Segmentectomía lateral izquierda laparoscópica en donante vivo para trasplante hepático adulto-pediátrico

Introducción: La segmentectomía lateral izquierda es el procedimiento más empleado para la cirugía del donante en trasplante hepático con donante vivo adulto-pediátrico (THDVA-P), y ha demostrado ser seguro y reproducible. Sin embargo, la información aún es escasa respecto al abordaje laparoscópico. Objetivo: El objetivo de este artículo es dar a conocer los resultados posoperatorios de la segmentectomía lateral izquierda laparoscópica (SLI-L) para THDVA-P. Materiales y Método: Realizamos un estudio retrospectivo, observacional, de un solo centro, Hospital del Salvador; con vasta experiencia en trasplante hepático y en resecciones hepáticas laparoscópicas. Se ofreció realizar el procedimiento de SLI-L para la cirugía del donante vivo. Se describe la técnica quirúrgica y los resultados posoperatorios de los donantes. Resultados: Entre abril de 2015 y enero de 2021, 36 pacientes, 25 de ellos hombres, fueron sometidos a SLI-L. El 86% eran madre o padre del receptor, con una mediana de 30 años (19-45). Mediana de tiempo operatorio de 360 min (240-480). Hubo conversión en un caso debido a sangrado venoso de difícil manejo y en dos oportunidades se utilizó técnica mano asistida por la misma causa. Morbilidad Clavien-Dindo III en un paciente debido a fuga biliar precoz, manejada con prótesis vía colangiopancreatografía retrógrada endoscópica exitosamente. La mediana de hospitalización fue de 4 días (3-12) y no hubo mortalidad. Conclusión: La SLI-L ha evolucionado, desde un procedimiento innovador hasta convertirse en el actual procedimiento estándar para THDVA-P. Los buenos resultados en términos de morbimortalidad sugieren que podría ser una técnica segura y reproducible en contextos similares al del centro.

Introduction: Living donor left lateral sectionectomy is a well-established alternative in cadaveric donor pediatric liver transplantation. This procedure has proven to be safe and reproducible. However, laparoscopic approach is still under development and evidence of its feasibility is limited. Aim: The aim of this article is to present the surgical technique and postoperative outcomes of the cases of laparoscopic left lateral sectionectomy performed in this center. Materials and Method: A retrospective, observational, single center study was conducted in Hospital del Salvador. From 04/2015 - 01/2021 laparoscopic left lateral sectionectomy was offered for donor surgery. We present the surgical technique, perioperative care, and early postoperative outcomes in donors. Results: This series includes 36 patients, 25 (69%) of them were males. A total of 31 (86%) donors were mother or father of the recipient. Median age of donors was 30 years (19-45), median operative time was 360 min (240-480). All the patients underwent laparoscopic left lateral sectionectomy. Conversion was necessary in one case due to difficult management of a venous bleeding. Clavien-Dindo Morbidity III, in one patient who required endoscopic retrograde cholangiopancreatography due to an early bile leak. Median hospitalization was 4 days (3-14). There was no mortality. Conclusion: Laparoscopic left lateral sectionectomy has proven to be safe and reproducible. This technique has evolved from an innovative procedure to become the current standard of practice in our center, with excellent results in terms of morbidity and mortality.

[Living donor graft versus cadaveric in pediatric liver transplantation. Multicentric study]. / Injerto de donante vivo versus fallecido en trasplante hepático pediátrico. Estudio multicéntrico.

Liver transplantation (LT) is the therapy of choice in patients with end-stage chronic liver disease, se vere acute liver failure, and metabolic diseases, among other pathologies. Historically, more patients have been on the waiting list than organs for transplantation. In 1999, we started a living-related donor liver transplantation program. OBJECTIVE: to compare surgical results and graft survival in liver transplanted patients with living donor graft (LDG) versus deceased donor graft (DDG). PATIENTS AND METHOD: Retrospective observational analytical study of pediatric patients undergoing LT at the Dr. Luis Calvo Mackenna Hospital and Las Condes Clinic between 1999 and 2020 in Santia go, Chile. They were grouped into LDG and DDG and demographic characteristics, complications, and graft and patient survival were compared. RESULTS: 276 LT were performed. Of these, 198 were included, of which 81 were LDG and 117 were DDG. The recipients of LDG had a lower average weight (p < 0.001), a higher frequency of portal vein thrombosis (13.6% versus 4.3%; p = 0.006), biliary stricture (38.3% versus 14.5%; p < 0.001), and surgical reintervention (76.5% versus 57.3%, p = 0.006). Survival of DDG and LDG patients at 1 year and 5 years was 86.1% and 72.3% versus 82.5% and 81.1%, respectively (p = 0.16). Graft survival at one year and 5 years was significantly higher in LDG with 80% and 78.6% versus 79% and 62% in DDG, respectively (p = 0.032). The recipient's weight between 9-13 kg was significantly correlated with a higher frequency of hepatic artery thrombosis (RR = 1.98) in the multivariate analysis. CONCLUSION: Our study demonstrated comparable long-term results in LDG despite greater postoperative complications, which supports continuing its use as an option in pediatric LT.

PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) en el tratamiento de la carcinomatosis peritoneal: primeros casos en Chile / PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) in the treatment of peritoneal carcinomatosis: first cases in Chile

Resumen Introducción: PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) Es una técnica que, vía laparoscopía, permite administrar quimioterapia en aerosol intraperitoneal, para el tratamiento de la carcinomatosis, ya sea para disminuir masa tumoral y aumentar la resecabilidad, o como paliación sintomática. Objetivo: Presentar los dos primeros casos de PIPAC en Chile, las consideraciones técnicas y revisión de la literatura. Pacientes y Método: Se describe la forma en que un programa PIPAC fue implementado en Clínica Las Condes. Se describe la técnica. Este procedimiento se realizó en dos pacientes, ambas portadoras de carcinomatosis con ascitis refractaria. Resultados: No hubo complicaciones. Alta a las 24 h. Ambas pacientes presentaron disminución de la ascitis, la que se ha mantenido a los seis meses de seguimiento. Discusión: PIPAC es una técnica emergente, que ha demostrado ser segura, con escasas complicaciones, cuya indicación incluye carcinomatosis por cáncer de colon y ovario y que se está extendiendo a páncreas, vía biliar y estómago. Su rol exacto está por definirse. Conclusiones: PIPAC es una técnica factible de realizar en nuestro país; sus resultados preliminares son alentadores y exentos de complicaciones.

Introduction: PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy is a technique that allows laparoscopic administration of aerosol chemotherapy in the peritoneum. This procedure is utilized for treatment of carcinomatosis, for debulk abdominal tumors, increasing resectability, or for palliation of abdominal symptoms. Aim: To present the first two cases of PIPAC performed in Chile, technical considerations and review of the literature. Patients and Method: The way this program was started at Clínica Las Condes is presented. The technique is described. This procedure was performed in two females, both with refractory ascites due to carcinomatosis. Results: The procedure was uneventfully and patients were discharged 24 hours later. Both patients showed important reduction of ascites, maintained at 6 months of followup. Discussion: PIPAC is a safe emerging technique, with low complication rate. It is indicated in carcinomatosis of colonic and ovarían origin and in selected cases of pancreatic, bile duct and gastric carcinomatosis. More prospective, randomized studies should be done to stablish its exact role. Conclusions: PIPAC is a feasible technique to perform in our country. Preliminary results are encouraging and no complications were observed.

Efectos de la pandemia en los programas de formación en cirugía: problemas y soluciones / Effects of pandemic on training programs in surgery: problems and solutions

Resumen La pandemia por el virus SARS-CoV-2 ha afectado fuertemente los programas de educación quirúrgica. El Capítulo Chileno del American College of Surgeons realizó un webinar para evaluar y discutir los efectos de la pandemia en la educación quirúrgica. Este evento contó con la asistencia de 450 personas de 17 países, incluyendo la participación de destacados docentes del área quirúrgica. Las principales conclusiones de este webinar fueron que la pandemia alteró considerablemente los programas de educación quirúrgica. Un 26% de los residentes se contagiaron, pero la mayoría no precisó cuidados especiales. Las intervenciones quirúrgicas disminuyeron hasta en un 90% en algunos programas. Los residentes debieron asumir el cuidado de pacientes COVID-19. Se han implementado sistemas de enseñanza virtual, como seminarios en línea o webinars, discusión de casos clínicos, videos y simulación. Dichas actividades teóricas, al igual que la simulación quirúrgica fueron evaluadas, mayoritariamente, vía web. Las sociedades científicas han tenido un importante rol en estas actividades. En el futuro, los programas universitarios enfrentarán escenarios con menos pacientes y una reducción de las oportunidades de enseñanza para residentes. Las actividades en línea y simulación adquirirán mayor relevancia. Es posible superar esta crisis como lo han hecho los países desarrollados, comparados con ellos, carecemos de un plan nacional de emergencia en salud, en el que los estudiantes y personal sanitario tengan un rol definido en áreas específicas, con metas concretas. El retorno a la "nueva normalidad" estará lleno de desafíos.

