Journal Information
Vol. 80. Issue 3.
Pages 198-204 (July - September 2015)
Visits
...
Vol. 80. Issue 3.
Pages 198-204 (July - September 2015)
Original article
Open Access
Laparoscopic management of pancreatic pseudocysts: experience at a general hospital in Mexico City
Manejo laparoscópico de los seudoquistes pancreáticos: experiencia de un hospital general en la Ciudad de México
Visits
...
B.A. Crisanto-Camposa,
Corresponding author
braulioaaroncc@hotmail.com

Corresponding author. Hospital General Dr. Manuel Gea González, Departamento de Cirugía Endoscópica y Endoscopia Gastrointestinal, Calzada de Tlalpan no 4800, México, D.F., C.P. 14080. Tel.: +01 55 4000 3000; ext.: 3329; Cel: 044 55 3225 7837.
, E. Arce-Liévanob, L.E. Cárdenas-Lailsonc, L.S. Romero-Loerad, M.E. Rojano-Rodrígueze, M.A. Gallardo-Ramírezf, J. Cabral-Oliverg, M. Moreno-Portilloe
a Clínica de Cirugía Hepatobiliar y Pancreática del Departamento de Cirugía General, Cirugía Endoscópica y Endoscopia Gastrointestinal, Hospital General Dr. Manuel Gea González, Secretaría de Salud, Mexico City, Mexico
b Departamento de Cirugía Endoscópica, Hospital General Dr. Manuel Gea González, Secretaría de Salud, Mexico City, Mexico
c Clínica de Cirugía Hepatobiliar y Pancreática del Departamento de Cirugía General, Hospital General Dr. Manuel Gea González, Secretaría de Salud, Mexico City, Mexico
d Departamento de Cirugía General, Hospital General Dr. Manuel Gea González, Secretaría de Salud, Mexico City, Mexico
e Departamento de Cirugía Endoscópica y Endoscopia Gastrointestinal, Hospital General Dr. Manuel Gea González, Secretaría de Salud, Mexico City, Mexico
f Departamento de Endoscopia Gastrointestinal, Hospital General Dr. Manuel Gea González, Secretaría de Salud, Mexico City, Mexico
g Departamento de Cirugía Bariátrica, Hospital General Dr. Manuel Gea González, Secretaría de Salud, Mexico City, Mexico
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Tables (3)
Table 1. Laparoscopic pancreatic pseudocyst treatment case series.
Table 2. Patients with pancreatic pseudocyst treated through the laparoscopic surgical approach at our hospital center.
Table 3. Results of the laparoscopic surgical approach.
Show moreShow less
Abstract
Background

Invasive management of pancreatic pseudocysts (PP) is currently indicated in those patients with symptoms or complications. Treatment options are classified as surgical (open and laparoscopic) and non-surgical (endoscopic and radiologic).

Aim

To describe the morbidity, mortality, and efficacy in terms of technical and clinical success of the laparoscopic surgical approach in the treatment of patients with PP in the last 3 years at our hospital center.

Methods

We included patients with PP treated with laparoscopic surgery within the time frame of January 2012 and December 2014. The morbidity and mortality associated with the procedure were determined, together with the postoperative results in terms of effectiveness and recurrence.

Results

A total of 38 patients were diagnosed with PP within the last 3 years, but only 20 of them had invasive treatment. Laparoscopic surgery was performed on 17 of those patients (mean pseudocyst diameter of 15.3, primary drainage success rate of 94.1%, complication rate of 5.9%, and a 40-month follow-up).

Conclusions

The results obtained with the laparoscopic technique used at our hospital center showed that this approach is feasible, efficacious, and safe. Thus, performed by skilled surgeons, it should be considered a treatment option for patients with PP.

Keywords:
Pancreatic pseudocyst
Laparoscopic drainage
Walled off pancreatic necrosis
Acute peripancreatic fluid collections
Resumen
Antecedentes

Actualmente el manejo invasivo de los seudoquistes pancreáticos (SP) está indicado en aquellos que ocasionan síntomas en el paciente o que desarrollan complicaciones. Las opciones de tratamiento se clasifican en quirúrgicas (convencionales y laparoscópicas) y no quirúrgicas (endoscópicas y radiológicas).

Objetivo

Describir la morbilidad, la mortalidad y la eficacia en términos de éxito técnico y clínico del abordaje quirúrgico laparoscópico en el tratamiento de los pacientes con SP de los últimos 3 años en el hospital sede.

Materiales y métodos

Se incluyeron pacientes con SP tratados de manera quirúrgica laparoscópica en el periodo comprendido de enero de 2012 a diciembre de 2014. Se determinó la morbimortalidad asociada al procedimiento y los resultados posquirúrgicos en términos de efectividad y recurrencia.

