Adenoma hepatocelular con captación de 18 flúor deoxiglucosa en PET-TC SCAN. Una "mini-review" e informe de un nuevo caso / 18-fluoro-deoxyglucose uptake on PET-CT in hepatocellular adenoma. A mini review with a new case Report

RESUMEN La captación de 18 FDG en PET-TC por un adenoma hepatocelular (HCA) es poco frecuente. Esta situación genera dudas en cuanto a los diagnósticos diferenciales y tratamiento. El objetivo de este artículo fue realizar una mini revisión de los últimos 37 años de HCA con avidez por el 18FDG y presentar un nuevo caso. Sobre la base de un estudio realizado por otros autores entre 1984 y 2014, se amplía la búsqueda utilizando las mismas palabras clave hasta el año 2021. Se analizan los datos relevantes. Entre 1984 y 2021 detectamos 38 casos en 37 años. Fue más frecuente en mujeres en edad reproductiva. Los subtipos H-HCA e I-HCA fueron los más frecuentes. El tratamiento quirúrgico fue el más empleado. La diferenciación celular y los trastornos metabólicos de la glucosa y de los lípidos favorecerían la captación de 18FDG. La resección hepática ofrecería mayores garantías permitiendo el estudio completo de la lesión.

ABSTRACT Hepatocellular adenoma (HCA) uptake of 18FDG uptake on PET-CT is rare. This situation poses doubts about the differential diagnoses and treatment. The aim of this article is to perform a mini review of 18FDG avid HCA over the past 37 years and to describe a new case presentation. Based on a study conducted by other authors between 1984 and 2014, we extended the search until 2021 using the same keywords. The relevant data were analyzed. Between 1984 and 2021 we detected 38 cases in 37 years. HCAs were more common in women of childbearing age. The most common types were H-HCA an I-HCA. Surgical resection was the treatment most used. Cell differentiation and glucose and lipid metabolic diseases would favor 18FDG uptake. Liver resection provides better outcomes, allowing for a complete examination of the lesion.

IS THE ANATOMICAL SEQUENCE OF GASTRIC AND BILIARY ANASTOMOSIS IN THE PANCREATODUODENECTOMY RECONSTRUCTION THE CAUSE OF AN INCREASE IN THE INCIDENCE OF CHOLANGITIS? A TECHNICAL VARIANT PRESENTATION AND INITIAL RESULTS.

BACKGROUND: Several methods have been proposed for the reconstruction of digestive transit after pancreatoduodenectomy. Biliary anastomosis positioned before gastric anastomosis helps reduce postoperative reflux and cholangitis. AIMS: The objective of this study was to present the anatomical sequence of gastric and biliary continuity after pancreatoduodenectomy in patients with pancreatic tumor and to evaluate the short- and long-term results in an initial series of cases. METHODS: Two techniques were used: one with Roux-en-Y reconstruction and pancreaticojejunostomy and the other with a single jejunal loop and pancreatogastroanastomosis. In both the cases, the gastric anastomosis was placed performed before the biliary one. An analysis of demographic data, Wirsung's duct and common bile duct dilatation, the use of percutaneous drainage, and postoperative complications was carried out. RESULTS: A total of seven patients (four men and three women), with a mean age of 62 years, underwent surgery. All cases had Wirsung's duct and common bile duct dilatation. A percutaneous external biliary drainage was performed in four patients. There were three postoperative complications: one related to delayed gastric emptying and two related to wound infections. During a median follow-up of 12 months, no episode of cholangitis was recorded. CONCLUSIONS: Elevated percentages of cholangitis are reported in different reconstructions after pancreatoduodenectomy, and it is difficult to conclude reflux as the main etiology. The proposed gastric and biliary reconstructions show conforming results, facilitating posterior endoscopic access. Late follow-up and large number of cases may help assess whether the etiology of postoperative cholangitis is reflux or other factors unrelated to the order of the anastomoses.