The SARS-CoV-2 pandemic has had an impact in surgical residency programs. The Chilean chapter of the American College of Surgeons organized a webinar to discuss and address the effects of this pandemic on surgical education. This meeting had a virtual attendance of 450 people from 17 countries, including the participation of surgical educators. Conclusions of this webinar were that COVID-19 has strongly affected surgical education programs. Twenty six per cent of residents were infected. Most of them did not need special care. Surgical opportunities have decreased up to 90% in some programs. Residents have had to be involved in managing COVID-19 patients. Changes in surgical education, led to a virtual instruction which includes seminars, webinars, case discussion, videos and simulation. Assessment has been performed of theoretical activities, via web. Simulation tasks also have been evaluated. Scientific societies had a very important role in these activities. In the near future, university programs will face different scenarios in hospitals and clinical centers, with fewer patients and reduced clinical instruction for residents. Online activities and simulation will increase in relevance in years to come. It is possible to overcome this crisis, as some developed countries have already done, compared to them, we lack a national emergency health plan in which medical students, residents, doctors, and all health care providers have a designated role in specific areas with clear goals. The return to "the new normal" will be filled with challenges.

Trasplante hepático en Chile: pasado, presente y futuro / Hepatic transplantation in Chile: past, present and future

Resumen La donación de órganos en Chile es insuficiente, con una tasa histórica de alrededor de seis donantes por millón de habitantes. Las reformas legales, mejoras organizacionales y campañas comunicacionales han permitido hacer del año 2019 el más exitoso en cuanto a donación de órganos y trasplantes. El trasplante hepático en Chile fue realizado por primera vez en el año 1969 en el Hospital Naval de Valparaíso, falleciendo el receptor precozmente. El primer trasplante exitoso fue realizado en el año 1985 en el Hospital Militar de Santiago. Desde esa fecha hasta la actualidad se han realizado 1.812 trasplantes de hígado, el 43,6% en hospitales universitarios, el 35,1% en clínicas privadas y un 21,5% en hospitales estatales. El 23,1% en la Pontificia Universidad Católica (PUC), el 20,6% en el Hospital Clínico de la Universidad de Chile (HCUCH), el 15,9% en el Hospital Luis Calvo Mackenna (HLCM), el 15,9% en Clínica Las Condes (CLC), el 14,3% en Clínica Alemana de Santiago (CA), el 5,6% en el Hospital del Salvador (HdS), 2% en Clínica Dávila (CD), 2% en el Sanatorio Alemán de Concepción (SA) y 0,9% en Clínica Santa María (CSM) De este total, 455 son en pacientes pediátricos, de ellos 63,3% en Hospital Luis Calvo Mackenna el 21,1% en la Clínica Las Condes el 7,7% en la Pontificia Universidad Católica de Chile, el 6,4% en la Clínica Alemana y 1,5% en el Sanatorio Alemán. Desde el 2015, aproximadamente el 80% de los trasplantes pediátricos se realizan en el HLCM. Sobrevidas reportadas en adultos van del 75% a 85% al año y de 75% a 92% al año en pacientes pediátricos dependiendo el período. Hay centros que nunca han reportado sus resultados. Se espera mejorar la educación en pro de una sociedad proclive en la donación, mejorar la organización de detección, mantención y procuramiento, aumentar la utilización de órganos, potenciar la utilización los de donantes cadáveres, con técnica Split o hígado dividido y, mientras no tengamos un sistema de donación que dé cuenta de las necesidades del país, mantener los programas de donante vivo. Finalmente debe motivarse a generaciones jóvenes para que se dediquen a esta importante actividad.

