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La Sociedad de Cirujanos de Chile en concordancia con su misión, actualizó las propuestas en relación a la formación en la especialidad, trabajo que se había iniciado en el año 2008. Para este efecto se nombró una Comisión que fijó los delineamientos e invitó a sus pares a un taller de trabajo. Participaron 20 cirujanos, quienes se dividieron en grupos con un moderador y se discutieron las siguientes temáticas: caracterización del cirujano recién formado, características de los planes de formación, rol de la Sociedad de Cirujanos en la formación, impacto del desarrollo de las especialidades derivadas en la formación y en el desempeño del cirujano general, además de temas que surgieron de la discusión central. Cada grupo entregó las conclusiones de su análisis, las que fueron consolidadas en sucesivas sesiones de la Comisión. Sus resultados representan la base del presente informe.

Obstructive jaundice secondary to hepatocellular carcinoma fragments migrated to common bile duct Obstructive jaundice is a rare presentation of hepatocellular carcinoma (HC), and when it occurs, usually is due to progressive damage from cirrhosis, or extensive tumor infiltration. Tumor growth through the bile duct is being described with increasing frequency as a cause of obstructive jaundice. Rarely, it may be hepa- tocarcinoma fragments that migrate to the bile duct, obstructing it. We present a case of obstructive jaundice due to migration of fragments of hepatocellular carcinoma to the bile duct in a patient treated 7 years before, for an HC with a curative resection.

Se trata de una encuesta realizada con el objeto de conocer la frecuencia e incidencia de las principales patologías y técnicas quirúrgicas de la esfera hepato-bilio-pancreática atendida en centros de salud públicos y privados del país durante el año 2007. La encuesta fue respondida por 17 instituciones nacionales. Entre los resultados resaltan el total de colecistectomías reportadas de 9.505, de las cuales entre un 21 y 98% son realizadas por vía laparoscópica. Lesiones iatrogénicas de vía biliar ocurrieron dentro de un rango de 0 a 1,5%, con una mediana de 0,3%. La frecuencia de coledocolitiasis asociada a la colelitiasis ocurrió entre un 0 a 21%, aunque el empleo de colangiografía intraoperatoria es en general de ocurrencia incidental. La incidencia de cáncer vesicular en colecistectomías por colelitiasis es claramente distinta según se trate de instituciones de centro-norte y sur del país, con incidencias que varían entre 0,2 y 8,9%. Las metástasis hepáticas operadas son principalmente de origen colorrectal, y son los tumores hepáticos más frecuentemente tratados. La hidatidosis hepática manifiesta en esta encuesta su conocida distribución geográfica, siendo más frecuentemente tratada en los centros del sur del país. La cirugía pancreática resectiva tiende a estar concentrada en las instituciones de la región metropolitana.

Acute liver failure in children. Experience of a liver transplant center Background: Acute liver failure (ALF) in childhood is defined as biochemical evidence of liver injury, absence of known chronic liver disease and coagulopathy not corrected by vitamin K administration, with INR greater than 1.5 if the patient has encephalopathy or greater than 2.0 if the patient does not have encephalopathy. Objective: Report the experience of a single liver transplant center (LT) in the treatment of 8 children with ALF and review the literature. Method: Retrospective review of clinical charts of patients with ALF. Results: The median age was 8 years-old (range 0-11), three females. Five patients underwent LT. Two patients died, one of them LT. The etiologies were 4 undetermined, 1 autoimmune, 1 Wilson Disease, 1 Parvovirus and 1 chronic graft rejection. All grafts were from cadaver donor, 3 of them reduced. Two out of five patients with encephalopathy grade III-IV died. The one year survival rate was 75%. Conclusions: Children with ALF should be treated in experienced centers with facilities for liver transplant. Transplantation should be offered only if the underlying disease is treatable by liver replacement and if transplant prognosis is better than that of the underlying disease. (Key words: acute liver failure, liver transplant). Rev Chil Pediatr 2009; 80 (2): 144-149

Sirolimus (SRL) is an immunosuppressive drug increasingly used in children undergoing solid organ transplantation. SRL does not cause glucose intolerance, hypertension, nephrotoxicity or neurotoxicity offering significant potential advantages over calceneurin inhibitors (CM).To report five children treated with SRL.A retrospective review of four children undergoing orthotopic liver transplantation (OLT) and one undergoing renal transplantation with recurrent acute rejection (RAR), chronic rejection (CR) or toxicity due to CM, treated with SRL between June 2001 and November 2006.As primary immunosuppressive therapy, all patients received 3 drugs: CM (Tacrolimus (FK) or Cyclosporine), mycophenolate mofetil and steroids. Mean age at treatment with SRL was 98 months. Children undergoing OLT had a late introduction of SRL (mean time after OLT: 37 months), and mean follow-up was 24 months. In this group rescue indications of SRL were RAR in one, CR in one, thrombotic thrombocytopenic purpura (TTP) in one, food allergy in one and other CM toxicity in three. Only one did not experience adverse events due to SRL, but no one required discontinuation of SRL. There were remissions of RAR, CR, TTP and food allergy. The patient with RT was switched from FK to SRL at day 18th after RT, but he had severe neutropenia that led to discontinuation of SRL.SRL may be useful in pediatric solid organ transplant recipients suffering from RAR, CR, TTP, food allergy and CM toxicity. Careful attention should be directed to detect side effects and avoid severe complications.