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

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

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

Dilataciones quísticas congénitas de las vías biliares (segunda parte). Vías biliares extrahepáticas / Congenital bile duct cystic dilatations (part 2). Extrahepatic bile ducts

RESUMEN Las dilataciones quísticas congénitas de la vía biliar extrahepática son infrecuentes, principalmente en Occidente, y afectan sobre todo a niños pero son poco comunes en adultos. El diagnóstico requiere un alto índice de sospecha y suele llevarse a cabo con estudios colangiográficos de los cuales la CRMN es, en la actualidad, el de mayor utilidad. Es conocido el aumento de malignización de estas dilataciones, por lo que el tratamiento completo de la bolsa quística es obligatorio.

ABSTRACT Congenital dilatation of extrahepatic bile ducts is rare in the Western countries and is more common in children than in adults. The diagnosis requires high level of suspicion and is made by cholangiography tests, among which MRCP is the most useful nowadays. Malignant transformation of these cystic dilatations is well-known; therefore, complete resection of the cystic pouch is mandatory.

Is the anatomical sequence of gastric and biliary anastomosis in the pancreatoduodenectomy reconstruction the cause of an increase in the incidence of cholangitis? a technical variant presentation and initial results / A sequência anatômica da anastomose gástrica e biliar na reconstrução da pancreatoduodenectomia é a causa de aumento da incidência de colangite? apresentação de variante técnica e resultados iniciais

ABSTRACT - BACKGROUND: Several methods have been proposed for the reconstruction of digestive transit after pancreatoduodenectomy. Biliary anastomosis positioned before gastric anastomosis helps reduce postoperative reflux and cholangitis. AIMS: The objective of this study was to present the anatomical sequence of gastric and biliary continuity after pancreatoduodenectomy in patients with pancreatic tumor and to evaluate the short- and long-term results in an initial series of cases. METHODS: Two techniques were used: one with Roux-en-Y reconstruction and pancreaticojejunostomy and the other with a single jejunal loop and pancreatogastroanastomosis. In both the cases, the gastric anastomosis was placed performed before the biliary one. An analysis of demographic data, Wirsung's duct and common bile duct dilatation, the use of percutaneous drainage, and postoperative complications was carried out. RESULTS: A total of seven patients (four men and three women), with a mean age of 62 years, underwent surgery. All cases had Wirsung's duct and common bile duct dilatation. A percutaneous external biliary drainage was performed in four patients. There were three postoperative complications: one related to delayed gastric emptying and two related to wound infections. During a median follow-up of 12 months, no episode of cholangitis was recorded. CONCLUSIONS: Elevated percentages of cholangitis are reported in different reconstructions after pancreatoduodenectomy, and it is difficult to conclude reflux as the main etiology. The proposed gastric and biliary reconstructions show conforming results, facilitating posterior endoscopic access. Late follow-up and large number of cases may help assess whether the etiology of postoperative cholangitis is reflux or other factors unrelated to the order of the anastomoses.

RESUMO - RACIONAL: Múltiplas são as propostas de reconstrução do trânsito digestivo após as pancreadoduodenectomias. A anastomoses biliar posicionada antes da anastomose gástrica oferece argumentos de evitar refluxo e colangite pós-operatória. OBJETIVOS: apresentar a técnica de continuidade gástrica e biliar com sequência anatômica após pancreatoduodenectomia em portadores de adenocarcinoma de pâncreas e avaliar os resultados em uma série inicial de casos. MÉTODOS: Foram utilizadas duas técnicas, uma com reconstrução em Y de Roux e pancreaticojejunostomia e outra com alça única de jejuno e pancreatogastroanastomose. Em ambos, a anastomose gástrica foi colocada antes da biliar. E análise de dados demográficos, dilatação do ducto de Wirsung e ducto biliar comum, uso de drenagem percutânea e complicações pós-operatórias. RESULTADOS: Foram operados 7 doentes: 4 homens e 3 mulheres, com média de idade de 62 anos. Todos os casos apresentavam dilatação do ducto de Wirsung e ducto biliar comum. Em 4 dos casos foi realizada drenagem biliar externa percutânea. Ocorreram 3 complicações pós-operatórias, 1 esvaziamento gástrico retardado e 2 infecções de ferida operatória. Durante o acompanhamento médio de 12 meses, não foram registrados episódios de colangite. CONCLUSÕES: Porcentagens elevadas de colangite são relatadas nas diferentes reconstruções após pancreatodudenectomias, sendo difícil atribuir de forma absoluta o refluxo como a principal etiologia. As reconstruções gástrica e biliar propostas são mais harmoniosas, além de facilitar o acesso endoscópico posterior. Seguimento tardio e número maior de casos, pode esclarecer se a etiologia da colangite pós-operatória pode ser o refluxo ou a outros fatores não relacionados à ordem das anastomoses.