Organ donation in Chile is insufficient, with a historical rate of six donors per million inhabitants. Legal reforms, organizational improvements, and communications campaigns have made 2019 the most successful year in terms of organ donations and transplants. The first liver transplant in Chile was performed in 1969 at the Naval Hospital in Valparaíso. However, the patient passed away shortly after. The first successful transplant was performed in 1985 at the Militar Hospital in Santiago. As of that date to present day, 1.812 liver transplants have been performed: 43.6% of these in university hospitals, 35.1% in private clinics, and 21.5% in state hospitals. Of these, 23.1% were performed at the Pontificia Universidad Católica de Chile (PUC), 20.6% at the Universidad de Chile Clinical Hospital (HCUCH), 15.9% at the Luis Calvo Mackenna Hospital (HLCM), 15.9% at the Las Condes Clinic (CLC), 14.3% at the Alemana Clinic in Santiago (CA), 5.6% at the del Salvador Hospital (HdS), 2% at the Dávila Clinic (CD), 2% at the Alemán Sanatorium in Concepción (SA), and 0.9% at the Santa María Clinic (CSM). Of this total, 455 correspond to pediatric patients. Of these patients, 63.3% were at the Luis Calvo Mackenna Hospital, 21.1% at the Las Condes Clinic, 7.7% at the Pontificia Universidad Católica de Chile, 6.4% at the Alemana Clinic, and 1.5% at the Alemán Sanatorium. Since 2015, approximately 80% of pediatric transplants are performed at the HLCM. Reported one-year survival range from 75% to 85% in adults and 75% to 92% in pediatric patients per year, depending on the period. Some centers have never reported their results. It is expected that education of a society prone to organ donation improves, as well as improving the detection, maintenance, and procurement of potential donors, increasing the utilization of organs, enhancing the utilization of organs from deceased donors with Split technique, and, while we are building towards a donation system that responds to the needs of the nation, upholding live donor programs. Finally, younger generations are to be motivated so that they dedicate themselves to this important activity.

Asociación de la partición hepática y ligadura de la vena portal para hepatectomía por etapas, un nuevo procedimiento en cirugía hepática / Associating liver partition and portal vein ligation for staged hepatectomy, a new hepatic procedure

Introduction: Hepatic resection is the standard treatment for the liver tumors and in most cases the only potentially curative option. The most feared complication, in the major hepatic resection, is the postoperative liver failure. A new technique has recently been published in the literature: Liver partition associated to a portal vein ligation for staged hepatectomy. This technique allows an accelerated hipertrophy of the remnant liver, facilitates greater resection surgery, reducing the risk of postoperative hepatic ischemia. The results reported in the literature are promising. We report the first case in Chile with its evolution to 2 years and a discussion about the topic.

La resección hepática es el tratamiento estándar para los tumores hepáticos malignos y en la mayoría de los casos la única opción potencialmente curativa. La complicación más temida, en las grandes resecciones, es la insuficiencia hepática postquirúrgica. Una nueva técnica ha sido recientemente publicada en la literatura: La partición hepática asociada a la ligadura de la vena portal para realizar una hepatectomía por etapas. Esta técnica permite una hipertrofia acelerada del hígado remanente que posibilita una cirugía resectiva mayor, disminuyendo el riesgo de isquemia hepática postquirúrgica. Los resultados expuestos en la literatura son promisorios. Presentamos el primer caso clínico en Chile con su evolución a 2 años y una discusión del tema.

Resección de metástasis hepáticas en cáncer de colon: nuevas perspectivas / Resection of liver metástasis in colon cancer: new perspectives

Liver metastasis of colon cancer is a very common clinical entity. Resective surgery can be used to improve the overall survival and disease-free. The problem is that major resections are associated with hepatic failure caused by an inadequate residual volume. Chemotherapy with diagrams as FOLFOX, FOLFIRI associated with antibodies such as bevacizumab, cetuximab or panitumumable added an important role in the conversion of unresectable to resectable tumors. Another widely used technique is portal vein ligation in a first surgical procedure, that generates left hepatic growth, to perform the resection in a second surgical procedure. The liver hypertrophy is achieved in a period of 2 months. The latest new technical procedure is the association of the ligation portal to the liver partition of the hepatic parenchyma without resection, which allows a segmental hypertrophy of the liver remnant between 7 to 10 days. This technique is called ALPPS. Radiofrecuency also has a role in the treatment of liver metastases. However,it is secondary.

