Gustavo A. Nari

Preparation of a three-dimensional extracellular matrix by decellularization of rabbit livers

INTRODUCTION the availability of transplantable livers is not sufficient to fulfill the current demand for grafts, with the search for therapeutic alternatives having generated different lines of research, one of which is the use of decellularized three-dimensional biological matrices and subsequent cell seeding to obtain a functional organ. OBJECTIVE to produce a decellularization protocol from rabbit liver to generate a three-dimensional matrix. METHODS a combination of physical, chemical (Triton X-100 and SDS) and enzymatic agents to decellularize rabbit livers was used. After 68 h of retrograde perfusion, a decellularized translucent matrix was generated. To evaluate if the decellularization protocol was successful, with the extracellular matrix being preserved, we carried out histological (light microscopy and scanning electron microscopy) and biochemical (DNA quantification) studies. RESULTS the decellularization process was verified by macroscopic observation of the organ using macroscopic staining, which revealed a correct conservation of bile and vascular trees. A microscopic observation corroborated these macroscopic results, with the hematoxylin-eosin staining showing no cells or nuclear material and the presence of a portal triad. Wilde´s staining demonstrated the conservationof reticulin fibers in the decellularized matrix. In addition, scanning electron microscopy revealed a preserved Glisson´s capsule and a decellularized matrix, with the DNA quantification being less than 10 % in the decellularized liver compared to control. Finally, the time taken to develop the decellularization protocol was less than 96 hours. CONCLUSIONS the proposed decellularization protocol was correct, and was verified by an absence of cells. The hepatic matrix had preserved vascular and bile ducts with a suitable three-dimensional architecture permitting further cell seeding.

Una rara complicación de la CPRE: el hematoma subcapsular hepático

La colangiopancreatografı́a retrógrada endoscópica (CPRE) se ha impuesto como procedimiento diagnóstico-terapéutico mı́nimamente invasivo en enfermedades del árbol biliar, presenta una morbilidad que oscila entre el 2 y el 10% y una mortalidad de entre el 0,5 y el 1%. Entre las complicaciones más destacadas se encuentran la pancreatitis aguda, la hemorragia y la perforación duodenal. El hematoma subcapsular de hı́gado es una complicación extremadamente rara; en la literatura hay 4 casos comunicados. Nuestro objetivo es informar del quinto caso de hematoma subcapsular hepático secundario a CPRE. Mujer de 15 años de edad, sin antecedentes patológicos de relevancia, que ingresa a nuestro servicio de cirugı́a después de la realización de CPRE en otro centro por pancreatitis aguda biliar. La paciente ingresa en mal estado general, pálida, taquipneica con aleteo nasal, taquicárdica y febril (38 1C), con intenso dolor en el epigastrio y el hipocondrio derecho de tipo continuo que refirió como de inicio súbito con irradiación interescapular después de realizada la CPRE, acompañado de náuseas y vómitos gastrobiliares con episodios de deposiciones blandas. A la exploración fı́sica se objetiva dolor y defensa en el hipocondrio derecho, sin reacción peritoneal, con ruidos hidroaéreos presentes. El laboratorio de ingreso arrojó los siguientes datos: leucocitos, 21.400; hemoglobina, 10 g; bilirrubina total, 1,22; bilirrubina directa, 0,6; bilirrubina indirecta, 0,61; amilasemia, 63; fosfatasa alcalina, 130. Ecografı́a: imagen compatible con hematoma subcapsular de hı́gado de 135 49 35 mm. Páncreas de aspecto normal. La tomografı́a computarizada (TC) de abdomen objetiva hematoma subcapsular de lóbulo derecho del hı́gado (fig. 1). Se resuelve mantener conducta expectante y se inicia tratamiento con reposición de fluidos, antibióticos (cefalotina 1 g, gentamicina 80), analgesia (ketorolaco 30 mg, dipirona y rescates con nalbufina). La evolución de la paciente mostró desde el inicio una tendencia a la mejorı́a lo que se corroboró con el correr de los dı́as y se le dio de alta a los 9 dı́as de su ingreso con el siguiente resultado de laboratorio: leucocitos, 9.600; hemoglobina, 11,8 g; bilirrubina total, 0,48; bilirrubina directa, 0,2; bilirrubina indierecta, 0,28; amilasemia, 67; fosfatasa alcalina, 151. La ecografı́a muestra leve disminución del tamaño del hematoma. En el seguimiento ambulatorio la paciente presentó dolor en hipocondrio derecho en 2 oportunidades que se controló con ketorolaco; en la actualidad, después de 6 meses del alta, se encuentra libre de sı́ntomas y en buen estado general, con ecografı́a que informa hematoma residual de 32 17 mm. La CPRE tiene una constelación propia de complicaciones que oscilan entre el 2 y el 10%; la pancreatitis aguda, la hemorragia y la perforación duodenal son las más frecuentes. El porcentaje de morbilidad varı́a según la experiencia del operador. El hematoma subcapsular hepático como complicación de una CPRE es de extrema rareza, solo 4 casos han sido descritos en la literatura, el primero de ellos en el año 2000. Nuestro caso serı́a el quinto del que tenemos conocimiento. La fisiopatogenia por la cual se producirı́a el hematoma serı́a la lesión accidental de la vasculatura hepática después de la perforación de algún conducto biliar intrahepático por la guı́a metálica y el consiguiente sangrado y acumulación subcapsular. La clı́nica de presentación, fundamentalmente el dolor, de aparición súbita e inmediatamente tras el procedimiento, debe hacer sospechar esta complicación. En los parámetros de laboratorio, a excepción de una leucocitosis y, en casos graves, un descenso de la hemoglobina, no hay otros datos de importancia. La ecografı́a abdominal y la TC son las que indican el diagnóstico definitivo. En lo que respecta al tratamiento, y según lo observado en el presente caso y en 3 de los revisados en la literatura, creemos que debe ser inicialmente conservador, con antibióticos, aporte de fluidos y, fundamentalmente, una analgesia que involucre el uso de morfı́nicos ya que el dolor suele ser intenso. La indicación de cirugı́a quedarı́a reservada para los pacientes en los que el hematoma se rompa, se infecte o crezca, con riesgo de rotura o dolor inmanejable. Los procedimientos percutáneos podrı́an tener un lugar en el arsenal terapéutico, ası́ como los procedimientos angiográficos. ARTICLE IN PRESS