Dilataciones quísticas congénitas de las vías biliares (primera parte). Vías biliares intrahepáticas / Congenital bile duct cystic dilatation (part 1). Intrahepatic bile ducts

RESUMEN La enfermedad de Caroli es una enfermedad infrecuente que requiere un alto índice de sospecha para su diagnóstico. Puede afectar un segmento hepático, un lóbulo o todo el hígado; suele generar episodios repetidos de colangitis. Existe una amplia gama de propuestas terapéuticas que oscilan desde el tratamiento médico hasta el trasplante de hígado. En este trabajo presentamos 3 casos, realizamos una revisión de la literatura y proponemos una ampliación de la clasificación de Alonso-Lej modificada por Todani que, a nuestra manera de ver, tiene implicaciones a la hora de seleccionar un tratamiento.

ABSTRACT Caroli's disease is a rare condition, and its diagnosis requires high level of suspicion. The disease may affect one segment, one lobe or the entire liver, and may result in repeated episodes of cholangitis. The disease can be managed using different therapeutic approaches ranging from medical treatment to liver transplantation. In this paper we report 3 cases with review of the literature and propose a modification of the classification by Alonso-Lej modified by Todani which we believe may be useful to guide treatment.

THERE ARE NO ADVANTAGES BETWEEN LAPAROSCOPIC AND OPEN LIVER RESECTIONS WITHIN AN ENHANCED RECOVERY PROGRAM (ERAS).

BACKGROUND: The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results. AIM: To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them. METHODS: In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed. RESULTS: Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery. CONCLUSION: The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation.

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

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

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

There are no advantages between laparoscopic and open liver resections within an enhanced recovery program (eras) / Não há vantagens entre as ressecções hepáticas laparoscópicas e abertas dentro de um programa de recuperação avançada (eras/acerto)

ABSTRACT Background: The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results. Aim: To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them. Methods: In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed. Results: Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery. Conclusion: The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation.

RESUMO Racional: O uso do protocolo Recuperação Otimizada Após Cirurgia (ERAS/ACERTO) com sucesso na cirurgia colorretal favoreceu a aplicação dele em outros órgãos; as ressecções hepáticas não foram excluídas dessa tendência. Alguns autores sugerem que a abordagem laparoscópica é elemento central para a obtenção de melhores resultados. Objetivo: Comparar as ressecções hepáticas laparoscópicas e abertas dentro de um ACERTO para avaliar se existem diferenças entre as duas técnicas. Métodos: Estudo descritivo comparando 80 ressecções hepáticas divididas em dois grupos, as realizadas por laparoscopia e aquelas por laparotomia. Foram analisados dados demográficos, referentes à hepatectomia e ao ACERTO. Resultados: Foram realizadas 47 ressecções por laparotomia e o restante por laparoscopia; houve apenas uma conversão para laparotomia no grupo da laparoscopia. Do total, 17 ressecções foram hepatectomias maiores e em 18 ressecções simultâneas. Não houve diferenças entre os procedimentos quanto ao tempo de internação e número de complicações. Houve maior adesão ao ACERTO (p=0,046) e deambulação mais rápida (p=0,001) na operação aberta. Conclusão: O procedimento, seja laparotômico ou laparoscópico nas ressecções hepáticas, não parece mostrar diferenças em uma avaliação ERAS/ACERTO.