La metástasis hepáticas del cáncer de colon es una entidad clínica muy frecuente. La cirugía resectiva permite mejorar la sobrevida global y libre de enfermedad. El problema es que grandes resecciones se asocian a insuficiencia hepática por un inadecuado volumen residual. La quimioterapia con esquemas como FOLFOX, FOLFIRI asociada a anticuerpos como bevacizumab, cetuximab o panitumumable agregan un rol importante en la conversión de tumores irresecables a resecables. Otra técnica utilizada es la ligadura portal en un primer tiempo, que genera crecimiento hepático izquierdo, para realizar la resección en un segundo tiempo quirúrgico. La hipertrofia hepática se logra en un período de 2 meses. La última novedad técnica es la asociación de la ligadura portal a la transección del parénquima hepático sin resección, lo que permite una hipertrofia segmentaria del hígado remanente entre 7 a 10 días. Esta técnica se denomina ALPPS. La radiofrecuencia también tiene un rol en el tratamiento de las metástasis hepáticas, aunque este es secundario.

Ictericia post-operatoria / Post-operative jaundice

The occurrence of postoperative jaundice should encourage the surgeon to review the wide spectrum of possible causes of jaundice and perform detailed history, physical examination and laboratory tests to define the causes, and take the measures to treat the patient properly. We also emphasize the need to prevent the presence of residual stones in the bile duct and bile duct iatrogenic injuries. This paper describe the possible causes of postoperative jaundice and current recommendations for adequate treatment.

La aparición de ictericia en el postoperatorio debe alertar al cirujano y llevarlo a revisar el gran espectro de causas posibles del cuadro. Se debe realizar una anamnesis y examen físico detallado y complementarlo con exámenes de laboratorio e imágenes según el caso. Además, se insiste en la necesidad de prevenir la presencia de cálculos residuales en colédoco y lesiones iatrogénicas de vía biliar. Se revisan las causas posibles de ictericia postoperatoria y las recomendaciones actuales de manejo.

Alternativas de manejo de colecciones en pancreatitis aguda / Alternatives in the treatment of collections in acute pancreatitis

Acute pancreatitis is a disease that presents heterogeneously with varying severity depending on pancreatic parenchyma and peripancreatic fat. The aim of this publication is to present the nomenclature in use in the different collections that develop in the evolution of acute pancreatitis, and management options of these collections, focusing on the management of infected pancreatic necrosis; emphasizing the benefits, results and limitations of each technique and describing some techniques under development.

La pancreatitis aguda es una enfermedad que se presenta en forma heterogénea con distinta gravedad según el compromiso del parénquima pancreático y de la grasa peripancreática. El objetivo de esta publicación es dar a conocer la nomenclatura en uso en las distintas colecciones que se manifiestan en la evolución de la pancreatitis aguda y las opciones de manejo de estas colecciones, enfocándose en el manejo de la necrosis pancreática infectada; enfatizando las ventajas, resultados y limitaciones de cada técnica, además de describir algunas técnicas en desarrollo.

Manejo inicial y conceptos en trauma: vía aérea, reposición de volumen, toracotomía de urgencia / Initial approach and trauma concepts: airway, volume reposition and resuscitative thoracotomy

La atención inicial del paciente politraumatizado incluye una evaluación inicial y resucitación, una fase intermedia o de monitorización y una evaluación secundaria, diagnóstica en la que se debe realizar un examen detallado por órganos y sistemas para proceder a un tratamiento definitivo. En este artículo se tratan aquellas patologías que ponen en peligro la vida del paciente y que precisan acciones terapéuticas inmediatas, como son la obstrucción de vía aérea, el neumotórax a tensión, el taponamiento cardiaco, neumotórax simple y neumotórax abierto. El shock, definido por un grado severo de hipoperfusión tisular, necesita ser corregido mediante una infusión adecuada de volumen incluyendo factores de coagulación para evitar el círculo vicioso de la llamada “tríada letal” que corresponde a hemorragia, hipotermia y coagulopatía, que a su vez perpetúa la hemorragia. La toracotomía de reanimación tiene indicaciones precisas y sus resultados dependen de la etiología del traumatismo, siendo mejor al utilizarse en lesiones penetrantes cardiacas y con el menor tiempo en que se efectúa.

