado no cirrótico tras su resección: presentación de 51 casos / Prognostic factors after resection of hepatocellular carcinoma in the non-cirrhotic liver: Presentation of 51 cases

Introducción La presentación, el tratamiento y el pronóstico del hepatocarcinoma dependen de la presencia o la ausencia de cirrosis. Existen pocos estudios de hepatocarcinoma en pacientes sin cirrosis. Objetivo Analizar una serie consecutiva de pacientes operados por hepatocarcinoma en hígado no cirrótico e identificar los factores de pronóstico de la recidiva y la supervivencia. Material y método Se operó a 51 pacientes entre 1990 y 2006. Se organizó una base de datos retrospectiva hasta el año 2001 y prospectiva desde esa fecha. Se evaluaron los resultados de la cirugía. Se realizaron análisis univariado y multivariado para identificar los factores asociados con la supervivencia y el tiempo libre de enfermedad. Resultados Treinta y tres pacientes eran de sexo masculino (mediana de edad de 49,8 años). Al 72,5% se le realizó una hepatectomía mayor. La mortalidad intrahospitalaria fue del 0% y la morbilidad del 43%. El tiempo de supervivencia fue del 90, el 75 y el 67% a uno, a 2 y a 3 años. El tiempo libre de enfermedad fue del 65, el 41 y el 37% a uno, a 2 y a 3 años. En el análisis univariado, la invasión vascular y la infiltración ganglionar fueron estadísticamente significativas para la supervivencia, pero ninguno de éstas fue significativa en el estudio multivariado. Conclusiones La resección hepática mayor es un tratamiento seguro para el tratamiento del hepatocarcinoma en el hígado no cirrótico. Tanto la presencia de invasión vascular como la infiltración ganglionar están estadísticamente relacionadas con la supervivencia, pero no se identificaron como factores pronósticos independientes de ésta (AU)

Background Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients. Objective To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival. Material and methods Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival. Results Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis. Conclusions Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable (AU)

[Prognostic factors after resection of hepatocellular carcinoma in the non-cirrhotic liver: presentation of 51 cases]. / Factores pronósticos del hepatocarcinoma en el hígado no cirrótico tras su resección: presentación de 51 casos.

BACKGROUND: Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients. OBJECTIVE: To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival. MATERIAL AND METHODS: Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival. RESULTS: Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis. CONCLUSIONS: Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable.

Endoscopic management of biliary complications after adult living-donor versus deceased-donor liver transplantation.

BACKGROUND: Although data about the incidence and management of biliary complications after deceased-donor liver transplantation (DDLT) are well defined, those pertaining to adult living-donor liver transplantation (LDLT) are conflicting. METHODS: We retrospectively compared endoscopic retrograde cholangio-pancreatography (ERCP) findings in 30 LDLT vs. 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction. LDLT and DDLT recipients were followed up for median durations of 30.5 and 36.0 months after the last ERCP, respectively. RESULTS: Postoperative biliary complications were more frequently identified at ERCP after LDLT versus DDLT (10/30 [33.3%] vs. 34/357 [9.5%]; P<0.001). Complications mainly consisted of anastomotic biliary strictures (10/30 [33.3%] vs. 27/357 [7.6%]; LDLT vs. DDLT recipients, respectively; P<0.001) and biliary leaks (4/30 [13.3%] vs. 6/357 [1.7%]; LDLT vs. DDLT recipients, respectively; P=0.005; some patients had both complications). Stricture dilation was successful in 4/10 (40%) LDLT vs. 27/27 (100%) DDLT recipients (P<0.001), and bile ducts remained patent up to the end of follow-up without further intervention in 2/10 (20.0%) vs. 21/27 (77.8%) patients, respectively (P=0.002). Endoscopic treatment of bile leaks was successful in 3/4 (75.0%) vs. 5/6 (83.3%) LDLT versus DDLT recipients, respectively (NS). CONCLUSIONS: Biliary complications were more frequent after LDLT compared with DDLT. Endoscopic treatment of anastomotic biliary strictures was successful in a minority of patients after LDLT, in contrast with DDLT. Most biliary leaks were successfully treated at endoscopy after LDLT or DDLT.