Open versus laparoscopic hepatectomies within an ERAS (Enhanced Recovery After Surgery) program. Are there differences?

BACKGROUND: Laparoscopic procedures have gained popularity because they favor a faster recovery. In the same way, the establishment of an enhanced recovery after surgery (ERAS) program in major abdominal surgery has shortened the hospital stay. There are several studies that report the results on ERAS programs applied to open or laparoscopic hepatectomies or comparing one of them with the classic approach but few have compared the results between both within an ERAS program. OBJECTIVE: To compare the results between open and laparoscopic hepatectomies in the same ERAS program. METHOD: Thirty-six patients undergoing hepatectomies were enrolled in this study and were either laparoscopically or open in an identical ERAS program. Hospital stay and the number of complications were taken as primary end points. RESULTS: There were no significant differences between both groups in terms of hospital stay or number of complications. The differences were in a shorter time of surgery and an earlier ambulation in favor of open surgery and a better full recovery in favor of the laparoscopic approach. CONCLUSIONS: Initial data suggest that there would be no benefits in terms of hospital stay and complication rate of laparoscopic hepatectomies over open ones within an ERAS program.

ANTECEDENTES: Los procedimientos laparoscópicos ganaron popularidad porque favorecen una recuperación rápida. El establecimiento de programas ERAS (Enhanced Recovery After Surgery) en cirugía mayor abdominal ha acortado la estancia hospitalaria independientemente de la vía de abordaje. Varios trabajos informan los resultados sobre programas ERAS aplicados a hepatectomías abiertas o laparoscópicas, o comparando una de ellas con el abordaje clásico, pero pocos han comparado los resultados entre ambas dentro de un programa ERAS. OBJETIVO: Comparar, dentro un mismo programa ERAS, los resultados entre hepatectomías abiertas y laparoscópicas. MÉTODO: Se incorporaron a este estudio 36 pacientes sometidos a hepatectomías que fueron abordados por vía laparoscópica o abierta dentro de un programa ERAS. Los objetivos primarios fueron la estancia hospitalaria y el número de complicaciones. RESULTADOS: No hubo diferencias significativas entre ambos grupos en cuanto a estancia hospitalaria ni número de complicaciones. Las diferencias radicaron en un menor tiempo de cirugía y una deambulación más precoz a favor de la cirugía abierta, y una recuperación total mejor a favor del abordaje laparoscópico. CONCLUSIONES: Los datos iniciales sugieren que no habría beneficios en cuanto a estancia hospitalaria e índice de complicaciones de las hepatectomías laparoscópicas sobre las abiertas dentro de un programa ERAS.

Resultados de la aplicación de un programa Enhanced Recovery (ERP) en resecciones hepáticas abiertas / Results of the implementation of an enhanced recovery program (ERP) in open liver resections

Antecedentes: los programas fast-track en cirugía hepática muestran ventajas con respecto al manejo perioperatorio tradicional al favorecer principalmente una disminución de la estancia hospitalaria y, por ende, de los costos hospitalarios. Material y métodos: en un estudio observacional y descriptivo se analizan resecciones hepáticas abiertas dentro de un programa de recuperación rápida, haciendo especial hincapié en la adherencia a este, la recuperación total de los enfermos, la morbilidad y la estancia hospitalaria. Resultados: se realizaron 32 hepatectomías en 30 pacientes, 27 de los cuales fueron oncológicos. La adherencia al programa utilizado fue del 78,1% y la recuperación total al momento del alta del 75%. La morbilidad fue del 12,5% y las complicaciones fueron de baja complejidad, aunque 2 pacientes necesitaron reingresar. La estancia hospitalaria tuvo una media de 3,4 días y, sumando los reingresos, de 3,6 días. Conclusión: la aplicación de un ERP en cirugía hepática no solo es factible sino trae aparejada como principal beneficio una disminución en la estancia hospitalaria y, por ende, de los costos. Pero no estamos convencidos de que un ERP mejore la morbilidad de los pacientes.