The initial care of trauma patients includes an initial assessment and resuscitation an intermediate or secondary monitoring and evaluation (diagnostic) in which to undertake a detailed examination of organs and systems to proceed to definitive treatment. This article discusses those conditions that threaten the life of the patient and require immediate therapeutic actions. These situations are airway obstruction, tension pneumothorax, cardiac tamponade and simple or open pneumothorax. The treatment of Shock, defined by a severe degree of tissue hypoperfusion, needs to be corrected by adequate volume infusion including clotting factors to prevent the vicious circle of the "lethal triad": hemorrhage, hypothermia and coagulopathy. In the case of need for a resuscitative thoracotomy, this technique has precise indications and its results depend on the etiology of the trauma and with better results if to be used in penetrating cardiac trauma and incases of rapid use after production of the damage.

Trasplante hepático pediátrico estudio descriptivo de la experiencia recogida por el grupo de trasplante pediátrico de Clínica Las Condes y Hospital Luis Calvo Mackenna / Pediatric liver transplantation: descriptive study of the experience in liver transplantation at Clínica Las Condes and Luis Calvo Mackenna Hospital

El trasplante hepático pediátrico (THP) es la única alternativa de tratamiento para niños que padecen enfermedades hepáticas terminales, ya sean éstas agudas o crónicas. En Chile el THP representa aproximadamente un 20 por ciento del total de trasplantes de hígado realizados en nuestro país. Objetivo: Exponer las indicaciones, procedimientos y principales complicaciones del THP desde el punto de vista teórico y realizar un estudio descriptivo de la experiencia recogida por el grupo de trasplante pediátrico de Clínica Las Condes y Hospital Luis Calvo Mackenna desde 1994 a 2009 en esta materia. Material y Métodos: Se recolectaron los datos de 209 trasplantes hepáticos realizados a 173 pacientes menores de 18 entre 1994 y 2009 en ambos centros, realizando estadística descriptiva y curvas de sobrevida de Kaplan y Meier. Resultados: Las principales causas de trasplante fueron Atresia de Vías Biliares (48 por ciento) y Falla hepática aguda (28 por ciento). Cuarenta y un trasplantes se realizaron en niños menores de 10 kilos. Se trasplantaron con donante vivo 27 por ciento de los casos. Las complicaciones vasculares se presentaron en 13 por ciento de los casos y las biliares en 14 por ciento. Rechazos moderados o severos se diagnosticaron en 36 por ciento de los trasplantes. Enfermedad por Citomegalovirus se detectó en 30 por ciento de los pacientes dentro del primer año post trasplante y síndrome linfoproliferativo en 5 por ciento. La sobrevida actuarial de pacientes a 1 año ha sido de 76 por ciento, a 5 años de 67 por ciento y a 10 años de 65 por ciento. Conclusión: Los resultados del THP en términos de sobrevida y complicaciones es similar a la experiencia de centros extranjeros, la cual es superior a las expectativas y calidad de vida de los pacientes sin trasplante. Las áreas de mayor desarrollo de nuestro centro y que presentan los mayores desafíos son el trasplante hepático en niños menores de 10 kilos, en falla hepática aguda, y el uso de donante vivo.

Pediatric liver transplantation (PLT) is the only therapeutic option for children with acute or chronic end stage liver disease. In Chile PLT represents approximately 20 percent of all liver transplants performed. Objective: To present indications, procedures and main complications of PLT from an theoretic point of view and describe the experience achieved by the pediatric liver transplant team of Clínica Las Condes and Hospital Luis Calvo Mackenna from 1994 to 2009 in this field. Methods: Data from 209 liver transplants performed in 173 patients younger than 18 years old, between 1994 and 2009 were analyzed with descriptive statistics. Kaplan-Meier’sactuarial survival graphs were calculated. Results: The main liver diseases leading to PLT were Biliary Atresia (48 percent) and Acute Liver Failure (28 percent). Forty-one transplants were performed in children weighting b 10 kilograms. Living donor was used in 27 percent of the cases. Vascular complications occurred in 13 percent and biliary reoperations performed in 14 percent. Moderate and severe acute graft rejection was diagnosed in 36 percent of the transplants. Cytomegalovirus disease occurred in 30 percent of the cases and post transplant lymphoproliferative disease in 5 percent. Actuarial patients survival at 1 year has been 76 percent, at 5 years 67 percent and at 10 years 65 percent. Conclusion: Results of PLT in terms of survival and complications is comparable to foreign transplant centers, which is superior to life expectancy and quality of life of these patients without liver transplant. The areas that have exhibit major development in our center and represent the biggest challenge are liver transplant in small children, in patients with acute liver failure, and the use of living donors.