Liver transplantation: the last measure in the treatment of bile duct injuries.

BACKGROUND: Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI. METHODS: Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan-Meier test. RESULTS: Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24-152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively. CONCLUSION: Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.

[Clinical course of inflammatory bowel disease in patients transplanted for primary sclerosing cholangitis]. / Evolución de la enfermedad inflamatoria intestinal en pacientes sometidos a trasplante hepático por colangitis esclerosante primaria.

UNLABELLED: Primary sclerosing cholangitis is frequently associated with inflammatory bowel disease. OBJECTIVE: to evaluate the evolution of IBD in patients transplanted for PSC and the incidence of severe dysplasia/carcinoma. PATIENTS AND METHODS: we included 32 patients transplanted between 1988 and 2006 for PSC. Median follow-up: 8.7 years (1-20 y). All patients were evaluated pre-OLT with colonoscopy and multiple intestinal biopsies. Post-OLT surveillance colonoscopies were performed every 12 months. RESULTS: of 32 patients included, 26 had inflammatory bowel disease pre-OLT (ulcerative colitis 25, Crohn's disease 1). 12 patients had active intestinal disease pre-OLT and 2 patients had moderate dysplasia but were not surgically treated due to the severity of their liver disease. Among the 26 patients with IBD pre-OLT, 2 died in the postoperative period due to complications related to the transplantation procedure. Among the other 24 patients, 16 had a quiescent colonic disease post-OLT. Among them, 12 had quiescent disease pre-OLT and 4 showed improvement in their colonic symptoms after transplantation. Eight patients were symptomatic pre-OLT and had a transitory improvement in their symptoms post-OLT, with worsening of their intestinal disease by 5.7 +/- 2.8 months after transplantation. Three patients developed severe dysplasia or colonic cancer. CONCLUSIONS: over half of patients transplanted for PSC presented with quiescent intestinal disease. Yet, there was a group of patients that worsened their colonic symptoms and had a high incidence of dysplasia/carcinoma. It is necessary to maintain an adequate colonic surveillance even in the absence of colonic symptoms or active disease.

Ecografía intraoperatoria del páncreas / Intraoperative ultrasound in pancreatic pathology

Antecedentes: La ecografía intraoperatoria (EIO) es una herramienta fundamental que asiste al cirujano en la toma de decisiones con respecto a la resecabilidad de los tumores periampulares y para la detección y guía terapéutica de los tumores neuroendocrinos del páncreas. Objetivo: Evaluar la utilidad de la ecografía intraoperatoria en patología pancreática. Lugar de aplicación: Hospital Privado de Comunidad. Diseño: Serie de casos. Retrospectivo. Material y método: En el período junio 1996 a diciembre 1999, se realizaron 64 ecografías intraoperatorias en 64 pacientes operados de páncreas. La edad promedio de la población fue de 58 años. Las patologías tratadas fueron 46 carcinomas periampulares (5 de ellos con diagnóstico preoperatorio de irresecabilidad por tomografías computadas), 12 tumores quísticos, 4 pancreatitis crónicas y 2 tumores neuroendocrinos. Resultados: EIO modificó la estrategia intraoperatoria en 44 pacientes (67,2 por ciento). En carcinomas periampulares, la EIO fue útil para comprobar la invasión portal en 37 pacientes (80,4 por ciento) 8 de ellos también presentaron metástasis hepáticas (17,4 por ciento). En tumores quísticos, en 6 pacientes se encontró criterios ecográficos de malignidad (50 por ciento). En un paciente con insulinoma pancreático la EIO demostró enfermedad multicéntrica siendo necesario realizar pancretectomía total. En pancreatitis crónica la EIO fue útil para realizar punción biopsia de ganglios paraaórticos y también para elegir el lugar apropiado para realizar quisto-gastro anastomosis. Conclusiones: EIO en patología pancreática cambió la estrategia quirúrgica en 67,2 por ciento de los pacientes. En carcinoma periampular la visión de la invasión portal fue útil para no realizar una exploración quirúrgica agresiva y para evitar maniobras riesgosas. En tumores quísticos fue útil para diferenciar lesiones benignas de lesiones maliganas. Pequeños tumores neuroendocrinos fueron localizados con este método. En pseudoquistes pancreáticos el espesor de la pared y el lugar correcto para la anastomosis pudieron ser evaluados