Resultados

Treinta y ocho pacientes fueron diagnosticados con SP en los últimos 3 años de los cuales 20 tuvieron indicación de tratamiento invasivo; a 17 se les sometió a tratamiento quirúrgico laparoscópico (diámetro promedio del SP 15.3cm, éxito primario de drenaje del 94.1%, el 5.9% presentó complicaciones, 40 meses de seguimiento).

Conclusiones

Los resultados obtenidos con la técnica laparoscópica utilizada en el hospital sede demuestran que dicho abordaje es factible, eficaz y seguro; por lo que, en manos expertas debe considerarse como una opción para el tratamiento de pacientes con SP.

Palabras clave:
Seudoquiste pancreático
Drenaje laparoscópico
Necrosis pancreática encapsulada
Colecciones peripancreáticas agudas
Full Text
Introduction

Pancreatic and peripancreatic collections are divided into 4 categories (acute collections, post-necrotic acute collections, pancreatic pseudocysts [PPs], and encapsulated pancreatic necrosis). At present, PPs are the most common cause of cystic lesions of the pancreas.1,2

Current PP management indications are based on the presence of symptoms (abdominal pain, early satiety, weight loss, persistent fever) or complications (infection, gastric or biliary obstruction, rupture, vascular thrombosis, or pseudoaneurysm formation).3,4

Treatment options for PPs are classified as surgical (open and laparoscopic) and nonsurgical (endoscopic and radiologic).5,6

Internal drainage of PPs through conventional open surgery was first described in 1923 when Jedlica published the cystogastrostomy technique.7 In 1996 Gumaste et al. published a systematic review of the literature that included 1,032 patients from 14 different studies that underwent conventional open surgery for internal PP drainage and reported morbidity of 40% and mortality of 5.8%.8

Because of this elevated morbidity and mortality rate, in the 1990s interest was sparked in developing minimally invasive surgical treatment options that resulted in the description of different internal drainage techniques with the laparoscopic approach, such as laparoscopic posterior or exogastric cystogastrostomy reported by Morino et al. in 1995 and by Park and Schwartz in 1999, transgastric or anterior cystogastrostomy, endogastric cystogastrostomy, and cystojejunostomy with a Roux-en-Y jejunal loop.9,10

Since then, there have been numerous case series describing the success and morbidity and mortality rates of different laparoscopic drainage techniques (table 1). In 2007 Aljarabah and Ammori carried out a systematic review of the literature and reported complication, mortality, and recurrence rates of 4.6, 0, and 0%, respectively, in patients with laparoscopically treated PP.11

Table 1.

Laparoscopic pancreatic pseudocyst treatment case series.

Author  Number of patients  Etiology  Surgical approach  Surgery duration (min)  Technical success (%)  Days of postoperative hospital stay  Complications (%)  Follow-up (months)  Recurrence rate (%) 
Palanivelu et al.  108  54% biliary 18.5% ethylic  83.4% LTCG 7.4% LCJ 7.4% LED 1.8% LEnCG  86 126 58 110  100  5.6  4.6%  54 
Park et al.  29  48% biliary 34% ethylic  38% LTCG 31% LPCG 17% LEnCG 11% LCJ 3% LED  168 168 150 234 105  97  4.4  15.8 
Hamza et al.  28  46% biliary29% ethylic  57% LTCG 14% LPCG 11% LEnCG 14% LCJ 4% LCD  70 120 165 135 NR  97  3.3%  15  7.1 
Hauters et al.  17  59% biliary 30% ethylic  35% LEnCG 24% LTCG 41% LCJ  105 85 240  96  12%  12 
Mori et al.  14  50% biliary 29% ethylic  100% LEnCG  NR  71  8.6  7%  19 
Dávila-Cervantes et al.  10  40% biliary 40% ethylic  40% LTCG 20% LEnCG 40% LCJ  240  100  20%  22 

LCD: Laparoscopic cystoduodenoscopy; LCJ: Laparoscopic cystojejunoscopy; LED: Laparoscopic external drainage; LEnCG: Laparoscopic endogastric cystogastrostomy; LPCG: Laparoscopic posterior cystogastrostomy; LTCG Laparoscopic transgastric cystogastrostomy; NR: Not reported.