Background: Background: Fast-track programs in liver surgery offer advantages over traditional perioperative management, particularly in terms of reducing length of hospital stay and hospital costs. Material and methods: We conducted an observational and descriptive analysis of patients undergoing open liver resections as part of an enhanced recovery program. Adherence to the program, full recovery of the patients, complications and length of hospital stay were assessed. Results: A total of 32 liver resections were performed in 30 patients, 27 with cancer. The adherence to the program was 78.1% and full recovery on discharge was 75%. The incidence of complications was 12.5%; most of them were not severe but two patients required rehospitalization. Mean length of hospital stay was 3.4 days and 3.6 days when readmissions were considered. Conclusion: The implementation of an ERP after liver resections is feasible and offers advantages in terms of reducing length of hospital stay and hospital costs. We do not think that ERP improves morbidity in these patients.

Fístula pancreática posduodenopancreatectomía: Pancreatogastrostomía vs. Pancreatoyeyunostomía / Pancreatic fistula after pancreaticoduodenectomy: Pancreaticogastrostomy vs. Pancreaticojejunostomy

Antecedentes: la duodenopancreatectomía (DPC) continúa siendo el tratamiento de elección para los tumores periampulares. Con una mortalidad de alrededor del 5% y una morbilidad que puede llegar a alrededor del 50%, la fístula pancreática es todavía la complicación preponderante. Diversos autores sostienen que la anastomosis del páncreas con el estómago tiene menor índice de fístula que cuando se realiza con el yeyuno. Objetivo: comparar la incidencia de fístula pancreática en las pancreatogastrostomías (PG) versus pancreatoyeyunostomías (PY). Evaluar algunos factores de riesgo de fístula. Material y métodos: se evaluaron 91 DPC, 43 de ellas con reconstrucción con PG y 48 con PY. Se evaluaron datos demográficos, quirúrgicos, y se comparó la incidencia de fístula entre ambos. Resultados: la incidencia global de fístula fue de 13 pacientes (14,3%), 5 de las cuales fueron de relevancia clínica. En la comparación de ambos grupos hubo diferencias en cuanto a edad y número de pacientes con Wirsung < 3 mm, el resto de los parámetros fue similar. No hubo diferencias entre ambos grupos con respecto a la cantidad de fístulas (p: 0,478). Respecto de la evaluación de factores predisponentes para fístula, tan solo un diámetro del Wirsung < 3 mm fue significativo. Conclusión: en nuestra serie y al igual que en otras no hubo diferencias en cuanto a fístulas pancreáticas entre PG y PY, lo que nos permite inferir que la adopción y confección sistemática de una ellas obtendrá los mejores resultados.

Background: Pancreaticoduodenectomy is still the treatment of choice in patients with periampullary tumors. Pancreatic fistula is the most common complication with a mortality rate of 5% and 50% of morbidity. Some authors state that the anastomosis of the pancreas with the stomach would decrease the incidence of pancreatic fistula when compared with pancreaticojejunostomy. Objective: The aim of this study was to compare the incidence of pancreatic fistula after pacreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) and analyze the risk factors associated with the development of fistula. Material and methods: 91 patients undergoing pancreaticoduodenectomy were evaluated; 43 with PG reconstruction and 48 with PJ reconstruction. Demographic and surgical data were evaluated and the incidence of pancreatic fistula with both techniques was compared Results: The incidence of fistula for the total series was 14.3% (n = 13) and 5 were clinically relevant. There were differences in age and pancreatic duct diameter < 3 mm between the groups. The incidence of fistula was similar in both groups (p = 0.478). Pancreatic duct diameter < 3 mm was the only significant predisposing factor for the development of fistula. Conclusion: In our series, and in coincidence with others, there were no differences in the incidence of pancreatic fistulas between PG and PJ. Practicing and mastering a repetitive, standardized technique would yield the best results.