Ecografía intraoperatoria del páncreas / Intraoperative ultrasound in pancreatic pathology

Antecedentes: La ecografía intraoperatoria (EIO) es una herramienta fundamental que asiste al cirujano en la toma de decisiones con respecto a la resecabilidad de los tumores periampulares y para la detección y guía terapéutica de los tumores neuroendocrinos del páncreas. Objetivo: Evaluar la utilidad de la ecografía intraoperatoria en patología pancreática. Lugar de aplicación: Hospital Privado de Comunidad. Diseño: Serie de casos. Retrospectivo. Material y método: En el período junio 1996 a diciembre 1999, se realizaron 64 ecografías intraoperatorias en 64 pacientes operados de páncreas. La edad promedio de la población fue de 58 años. Las patologías tratadas fueron 46 carcinomas periampulares (5 de ellos con diagnóstico preoperatorio de irresecabilidad por tomografías computadas), 12 tumores quísticos, 4 pancreatitis crónicas y 2 tumores neuroendocrinos. Resultados: EIO modificó la estrategia intraoperatoria en 44 pacientes (67,2 por ciento). En carcinomas periampulares, la EIO fue útil para comprobar la invasión portal en 37 pacientes (80,4 por ciento) 8 de ellos también presentaron metástasis hepáticas (17,4 por ciento). En tumores quísticos, en 6 pacientes se encontró criterios ecográficos de malignidad (50 por ciento). En un paciente con insulinoma pancreático la EIO demostró enfermedad multicéntrica siendo necesario realizar pancretectomía total. En pancreatitis crónica la EIO fue útil para realizar punción biopsia de ganglios paraaórticos y también para elegir el lugar apropiado para realizar quisto-gastro anastomosis. Conclusiones: EIO en patología pancreática cambió la estrategia quirúrgica en 67,2 por ciento de los pacientes. En carcinoma periampular la visión de la invasión portal fue útil para no realizar una exploración quirúrgica agresiva y para evitar maniobras riesgosas. En tumores quísticos fue útil para diferenciar lesiones benignas de lesiones maliganas. Pequeños tumores neuroendocrinos fueron localizados con este método. En pseudoquistes pancreáticos el espesor de la pared y el lugar correcto para la anastomosis pudieron ser evaluados (AU)

[Complications of hepatic resection surgery: a 12-month experience in a high case-load specialized center]. / Complicaciones de la cirugía de resección hepática: experiencia en 12 meses en un centro especializado de alto volumen.

BACKGROUND: Surgical treatment indications in benign and malignant hepatic tumors changed in last 20 years. Total number of hepatic resections increased in reference centers. OBJECTIVE: To evaluate complications after hepatic resections in a specific center, during a 12 months period. METHODS: Between January 2001 and January 2002, 80 patients with hepatic resection were analyzed. Mean age 55 years (r:14-79). Female: 55%. We analyze: tumor specifications, hepatic resection performed, transfusions, vascular clamping, operative time, associated procedures, length of hospital stage, postoperative complications and mortality. RESULTS: 61 patients (76.2%) were treated because of malignant pathology and 19 for benign. In 30 patients (37.5%) was made major resections and minor in 50 (62.5%). 16 patients (20%) required blood transfusions. Vascular intermittent clamping was used in 66 patients (82.5%). Associated procedures were made in 46 patients (58%). Mean operative time was 200'. Mean hospital stage: 6 days (r:3-12). Morbidity: 15 patients (18.7%). Complications were significantly higher in patients with: major hepatic resections (p: 0.002); primary hepatic tumors (p: 0.01); mean operative time more than 200' (p: 0.00007). Mortality associated with the procedure: 0%. CONCLUSIONS: 1-Hepatic resections performed in high volume centers have a low complication risk and almost with no mortality. 2-Major hepatic resection, primary malignant tumors and mean operative time more than 200', were risk factors associated with postoperative complications.