In 2014 Khaled published a retrospective study that directly compared the laparoscopic surgical technique with the conventional open approach for PP treatment and concluded that the former offered advantages in terms of shorter surgery duration, a lower morbidity rate, and shorter hospital stay, and therefore should be considered the first choice approach in centers that have the adequately trained personnel.12

Minimally invasive treatment techniques have recently been described for pancreatic and peripancreatic collections different from PP. In 2010 Van Santvoort et al. carried out a multi-center, prospective, randomized study showing that patients with infected necrotic pancreatitis treated through a minimally invasive technique (the step-up approach) using computerized axial tomography-guided fine needle aspiration and/or laparoscopic necrosectomy had a lower rate of multiple organ failure, a lower incidence of incisional hernia, and a lower incidence of new-onset diabetes than the patients treated through open necrosectomy.13

Aim

Our aim was to describe the morbidity, mortality, and efficacy in terms of technical and clinical success associated with the laparoscopic surgical approach in patients with PP treated at the Hepatobiliary and Pancreatic Clinic of our hospital center over the last 3 years.

Methods

A retrospective, cross-sectional, observational, and descriptive study was conducted. The case records were reviewed of the patients 18 years of age or older that were diagnosed with PP and treated through laparoscopic posterior cystogastrostomy at our hospital center within the time frame of January 2012 and December 2014.

A contrast-enhanced computerized axial tomography scan was carried out on the patients with a history of acute pancreatitis that were seen as outpatients 4 weeks after the inflammatory pancreatic event and presented with epigastric pain, early satiety, or persistent fever. PP was defined as a peripancreatic collection meeting the following tomographic criteria: round or oval, with a well-defined wall, content with a fluid density in Hounsfield units, and no evidence of solid debris or necrotic tissue in its interior. Infected PP was defined as a collection presenting tomographic evidence of gas in its interior.

The patients that fit the abovementioned criteria underwent internal drainage through laparoscopic cystogastrostomy as a first treatment option, performed by a surgeon and an assistant. The technique employed at our hospital center is described in detail in the 2012 Revista Mexicana de Gastroenterología14 and the most important steps are the following: with the patient under general anesthesia, the pneumoperitoneum is insufflated with a Veress needle, inserting a 10mm supraumbilical optical port and three 5mm working ports at the subxiphoid location and the mid-clavicular line in the right and left subcostal regions, respectively. To gain access to the pancreas, the gastrocolic ligament is dissected with monopolar and bipolar cautery. The posterior surface of the stomach and the anterior surface of the pseudocyst are located and dissected. The pseudocyst is incised using a monopolar hook and its content is aspirated. The posterior surface of the stomach is then incised at the level corresponding to the incision in the wall of the PP. A 3cm anastomosis is performed with 0 polypropylene separate sutures using an extracorporeal Gea knot. The procedure is finished by placing 2 Jackson-Pratt drains at the surgical site and closing the aponeurosis with Vicryl 1 and the skin with 3-0 polypropylene simple sutures. In cases with a biliary etiology of the patient's acute pancreatitis episode culminating in PP formation, conventional laparoscopic cholescystectomy following the Strasberg principles was performed as the initial step of the surgical procedure.

Patients resumed oral intake in the postoperative period as soon as gastrointestinal function was recovered (bowel sounds and the passage of flatus) and they were released from the hospital when they tolerated that diet and the drains had a serous output under 100 cc for 24h (the drains were removed on the day of release).

The drained pseudocyst diameter (measured through tomography), the percentage of conversion to open surgery, primary drainage success defined as the clinical and tomographic resolution of the pseudocyst in a single surgery, surgery duration, intraoperative blood loss, days of postoperative hospital stay, and complications requiring surgical or endoscopic intervention under general anesthesia (III b according to the Clavien-Dindo classification) during the first 30 postoperative days were recorded.

Outpatient follow-up consisted of monthly consultations for the first 6 postoperative months and then appointments every 3 months. At each consultation the patient was asked about possible recurrence symptoms, such as early satiety, abdominal pain, and weight loss. In addition, control tomography scans were done at the 2nd and 6th months of follow-up. Recurrence was considered if there were persistent symptoms or tomographic evidence of residual pseudocyst during the follow-up.

Statistical analysis

The data were registered on a data collection sheet specifically designed for this line of investigation and then put in a database (Microsoft Excel; Microsoft Corporation, Seattle, WA, USA). Descriptive statistics with simple percentages, means, and minimum and maximum values were used for establishing the results of the laparoscopic surgical approach in the treatment of patients with PP.

Results

A total of 38 patients diagnosed with PP were attended to at our hospital center over the last 3 years. Twenty-three were men and 15 were women and their mean age was 38.8 years (13-76 years).

A total of 18 patients (47.3%) did not meet the criteria for invasive management and remained under surveillance. The peripancreatic collection was reabsorbed in 100% of the cases and there were no remaining or residual local complications. Twenty patients (52.7%) met the criteria for invasive management (symptoms and complications).