[Cytomegalovirus infection and disease in pediatric solid organ transplantation. Experience in a Chilean multiorganic transplantation center]. / Infección y enfermedad por citomegalovirus en niños sometidos a trasplante de órgano sólido. Experiencia en un centro de referencia chileno.

UNLABELLED: Cytomegalovirus (CMV) infection and disease in transplant (Tx) recipients may severely complicate the patients outcome. AIM: To determine the incidence, clinical characteristics and risk factors for CMV infection and disease in liver and kidney transplant recipients in a tertiary care children's hospital. METHOD: A clinical and laboratory evaluation was prospectively performed in 44 and 20 children receiving a renal and liver Tx respectively in the Hospital Luis Calvo Mackenna between 2004 and 2006. RESULTS: At the time of the organ Tx 20.3% (13/64) children were seronegative for CMV. Thirty six per cent (23/64) patients were infected with CMV, of whom 32% (14/44) received kidney Tx and 9/20 (45%) received liver Tx. CMV disease occurred in 52% (12/23) of infected patients. CMV disease was characterized by fever (100%), anemia (50%), leucopenia (16.6%) and specific organ involvement (renal graft 60% liver graft 57.1%, lung 25%, intestine 16.6%). Variables significantly associated with infection were a CMV seronegative status (p = 0.035) and lower age 5.5 + 3.7 years old vs 8.3 + 4.4 years old (p = 0.01). CONCLUSIONS: Incidence of CMV infection was high in children receiving a solid organ transplant in our institution and near half of infected children developed CMV-associated disease.

Infección y enfermedad por citomegalovirus en niños sometidos a trasplante de órgano sólido: experiencia en un centro de referencia chileno / Cytomegalovirus infection and disease in pediatric solid organ transplarntation: experience in a Chilean multiorganic transplantation center

Cytomegalovirus (CMV) infection and disease in transplant (Tx) recipients may severely complícate the patients outcome. Aim: To determine the incidence, clinical characteristics and risk factors for CMV infection and disease in liver and kidney transplant recipients in a tertiary care children's hospital. Method: A clinical and laboratory evaluation was prospectively performed in 44 and 20 children receiving a renal and liver Tx respectively in the Hospital Luis Calvo Mackenna between 2004 and 2006. Results: At the time of the organ Tx 20.3 percent (13/64) children were seronegative for CMV. Thirty six per cent (23/64) patients were infected with CMV, of whom 32 percent (14/44) received kidney Tx and 9/20 (45 percent) received liver Tx. CMV disease occurred in 52 percent (12/23) of infected patients. CMV disease was characterized by fever (100 percent), anemia (50 percent), leucopenia (16.6 percent) and specific organ involvement (renal graft 60 percent liver graft 57.1 percent, lung 25 percent, intestine 16.6 percent). Variables significantly associated with infection were a CMV seronegative status (p = 0.035) and lower age 5.5 + 3.7 years oíd vs 8.3 + 4.4 years oíd (p = 0.01). Conclusions: Incidence of CMV infection was high in children receiving a solid organ transplant in our institution and near half of infected children developed CMV-associated disease.

La infección y enfermedad por citomegalovirus (CMV) en pacientes sometidos a trasplantes (Tx) es una complicación que condiciona la evolución del injerto y la sobrevida del paciente. Objetivos: Determinar la incidencia de infección y enfermedad por CMV durante los primeros seis meses de efectuados Tx hepático y renal. Caracterizar la enfermedad, e identificar factores de riesgo asociados a infección. Metodología: Análisis prospectivo en 64 pacientes pediátricos sometidos a Tx renal (n: 44) o hepático (n: 20) en el Hospital Luis Calvo Mackenna entre 2004 y 2006. Resultados: Al trasplante, 23,1 por ciento (13/64) eran receptores IgG CMV (-). Cumplieron criterio de infección 36 por cientoo (23/64) de los pacientes, con Tx renal 32 por ciento (14/44) y con Tx hepático 45 por ciento (9/20). Desarrolló enfermedad el 52 por ciento) (12/23) la que se caracterizó porfiebre (100 por cientoo), anemia (50 por cientoo), leucopenia (16,6 por cientoo), disfunción del órgano trasplantado 60 por cientoo en Tx renal, hepático 57, l por cientoo, compromiso pulmonar en 25 por cientoo e intestinal en 16,6 por cientoo del total de pacientes. Variables asociadas a infección fueron: ser receptor IgG CMV (-)pre-Tx (p=0,035) y una menor edad del paciente 5,5 +3,7 vs 8,3 + 4,4 (p= 0,01). Conclusiones: Hay una elevada tasa de infección por CMV en la población de pacientes con Tx renal y hepática en nuestro medio, la mitad de ellos desarrolló enfermedad amenazando la función del injerto.