Complicaciones de la cirurgia de reseccion hepatica: experiencia en 12 meses en un centro especializado de alto volumen / Complications of the hepatic resection surgery: a 12-month experience in a high case-load specialized center

Antecedentes: La indicación de cirurgía en los tumores hepáticos benignos y malignos cambió en los últimos 20 años, aumentando el número de hepatectomías anuales en centros de referencia. Objetivo: Evaluar las complicaciones asociadas a la cirurgía de resección hepática en un centro de alto volumen, durante un año. Lugar de Aplicación: Institución privada de atención terciaria. Diseño: Cohorte, retrospectivo. Población y Método: Se incluyeron 80 pacientes sometidos a resecciones hepáticas, entre enero de 2001 y enero de 2002. Promedio de edad 55años (r:14-79). Sexo femenino 55%. Se analizó:origem del tumor, magnitud de la resección, uso de transfusiones, tiempo operatorio, uso de campeo vascular, procedimientos asociados, dias de internación, morbilidad y mortalidad. Resultados: 61 pacientes (76.2%) presentaron patología maligna y 19 (23.8%) benigna. Magnitude de las resecciones: 30 hepatectomías mayores (37.5%) y 50 menores (62.5%). Campeo vascular en 66 pacientes (82.5%). En 46 pacientes (58%) se realizó algún procedimiento asociado. Tiempo operatorio promedio: 200 minutos. Promedio de internación: 6 días. Morbilidad 15 pacientes (18.7%). Las complicaciones fueron significativamente más frecuentes en: resecciones hepáticas mayores (p: 0.002), tumores hepáticos primarios (p:0.01) y en cirurgías de más de 200' (p: 0.00007). Mortalidad 0%. Conclusiones: 1- las resecciones hepáticas en centros de alto volumen presentan escasa morbi-mortalidad. 2- Las resecciones hepáticas mayores, los tumores malignos primarios y las operaciones de más de 200', fueron factores de riesgo asociados a complicaciones postoperatorias.

Complicaciones de la cirurgia de reseccion hepatica: experiencia en 12 meses en un centro especializado de alto volumen / Complications of the hepatic resection surgery: a 12-month experience in a high case-load specialized center

Antecedentes: La indicación de cirurgía en los tumores hepáticos benignos y malignos cambió en los últimos 20 años, aumentando el número de hepatectomías anuales en centros de referencia. Objetivo: Evaluar las complicaciones asociadas a la cirurgía de resección hepática en un centro de alto volumen, durante un año. Lugar de Aplicación: Institución privada de atención terciaria. Diseño: Cohorte, retrospectivo. Población y Método: Se incluyeron 80 pacientes sometidos a resecciones hepáticas, entre enero de 2001 y enero de 2002. Promedio de edad 55años (r:14-79). Sexo femenino 55%. Se analizó:origem del tumor, magnitud de la resección, uso de transfusiones, tiempo operatorio, uso de campeo vascular, procedimientos asociados, dias de internación, morbilidad y mortalidad. Resultados: 61 pacientes (76.2%) presentaron patología maligna y 19 (23.8%) benigna. Magnitude de las resecciones: 30 hepatectomías mayores (37.5%) y 50 menores (62.5%). Campeo vascular en 66 pacientes (82.5%). En 46 pacientes (58%) se realizó algún procedimiento asociado. Tiempo operatorio promedio: 200 minutos. Promedio de internación: 6 días. Morbilidad 15 pacientes (18.7%). Las complicaciones fueron significativamente más frecuentes en: resecciones hepáticas mayores (p: 0.002), tumores hepáticos primarios (p:0.01) y en cirurgías de más de 200 (p: 0.00007). Mortalidad 0%. Conclusiones: 1- las resecciones hepáticas en centros de alto volumen presentan escasa morbi-mortalidad. 2- Las resecciones hepáticas mayores, los tumores malignos primarios y las operaciones de más de 200, fueron factores de riesgo asociados a complicaciones postoperatorias. (AU)

Complicaciones de la cirugía de resección hepática: experiencia en 12 meses en un centro especializado de alto volumen. / [Complications of hepatic resection surgery: a 12-month experience in a high case-load specialized center]