Abscesos amebianos de hígado. Très años de experiencia

BACKGROUND: amebic liver abscess is frequently seen in endemic regions, and has a poor prognosis when diagnosis and treatment are inappropriate. AIM: to evaluate and compare our own results; to propose a new classification and therapeutic algorithm. DESIGN: an observational and retrospective study. METHOD: medical records were reviewed for sex, age, signs and symptoms, images, laboratory tests, size, location, treatment, hospital stay, and morbidity-mortality. RESULTS: sixteen patients with amebic liver abscess had been treated -9 were males, mean age was 30.56 years, all abscesses were solitary, 14 were in the right hepatic lobe, average size was 63.25, and 10 were of the collected type according to N Gbesso s classification. Seven patients had a good response to medical treatment, 6 needed percutaneous drainage, and 3 required surgery. Morbidity was 12.5% and mortality 0%. Average hospital stay was 7.68 days. CONCLUSION: our results are similar to those in other published series. The addition of two new groups to N Gbesso s classification provides better therapeutic orientation. We believe that early percutaneous drainage for collected abscesses bigger than 5 cm may improve symptoms and shorten hospital stay.

Colangiocarcinoma hiliar: el número de ganglios positivos y la relación ganglios positivos/ganglios totales son un factor pronóstico importante de supervivencia

INTRODUCTION Surgical treatment of hilar cholangiocarcinoma remains a challenge. Multiple prognostic factors have been proposed. The number of positive nodes and the ratio between positive lymph node and total lymph node (G+/Gt) are considered by some authors as the most important factor. MATERIAL AND METHODS We analyzed a series of 58 patients with Klatskin tumors. We evaluated the prognostic factors and survival with emphasis on the prognostic impact of the number of positive nodes and its relation to total lymph nodes. RESULTS Resectability was 78% with a 5-year survival of 32%. The median number of nodes examined was 9.5. No significant differences were found in several of the proposed prognostic factors. The presence of 2 or more positive nodes or a ratio G+/Gt ≥ 0.2 were found to be poor prognostic factors. CONCLUSION The relationship between positive lymph nodes and total lymph nodes and the number of positive lymph nodes are important prognostic factors.

Tratamiento laparoscópico de la hidatidosis hepática: experiencia inicial

INTRODUCTION Hepatic hydatidosis is a pathology that has a worldwide distribution, and is frequent in some rural areas in Argentina. Surgical treatment still offers the best results. The laparoscopic approach is controversial because of lack of experience with this technique. OBJECTIVE To evaluate the feasibility and efficacy of the laparoscopic approach in this pathology and to present the experience obtained in a medical center in Argentina. MATERIAL AND METHODS We prospectively evaluated patients with a diagnosis of non complicatedhydatidosis, over 15 years of age whose cyst had the following characteristics: unique cyst, size less than 5 centimeters, located in the anterior segments or easy access. Analyzed data were: sex, age, cyst localization, treatment, operating time, morbidity and mortality and recurrence. RESULTS Nine patients were operated using a laparoscopic approach. The cysts were localized in the segments iii, iv, v and vi. Six patients were operated with pneumoperitoneum and 3 with a parietal traction device, in all the patients the first approach was a laparoscopic PAIR (punction, aspiration, injection and reaspiration). Seven Mabit-Lagrot procedures were performed and 2pericystectomies. The operative time was a mean of 89.7min and a hospital stay of 52h. The morbidity was 22.2% and the mortality was 0%.Mean follow-up of 19 months showed no recurrences. CONCLUSION A higher number of patients and a longer follow-up are necessary to evaluate the efficacy of approach; the laparoscopic approach seems to be safe. Our results coincide with the majority of other publications.

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

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. Nari G, Layún J, Molina L, Barrionuevo L, Cecchetto E, Rojo S Rev Colomb Cir. 2017;32:283-89

Absceso perivesicular con compromiso de la pared abdominal. Una rara forma de presentación de patología biliar en el siglo XXI

Cholecystocutaneous fistulae are a rare form of presentation of gallbladder disease. Biliary lithiasis and gallbladder cancer are the main ethiologic causes. A rare case of cholecystocutaneous fistula secondary to cholelithiasis is presented in this paper. Palabras clave: fístulas biliares, litiasis biliar, complicaciones.