[Small bowel transplantation: Report of a single case]. / Primer trasplante de intestino en Chile: Caso clínico.

Small bowel transplantation is associated with a patient survival at one and five years, of 80% and 63%, respectively. We report a 36 year-old female with short bowel syndrome, subjected to the first small bowel transplantation performed in Chile. A cadaveric gran was used. Immunosuppression was achieved by means of alemtuzumab, tacrolimus, sirolimus, micofenolate mofetil and steroids. Serial endoscopies and biopsies were performed during seven months after transplantation. The most important late complications were a drug induced renal failure, infections caused by opportunistic agents and a gastrointestinal bleeding probably induced by drugs. After 29 months of follow up, the patient is ambulatory, on oral diet only and with no evidence of graft rejection.

Primer trasplante de intestino en Chile: Caso clínico / Small bowel transplantation: Report of a single case

Small bowel transplantation is associated with a patient survival atone and five years, of 80% and 63%, respectively. We report a 36 year-old female with short bowel syndrome, subjected to the first small bowel transplantation performed in Chile. A cadaveric graft was used. Immunosuppression was achieved by means of alemtuzumab, tacrolimus, sirolimus, micofenolate mofetil and steroids. Serial endoscopies and biopsies were performed during sevenmonths after transplantation. The most important late complications were a drug induced renal failure, infections caused by opportunistic agents and a gastrointestinal bleeding probably induced by drugs. After 29 months of follow up, the patient is ambulatory, on oral diet only, and with no evidence of graft rejection.

[Molecular mechanisms in liver ischemic-reperfusion injury and ischemic preconditioning]. / Mecanismos moleculares en el daño por isquemia-reperfusión hepática y en el preacondicionamiento isquémico.

Ischemia-reperfusion (IR) liver injury is associated with temporary clamping of hepatoduodenal ligament during liver surgery, hypoperfusion shock and graft failure after liver transplantation. Mechanisms of IR liver injury include: i) loss of calcium homeostasis, ii) reactive oxygen and nitrogen species generation, iii) changes in microcirculation, iv) Kupffer cell activation, and (v) complement activation. Pre-exposure of the liver to transient ischemia increases the tolerance to IR injury, a phenomenon known as hepatic ischemic preconditioning (IP). IP involves: i) recovery of the energy supply and calcium, sodium and pH homeostasis, ii) enhancement in the antioxidant potential, and iii) expression of multiple stress-response proteins, including acute phase proteins, heat shock proteins, and heme oxygenase. These observations and preliminary studies in humans give a rationale for the assessment of IP in minimizing or preventing IR injury during surgery and non surgical conditions of tissue hypoperfusion.

Mecanismos moleculares en el daño por isquemia-reperfusión hepática y en el preacondicionamiento isquémico / Molecular mechanisms in liver ischemic-reperfusion injury and ischemic preconditioning

Ischemia-reperfusion (IR) liver injury is associated with temporary clamping of hepatoduodenal ligament during liver surgery, hypoperfusion shock and graft failure after liver transplantation. Mechanisms of IR liver injury include: i) loss of calcium homeostasis, ii) reactive oxygen and nitrogen species generation, iii) changes in microcirculation, iv) Kupffer cell activation, and (v) complement activation. Pre-exposure of the liver to transient ischemia increases the tolerance to IR injury, a phenomenon known as hepatic ischemic preconditioning (IP). IP involves: i) recovery of the energy supply and calcium, sodium and pH homeostasis, ii) enhancement in the antioxidant potential, and iii) expression of multiple stress-response proteins, including acute phase proteins, heat shock proteins, and heme oxygenase. These observations and preliminary studies in humans give a rationale for the assessment of IP in minimizing or preventing IR injury during surgery and non surgical conditions of tissue hypoperfusion.