[Metástasis hepáticas sincrónicas de cáncer colorrectal. ¿Resección simultánea o diferida?] / Synchronous liver metastases from colorectal origin. Simultaneous or staged resection?

INTRODUCCIÓN: El 20-40% de las metástasis hepáticas de origen colorrectal son de tipo sincrónico. Actualmente existen tres estrategias quirúrgicas; dos de ellas proponen resecciones diferidas, y la otra, la resección simultánea. OBJETIVO: evaluar los resultados a corto y largo plazo de las resecciones simultáneas. MÉTODO: Evaluamos 212 metástasis hepáticas sincrónicas resecadas en dos centros y comparamos las intervenidas de forma simultánea con aquellas de manera diferida. Evaluamos las características demográficas, las resecciones hepáticas y las características de las metástasis. También evaluamos la morbimortalidad. RESULTADOS: Fueron resecados de manera simultánea con el tumor primario 63 pacientes, y no hubo diferencias significativas en las características demográficas. Hubo más resecciones mayores (p = 0.005) en el grupo de las diferidas. La morbimortalidad fue comparable. La insuficiencia hepática (p = 0.037) fue mayor en el grupo de las diferidas. La morbilidad fue del 33.2% en las diferidas y del 10.1% en las simultáneas (p = 0.256). La mortalidad fue del 2.83% en las diferidas y del 0.94% en las simultáneas (p = 0.508). CONCLUSIÓN: Los resultados a corto y largo plazo en ambos grupos son similares. Queda el interrogante de si la necesidad de una hepatectomía mayor favorecería la elección de un tratamiento diferido. INTRODUCTION: Between 20 and 40% of liver metastases from colorectal tumor are synchronous. Three types of surgical approaches are proposed; two of them propose a deferred resection and the other, simultaneous resection. The aim of this analysis is to assess the short- and long-term outcomes of simultaneous resections. METHOD: 212 synchronous liver metastases resected in two centers were evaluated. Comparison between those resected simultaneously with those that were in a deferred way was made. Demographics, liver resections and metastatic characteristics were evaluated. Morbidity and mortality of both alternatives are also evaluated. RESULTS: 63 patients were resected simultaneously with the primary tumor, there were no significant differences in demographic characteristics. There was a greater number of major resections (p = 0.005) in the deferred group. Morbidity and mortality was comparable in both groups. Liver failure (p = 0.037) was higher in the deferred group. Morbidity was 33.2% in the deferred and 10.1% for the simultaneous (p = 0.256). Mortality rate was 2.83% in the deferred and 0.94% in the simultaneous group (p = 0.508). CONCLUSION: Short and long-term outcomes for both groups are similar. A question remains to be answered: the need of a major hepatectomy will favor the election of a deferred treatment?

[Resultados a corto y largo plazo de las rehepatectomías como parte del tratamiento multimodal de las metástasis de origen colorrectal. Un estudio biinstitucional]. / Short and long-term outcomes of the re-hepatectomies as part of multi-modal treatment of hepatic metastases from colo-rectal origin. Bi-institutional study.