Background: Sirolimus (SRL) is an immunosuppressive drug increasingly used in children undergoing solid organ transplantation. SRL does not cause glucose intolerance, hypertension, nephrotoxicity or neurotoxicity, offering significant potential advantages over calceneurin inhibitors (CNI). Aim: To report five children treated with SRL. Material and methods: A retrospective review of four children undergoing orthotopic liver transplantation (OLT) and one undergoing renal transplantation with recurrent acute rejection (RAR), chronic rejection (CR) or toxicity due to CNI, treated with SRL between June 2001 and November 2006. Results: As primary immunosuppressive therapy, all patients received 3 drugs: CNI (Tacrolimus (FK) or Cyclosporine), mycophenolate mofetil and steroids. Mean age at treatment with SRL was 98 months. Children undergoing OLT had a late

El Directorio de la Sociedad de Cirujanos confecha 10 de Enero 2007 encargo al Dr. Juan HeppK. que coordinara el trabajo de una Comision inte-grada por los Drs. Attila Csendes J, FernandoIbanez, Osvaldo Llanos y Sergio San Martin, encar-gados de generar un documento que definiera losaspectos generales y contenidos de un “Programade Formacion de Postgrado en la especialidad deCirugia General”. Como resultado de dicho trabajose concluyo en los siguientes aspectos:INTRODUCCIONLa Cirugia General como especialidad se estaenfrentando en los ultimos anos, especialmente enEstados Unidos y Europa, a una crisis que se ma-nifiesta por los siguientes hechos: disminucion delos alumnos que la eligen como su primera priori-dad, aumento de las subespecialidades, lo quehace que la formacion de Cirugia General sea unpaso para alcanzar dicha especializacion; defini-cion demasiado amplia y difusa de los conocimien-tos y campo de accion del Cirujano General.Hay varios hechos que han ocurrido en losultimos 15 anos, que han cambiado el espectro delprograma de formacion de especialistas en cirugiageneral:- Cambios epidemiologicos de enfermedadestanto aumento como disminucion (obesidad y ulce-ra peptica por ejemplo).– Mayor dedicacion a areas mas especificasde la cirugia, lo que ha mejorado notablemente losresultados quirurgicos: cirujanos de “alto volumen”dedicados a temas mas especificos de la cirugia:esofagogastrica, mama, colorectal etc.–˜Desarrollo de nuevas tecnologias que noexistian hace 15 anos: cirugia laparoscopica yendoscopica, cirugia de trasplantes.– Incorporacion necesaria en la practica quirur-gica diaria de nuevos conocimientos como labioetica, la gestion clinica, la metodologia de lainvestigacion, conocimiento en computacion, etc.En Chile no hay una clara definicion de lascompetencias que debe tener el cirujano que nece-sita el pais. Tambien existe una discordancia entrelo que se aprende durante el programa de forma-cion de Cirugia General y lo que se hace en lapractica profesional. Esto se refiere basicamente alas tecnicas de especialidades como cirugia vas-cular, endocrinologica o torax.Dado que en hospitales de complejidad media-na no existe el superespecialista, y que por un ladola presion de la judicializacion de la medicina y porotro la evidencia de que cirugias complejas tienen

We report a 42 years old female that presented with abdominal pain and no palpable mass. Imaging abdominal ultrasound, CAT scan and magnetic resonance showed a solid tumor located in the retroperitoneum. The patient was operated on excising the tumor. Pathological examination of the surgical piece disclosed a retroperitoneal fibromatosis or desmoid tumor. Postoperative evolution of the patient was uneventful and she was discharged 12 days after the surgical procedure.

We report a 42 years old female that presented with abdominalpain and no palpable mass. Imaging abdominal ultrasound, CAT scan and magneticresonance showed a solid tumor located in the retroperitoneum. The patient was operated onexcising the tumor. Pathological examination of the surgical piece disclosed a retroperitonealfibromatosis or desmoid tumor. Postoperative evolution of the patient was uneventful and shewas discharged 12 days after the surgical procedure (Rev Med Chile 2006; 134: 85-9).(

