Desarrollo de una Unidad de Cirugía Hepatobiliar Compleja y Trasplante Hepático en un hospital público: a una década de su formación / Development of a complex hepatobiliary surgery and liver transplantation unit in a public hospital: a decade after its creation

RESUMEN Antecedentes: concentrar esta patología hepatobiliar en centros especializados puede permitir bajas cifras de morbimortalidad y mejores resultados alejados. Objetivo: describir las características clínico-patológicas y los resultados de una serie de pacientes operados en los primeros 10 años de una Unidad de Cirugía Hepatobiliar Compleja y Trasplante Hepático (TH), así como la actividad científica y docente de sus integrantes. Materiales y métodos: estudio retrospectivo descriptivo. Se recopiló información de una base de datos prospectiva. Se clasificaron los procedimientos según su complejidad y se analizaron los TH, las hepatectomías y los procedimientos biliares complejos, realizados entre 2013 y 2022. Resultados: sobre 1440 procedimientos quirúrgicos, 832 fueron de alta complejidad (58%). Se realizaron 452 trasplantes hepáticos (TH), 14 (3%) de ellos hepatorrenales; la sobrevida global del trasplante fue de 83%, 77% y 75% a 1, 3 y 5 años, respectivamente. La falla primaria del injerto se observó en 5 casos (1,1%). Se efectuaron 254 hepatectomías: 58 (23%) por patología benigna, 155 (61%) por patología maligna y 41 (16%) en donante vivo relacionado para TH. La morbilidad total fue del 27% y la mortalidad intrahospitalaria de 2%. Se efectuaron 106 derivaciones biliodigestivas: 53 en pacientes con lesión quirúrgica de la vía biliar. La morbilidad a 30 días fue del 42%, en su mayoría complicaciones menores (28%). Además, se realizaron 17 duodenopancreatectomías cefálicas y 3 esplenopancreatectomías. Se realizaron múltiples publicaciones, presentaciones y cursos, y desde 2015 se implementó una residencia posbásica de la especialidad. Conclusión: la concentración de patología hepatobiliar en un centro de alta complejidad permitió alcanzar resultados satisfactorios, comparables con series extranjeras.

ABSTRACT Background: Centralizing hepatobiliary disease in specialized centers can reduce morbidity and mortality rates and improve long-term outcomes. Objective: The aim of the present study was to describe the clinical and pathological features and surgical outcomes of a series of patients operated on in the Hepatobiliary Surgery and Liver Transplantation Unit of Hospital El Cruce during its first 10 years, as well as the scientific and educational activity of its members. Material and methods: We conducted a descriptive and retrospective study. The information was retrieved from a prospective database. The procedures were classified according to their complexity. An analysis was conducted on liver transplantations (LTs), liver resections and complex biliary procedures, performed from 2013 to 2022. Results: Of 1449 surgical procedures, 832 were high-complexity interventions (58%). A total of 452 LTs were performed, 14 (3%) were combined liver and kidney transplantations; overall transplant survival was 83%, 77% and 75% at 1, 3 and 5 years, respectively. Primary graft dysfunction was observed in 5 cases (1.1%). There were 254 liver resections; 58 cases (23%) were related to benign liver diseases, 155 (61%) to malignancies, and 41 (16%) were associated with living donor transplants. Overall morbidity was 27% and in-hospital mortality was 2%. A total of 106 bilio-digestive bypass procedures were carried out, 53 in patients with bile duct injury. Thirty-day morbidity was 42%, and most cases were minor complications (28%). Other procedures included 17 cephalic pancreaticoduodenectomies and 3 splenectomies and distal pancreatectomies. We have published numerous papers, delivered presentations and courses, and implemented a fellowship program in the specialty since 2015. Conclusion: Centralizing hepatobiliary diseases at a high-complexity center led to comparable outcomes with those reported in international series.

Prevalence of non-alcoholic fatty liver disease and liver fibrosis in a general population cohort from Argentina.