BACKGROUND: Surgical treatment indications in benign and malignant hepatic tumors changed in last 20 years. Total number of hepatic resections increased in reference centers. OBJECTIVE: To evaluate complications after hepatic resections in a specific center, during a 12 months period. Methods: Between January 2001 and January 2002, 80 patients with hepatic resection were analyzed. Mean age 55 years (r:14-79). Female: 55

. We analyze: tumor specifications, hepatic resection performed, transfusions, vascular clamping, operative time, associated procedures, length of hospital stage, postoperative complications and mortality. RESULTS: 61 patients (76.2

) were treated because of malignant pathology and 19 for benign. In 30 patients (37.5

) was made major resections and minor in 50 (62.5

). 16 patients (20

) required blood transfusions. Vascular intermittent clamping was used in 66 patients (82.5

). Associated procedures were made in 46 patients (58

). Mean operative time was 200. Mean hospital stage: 6 days (r:3-12). Morbidity: 15 patients (18.7

). Complications were significantly higher in patients with: major hepatic resections (p: 0.002); primary hepatic tumors (p: 0.01); mean operative time more than 200 (p: 0.00007). Mortality associated with the procedure: 0

. CONCLUSIONS: 1-Hepatic resections performed in high volume centers have a low complication risk and almost with no mortality. 2-Major hepatic resection, primary malignant tumors and mean operative time more than 200, were risk factors associated with postoperative complications.

Resecciones hepáticas: importancia de la técnica quirúrgica y anestésica en el consumo de sangre y hemocomponentes / Hepatic resections: relevance of the surgical and anesthetic techniques regarding the intraoperative hemoderived used

Antecedentes: La cirugía de resección hepática, se ha caracterizado desde sus inicios por una alta tasa de morbimortalidad, relacionada esencialmente con el riesgo de hemorragia y la necesidad de transfusiones masivas. La experiencia acumulada en 900 intervenciones, permitió el desarrollo de procedimientos quirúrgicos y anestésicos que disminuyeron el consumo de sangre y mejoraron los resultados. Objetivo: Conocer el efecto sobre el consumo de hemocomponentes y la evolución postoperatoria inmediata a partir de modificaciones en la técnica anestésica, quirúrgica, en enfermos sometidos a resecciones hepáticas, practicadas por el mismo equipo anestésico-quirúrgico. Material y método: 2 grupos de enfermos sometidos a resecciones hepáticas comparables. Grupo I: 45 enfermos consecutivos intervenidos entre 1983/1987. Técnica anestésica: Neuroleptoanestesia y Anestesia inhalatoria. Transfusión de sangre de acuerdo a la estimación de pérdidas. El parámetro intraoperatorio más importante fue la presión arterial. Grupo II: 45 enfermos consecutivos intervenidos en el año 2000. Técnica anestésica: endovenosa. Transfusión de sangre: separada en hemocomponentes y sangre autóloga, de acuerdo a guías de la ASA. Parámetro intraoperatorio más importante: presión arterial y presión venosa central. La última variable debe permanecer por debajo de 5 cm de H2O. Se utilizaron además drogas vasoactivas. Resultados: Grupo I: transfundidos: 77,8 por ciento, Grupo II: transfundidos 53,3 por ciento (p=0,027). Promedio de horas en respirador: Grupo I: 18,2, Grupo II: 4 (p=0,0001). Promedio de días en Unidad de Cuidados Intensivos: Grupo I: 9,11, Grupo II: 2,6 (p=0,06). Promedio de días de internación: Grupo I: 12, Grupo II: 7 (p=0,006). Morbilidad: Gupo I: 71 por ciento, Grupo II: 26,7 por ciento (p=0,0001). Mortalidad: Grupo I: 6,7 por ciento, Grupo II: 0 por ciento (p=0,24). Conclusiones: Las modificaciones en la técnica quirúrgica, anestésica y transfusional permitieron: Disminuir los requerimientos transfusionales, reducir el uso de la asistencia respiratoria mecánica, acortar la estadía hospitalaria y mejorar la morbilidad