Sirolimus (SRL) is a new immunosuppressive drug approved for renal transplantation, but is being used increasingly in orthotopic liver transplantation (OLT). Compared with the calcineurin inhibitors, SRL has different mechanisms of action and side effects profile. Thus, this drug offers significant potential advantages over other immunosuppressive agents. SRL does not cause glucose intolerance, hypertension or renal failure, but it may cause dyslipidemia, hepatic artery thrombosis, thrombocytopenia, anemia, leukopenia, oral mucosa ulcers, edema, arthralgias and wound complications. SRL inhibits the signal of interleukin 2 at a post-receptor level, inhibiting lymphocyte proliferation and fibroblast proliferation. It also has antineoplastic and antifungal effects. We report a 10 years old girl who underwent OLT, experiencing a biopsy-proven recurrent acute rejection (AR) in spite of using three immunosuppressive agents (tacrolimus, mofetil micofenolate and steroids). She developed diabetes mellitus as a consequence of the immunosuppressive therapy. She was rescued with SRL, not experiencing AR again. Mofetil micofenolate, steroids and insulin could be discontinued and tacrolimus doses were reduced, without experiencing severe complications. SRL is a new and safe immunosuppressive agent for rescue in patients with OLT and recurrent AR (Rev Méd Chile 2005; 133: 1221-4)

Introducción: La infección por parvovirus humano B19 (PHB 19) produce un amplio rango de enfermedades que van desde eritema infeccioso en niños hasta artritis aguda en adultos. Algunos estudios sugieren un rol patogénico del PHB 19 en el desarrollo de la hepatitis aguda (HA) y falla hepática fulminante (FHF) en niños y adultos. La Anemia aplástica (AA) es una complicación reconocida de la HA y FHF por PHB 19. Objetivo: Reportar un caso de FHF por infección por PHB 19 y revisar la literatura. Caso clínico: Niña de 7 años de edad con HA que en una semana desarrolló FHF con serología IgM anti-PHB 19 positiva. Otras causas virales, autoinmunes, metabólicas o toxicas fueron descartadas. Fue sometida a trasplante hepático ortotópico (THO) y un año después no ha presentado complicaciones. Conclusiones: El PHB 19 puede causar HA y FHF, su oportuno diagnóstico y tratamiento, que en el caso de la FHF incluye el THO puede resultar en un pronóstico favorable Acute liver failure by Parvovirus B19 and liver transplant: Case report Introduction: Human Parvovirus B19 (HPV) infection produces a wide variety of clinical manifestations including erythema infectiosum in children and acute arthritis in adults. Different studies have suggested a pathogenic role of HPV in the development of acute hepatitis (AH) and acute liver failure (ALF) in children and adults. Aplastic anemia (AA) is a well-recognized complication of AH and ALF by HPV infection. Case: A 7 years-old girl with AH that in one week developed ALF with HPV IgM antibody titer (+). Other viral, metabolic and toxic etiologies were ruled out. She underwent orthotopic liver transplantation (OLT), with no complications one year after still. Conclusions: HPV can cause AH and ALF. Early diagnosis and treatment including OLT in case of ALF may have a favorable outcome

End stage renal disease is not an absolute contraindication for liv-er transplantation (LT) in patients with end stage liver disease. Actuarial patient and graft sur-vival are comparable for children and adults who undergo LT alone and liver-kidney trans-plantation (LKT). The most common indications for LKT are the primary hyperoxaluria type I(PH1) and the liver and renal polycystic disease. We report a 12 years old boy with congenitalhepatic fibrosis with severe portal hypertension, encephalopathy and polycystic kidney diseasewith end stage renal disease on dialysis that underwent LKT. During the second postoperativeweek, he had a biopsy-proven acute liver and renal rejection, that had a good response to corti-costeroids. Thirty days after surgery, the liver biopsy was without rejection. No other complica-tions were observed (Rev Med Chile 2003; 131: 1309-12).(

Background: The success of orthotopic liver transplantation (OLT) has resulted in its widespread use for different liver diseases. Aim: To report our 8 years experience with adult OLT at Clinica Alemana de Santiago. Patients and methods: In all transplantations done at the center, we recorded patient's overall data and survival, postoperative medical and surgical complications and causes of death. Results: Between November 1993 and September 2001, 51 consecutive OLT were performed in 44 patients (22 females, median age 45 years old). Thirty eight patients presented with chronic and 6 with acute or sub-acute liver failure. Cryptogenic cirrhosis and hepatitis C infection were the most common causes for OLT. Postoperative bleeding and extra-hepatic biliary complications were seen in 17.6 and 21.5% of cases respectively. Acute rejection, bacterial infections, CMV infection or disease and post OLT hemodialysis were the most common medical complications (51, 31, 19.6 and 19.6% of cases respectively). The overall 1 and 5 years survival rates were 80% and 73% respectively. Considering exclusively the last 22 OLT performed since January 1999, the 1 year survival rate has improved to 91%. Conclusions: Liver transplantation in Chile provides a good long term survival with acceptable morbidity, due to a multidisciplinary approach management. The survival rates have improved over the last few years probably due to better surgical techniques, ICU care and immunosuppression. These overall results are comparable with those from other Centers in developed countries (Rev Méd Chile 2002; 130: 779-86)