INTRODUCTION AND OBJECTIVES: South America is one of the regions with the highest rates of non-alcoholic fatty liver disease (NAFLD). This study aimed to assess the prevalence and severity of NAFLD in suburban Argentina. PATIENTS AND METHODS: The study involved a general community cohort of 993 subjects evaluated sequentially with a comprehensive lifestyle questionnaire, laboratory testing, abdominal ultrasound (US) and transient elastography with XL probe. NAFLD was diagnosed according to standard criteria. RESULTS: The prevalence of NAFLD by the US was 37.2% (326/875) overall, 50.3% in subjects with overweight/obesity, 58.6% with hypertriglyceridemia, 62.3% with diabetes/hyperglycemia and 72.1% with all three risk factors. Male gender (OR 1.42, 95% CI 1.03-1.47, p = 0.029), age (50-59 years: OR 1.98, 95 CI 1.16-3.39, p = 0.013 and ≥60 years: OR 1.86, 95% CI 1.13-3.09, p = 0.015), BMI (25-29: OR 2.87, 95% CI 1.86-4.51, p<0.001 and ≥30: OR 9.57, 95% CI 6.14-15.20, p<0.001), diabetes/hyperglycemia (OR 1.65, 95% CI 1.05-2.61, p = 0.029) and hypertriglyceridemia (OR 1.73, 95% CI 1.20-2.48, p = 0.002) were independent predictors of NAFLD. Among patients with steatosis, 22.2% (69/311) had ≥F2 fibrosis (overweight 25%, hypertriglyceridemia 32%, diabetes/hyperglycemia 34%). BMI (OR 5.22, 95% CI 2.64-11.74, p<0.001), diabetes/hyperglycemia (OR 2.12, 95% CI 1.05-4.29, p = 0.04) and hypertriglyceridemia (OR 1.94, 95% CI 1.03-3.68, p = 0.040) were independent predictors of liver fibrosis. CONCLUSIONS: This general population study from Argentina showed a high prevalence of NAFLD. Significant liver fibrosis was present in 22% of subjects with NAFLD. This information adds to the existing knowledge of NAFLD epidemiology in Latin America.

Evaluación de la anatomía angiográfica de las arterias hepáticas y sus variantes / Evaluation of the angiographic anatomy of the hepatic arteries and its variants

Resumen Objetivo: Evaluar y describir la prevalencia de variantes anatómicas arteriales hepáticas observadas en una serie multicéntrica de pacientes con patologías hepatobiliares. Método: Estudio retrospectivo de anatomía arterial según la clasificación de Michels de angiografías digitales y tomografías computadas helicoidales abdominales realizadas entre febrero de 2009 y diciembre de 2020 en tres hospitales del Área Metropolitana de Buenos Aires. Resultados: Se incluyeron 275 pacientes en el estudio. Edad mediana 58,5 años. Sexo masculino 73,1%. Variante anatómica tipo 1 (normal) de la arteria hepática en 192 casos (69.8%); tipo 2 en 18 casos (6.5%); tipo 3 en 19 casos (6.9%); tipo 4 en 7 casos (2.5%); tipo 5 en 4 casos (1.5%); tipo 6 en 3 casos (1.1%); tipo 7 en 2 casos (0.7%); tipo 8 en 7 casos (2.5%); tipo 9 en 17 casos (6.2%) y otros tipos fuera de la clasificación de Michels en 6 casos (2.2%). También hallamos la presentación de 3 casos (1.1%) con arco de Bühler. Conclusiones: En nuestra serie se observaron variantes anatómicas no clásicas de la arteria hepática aproximadamente en un tercio de los casos. El conocimiento de las variantes anatómicas fue esencial para los procedimientos radiológicos y quirúrgicos en el tratamiento de tumores hepáticos, determinando la técnica de abordaje de las arterias involucradas.

Abstract Objective: To evaluate and describe the prevalence of hepatic artery anatomical variants observed in a multicenter series of patients with hepatobiliary pathologies. Method: Retrospective study of arterial anatomy according to Michels classification of digital angiographies and abdominal helical computed tomography performed between February 2009 and December 2020 in three hospitals of the Buenos Aires Metropolitan Area. Results: 275 patients were included in the study. Median age 58.5 years. Male sex 73.1%. Type 1 (normal) variant of hepatic artery anatomy in 192 cases (69.8%); type 2 in 18 cases (6.5%); type 3 in 19 cases (6.9%); type 4 in 7 cases (2.5%); type 5 in 4 cases (1.5%); type 6 in 3 cases (1.1%); type 7 in 2 cases (0.7%); type 8 in 7 cases (2.5%); type 9 in 17 cases (6.2%), and other types out Michels classification in 6 cases (2.2%). We also found 3 cases (1.1%) with Bühler's arch. Conclusions: In our series, non-classical anatomical variants of the hepatic artery were observed in approximately one third of cases. Knowledge of anatomical variants was essential for radiological and surgical procedures in the treatment of liver tumors, determining the approach technique of the arteries involved.