INTRODUCCIÓN: Un alto porcentaje de pacientes que reciben una hepatectomía por metástasis de cáncer colorrectal presentarán recidiva hepática, y en algunas será posible una nueva resección. La utilidad de las hepatectomías repetidas continúa siendo discutida. OBJETIVO: Evaluar los resultados obtenidos a corto y largo plazo. MÉTODO: Fueron analizadas 68 rehepatectomías de dos instituciones. Se analizaron datos demográficos y características de la enfermedad metastásica y de las resecciones hepáticas. Los tipos de complicaciones y la morbimortalidad también fueron analizados, al igual que la supervivencia y el tiempo libre de enfermedad. Se evaluaron algunos de los factores de mal pronóstico mencionados en la literatura. RESULTADOS: El análisis de los datos de corto plazo no mostró diferencias significativas entre los pacientes de primera hepatectomía y de hepatectomías repetidas, a excepción del porcentaje de fístulas biliares posoperatorias (p = 0.001). La supervivencia a 1 año es similar, mientras que a 3 y 5 años mostró diferencias significativas (p = 0.024 y 0.004, respectivamente). Los factores de mal pronóstico referidos en la literatura no fueron representativos en esta serie. CONCLUSIÓN: Los resultados a corto plazo de los pacientes con rehepatectomía son similares a los de aquellos resecados una vez. Los resultados a largo plazo de las rehepatectomías son inferiores a otros publicados. INTRODUCTION: A high percentage of patients undergoing hepatectomy for metastatic colorectal liver disease will have a recurrence. Of these, some can be subject to a new resection. The usefulness of repeated hepatectomy remains controversial. The aim of this study is to evaluate the results of short and long-term outcomes in repeated hepatectomies. METHODS: They were re-analyzed 68 repeated hepatectomies from two institutions. Demographics, characteristics of metastatic disease and hepatic resections were analyzed. Types of complications, morbidity and mortality were also analyzed as survival and disease-free time. Some of the factors of poor prognosis mentioned in the literature were evaluated. RESULTS: The analysis of short-term data showed no statistically significant differences between patients with first and repeated hepatectomy, except the percentage of postoperative biliary leakage (p = 0.001). The 1-year survival was similar while 3 and 5 years survival showed significant differences (p = 0.024 and 0.004, respectively). The factors of poor prognosis referred in the literature were not representative in this series. CONCLUSION: The short-term results of repeated hepatectomy are similar to those resected once. Long term result are inferior to other published series.

Hepatectomía en dos tempos con resección colorrectal simultánea abierta en el tratamiento multmodal de las metástasis hepáticas de origen colorrectal / Two stage hepatectomy with simultaneous open colon resecton for multmodal treatment of colorectal liver metastases

Antecedentes: los mejores resultados ante la presencia de metástasis (Mtis) hepáticas de origen co-lorrectal los ofrece la resección hepática. Aproximadamente el 50% de los pacientes afectados de cáncer de colon y recto presentará metástasis hepáticas en el transcurso de la enfermedad. Un grupo de pacientes con metástasis bilobares consideradas irresecables o marginales hace un tempo pueden, en la actualidad, ingresar en protocolos de resecabilidad con estrategias que involucran resecciones hepáticas escalonadas en dos tempos con quimioterapia neoadyuvante o sin ella. Objetivo: mostrar los resultados obtenidos en 3 pacientes con metástasis bilobares de origen colorrectal sometidos a este protocolo con el distintivo de la resección simultánea colónica en el primer paso. Material y métodos: se presentan tres pacientes tratados con una estrategia quirúrgica en dos tiempos por metástasis hepáticas simultáneas de origen colorrectal. Se analizan los datos demográficos, del tumor y los correspondientes a las resecciones. Resultados: los tres pacientes pudieron completar el tratamiento. No hubo mortalidad operatoria. No hubo morbilidad en el primer paso de la resección y sí hubo una complicación en el segundo paso. La supervivencia tene una mediana de 16,3 meses y un período libre de enfermedad de 10,6 meses. Hubo recurrencia en un solo paciente. Conclusión: la estrategia en dos tempos con resección simultánea en el primer paso es segura. Ofrece una alternativa de curación a estos pacientes o en su defecto una franca prolongación de su sobrevida cuando se la asocia a quimioterapia u otras estrategias.

Background: the best Results for hepatic metastasis of colorectal cancer are ofered by hepatic resecton. Approximately 50% of patentis with colon and rectum cancer will develop liver metastases in the course of the disease. Bilobular metastases, previously considered to be unresectable may be treated by two stage stage liver resecton with or without neoadjuvant chemotherapy. Objective: to describe the Results upon treatment of bilobular colorectal metastases with a two stage strategy in which a simultaneous colon resecton was done at the first stage. Material and methods: three patentis were treated with a two stage strategy for simultaneous hepatic metastases of colorectal cancer. Demographic, tumor, and resecton data were analyzed. Results: all three patentis were able to complete the treatment. No operative mortality occurred. There was no morbidity during the frst step of the resecton while a complicaton was seen during the second step. Survival and disease free tme were 16.3 months and 10.6 months, respectively. To date, recurrence was seen in only one patent. Conclusion: the two stage strategy with simultaneous colon resecton in the frst step is safe and may ofer a chance for cure or a prolongaton of survival when associated with chemotherapy or other treatment strategies.

Experiencia temprana en la aplicación de un programa ERAS en hepatectomías abiertas menores por metástasis de origen colorrectal, con resecciones simultáneas de colon o sin ellas / Early experience in the application of an ERAS program in minor open hepatectomies for metatstases of colorectal cancer, with or without simultaneous colon resection

Introducción. La aplicación de programas de tipo vía rápida (fast track) en cirugía abdominal mayor fue inicialmente implementada en cirugía abierta de colon con resultados comparables a los del abordaje laparoscópico. La disminución de la estancia hospitalaria y de los costos hospitalarios fueron las principales ventajas. Recientemente, se trasladó la aplicación de protocolos de recuperación posquirúrgica rápida (Enhanced Recovery After Surgery, ERAS) a la cirugía hepática con resultados aparentemente alentadores. El objetivo de este trabajo fue valorar los resultados iniciales obtenidos en un grupo de pacientes sometidos a hepatectomías menores por metástasis hepáticas, con resección simultánea de colon o sin ella. Métodos. Se evaluaron los datos de 13 resecciones hepáticas menores por metástasis hepáticas de origen colorrectal con resección simultánea del tumor primario o sin ella, las cuales se incorporaron a un protocolo ERAS. Se evaluaron los datos demográficos, de las hepatectomías, de la observancia del protocolo y de algunos factores que pueden afectar los resultados de una recuperación rápida, así como también lo que se considera recuperación total al momento del egreso. Resultados. En las 13 resecciones se pudo llevar adelante la aplicación del protocolo. Como resultado principal, se logró una corta estancia hospitalaria (3,69 días), el cumplimiento del protocolo fue alto y la recuperación total al egreso fue de 46,2 %. Conclusión. La aplicación de este protocolo ha sido exitosa en cuanto a una franca disminución de la estancia hospitalaria. El número de pacientes es pequeño, pero los resultados son esperanzadores

Introduction: The application of fast track programs in major abdominal surgery was initially implemented in open colonic surgery with comparable results to the laparoscopic approach. The decreases in hospital stay and in hospital costs were the main advantages. Recently the application of ERAS programs to liver surgery was transferred with apparently encouraging results. The aim of this study was to evaluate the initial results obtained in a group of patients undergoing hepatectomies due to hepatic metastases with or without simultaneous colon resection. Methods: Data from 13 minor liver resections for colorectal liver metastases with or without simultaneous resection of the primary tumor incorporated into an ERAS protocol were evaluated. Demographic data, hepatectomies, adherence to the protocol, and some factors that may affect the results of a rapid recovery, as well as what is considered full recovery at discharge, were evaluated. Results: in the 13 resections the application of the protocol could be carried out. As a main result, a short hospital stay (3.69 days) was achieved, adherence to the protocol was high and the total recovery at discharge was 46.2%. Conclusion: the application of this protocol has been successful in terms of a frank reduction of the hospital stay. The number of patients is small but the results are encouraging. Key words: Colonic neoplasms; neoplasm metastasis; hepatectomy; clinical protocols; learning curve; clinical evolution; cost-effectiveness evaluation