Of the 20 patients that required invasive management, 13 (64%) had a history of acute biliary pancreatitis. Of those patients, the underlying etiology of the acute pancreatitis was alcohol-related in 6 (32%) and in one (4%) it was due to hypertriglyceridemia. Of the 20 patients, 13 were men and 7 were women.

In the group of patients requiring invasive management, 17 (77.2%) underwent laparoscopic posterior cystogastrostomy as the first treatment option (table 2). The indication for invasive treatment was the presence of symptoms in 88.2% of the patients and infected pseudocyst in the remaining 11.8%. Of those patients, 11 were men and 6 were women and their mean age was 39.7 years (20-63 years). Acute pancreatitis etiology was biliary in 64.7% of the cases, alcohol-related in 29.4%, and due to hypertriglyceridemia in 5.8%.

Table 2.

Patients with pancreatic pseudocyst treated through the laparoscopic surgical approach at our hospital center.

  Age (years)  Sex  AP etiology  Drainage indication  PP diameter (cm)  PP location  Conversion to open surgery  Primary drainage success  Surgery duration (min)  Surgical bleeding (ml)  Complications  Days of postoperative hospital stay  Recurrence  Mortality 
27  Ethylic  EP, ES  15  Body and tail  No  Yes  90  200  No  No  No 
34  Biliary  EP,ES  13  Body and tail  No  Yes  180  100  subxiphoid port insertion site bleeding  No  No 
44  Ethylic  EP  Head  No  Yes  210  150  No  No  No 
39  Tg  EP,WL  18  Body and tail  No  Yes  180  240  No  No  No 
49  Biliary  IPP  17  Body and tail  No  Yes  210  20  No  No  No 
62  Biliary  EP  11  Body  No  Yes  350  80  No  No  No 
54  Ethylic  EP  10  Tail  No  Yes  121  100  No  No  No 
20  Biliary  EP  14  Body and tail  No  Yes  90  30  No  No  No 
34  Biliary  EP,ES  11  Body  No  Yes  150  200  No  No  No 
10  21  Ethylic  EP  5.5  Body  No  Yes  175  150  No  12  No  No 
11  25  Biliary  EP, ES, WL  24  Body and tail  No  Yes  101  150  No  No  No 
12  51  Biliary  EP, ES  14  Body  No  No  100  300  No  No  No 
13  43  Biliary  EP  18  Body  No  Yes  280  300  No  10  No  No 
14  63  Biliary  IPP  21  Body  No  Yes  260  150  No  10  No  No 
15  24  Ethylic  EP  19  Tail  No  Yes  180  100  No  10  No  No 
16  32  Biliary  EP, ES, WL  25  Body  No  Yes  180  160  No  18  No  No 
17  53  Biliary  EP  16  Body  No  Yes  160  150  No  No  No 

AP: Acute pancreatitis; EP: Epigastric pain; ES: Early satiety; IPP: Infected Pancreatic pseudocyst; M: Men; PP: Pancreatic pseudocyst; Tg: Triglycerides; W: Women; WL: Weight loss.

The mean transverse length of the laparoscopically-drained pseudocysts was 15.3cm (5.5-25cm). The entire procedure was laparoscopic and there was no need for conversion to open surgery in any of the 17 cases. The pseudocyst was resolved in 16 patients (94.1%) with a single surgical intervention (primary drainage success). In the remaining case (5.9%), despite having a preoperative computerized axial tomography scan that showed a collection with fluid content and no necrosis, abundant necrotic detritus was encountered during the procedure. Once the detritus was debrided, the cystogastrostomy continued with the previously described technique. In the postoperative period the patient presented with obstruction of the anastomosis by necrotic debris, which was resolved through endoscopic dilation. The mean surgery duration was 177min (range: 90-350min), being longer in the first cases. The mean intraoperative blood loss was 151ml (20-300ml).

Only one patient (5.9%) had a complication associated with the procedure. Due to the presence of blood output through the drain, he underwent a diagnostic laparoscopy that revealed bleeding from the subxiphoid trocar insertion site, which was controlled laparoscopically.

Postoperative hospital stay was a mean of 6.8 days (2-18 days). The current follow-up period is 40 months and so far no disease recurrence has been registered (table 3).

Table 3.

Results of the laparoscopic surgical approach.

Mean age  39.7 years (20-63) 
Sex (Men: Women)  11:6 
AP etiology  64.7% biliary29.4% ethylic5.8% triglycerides 
Mean PP diameter  15.3cm (5.5-25) 
Conversion to open surgery  0% 
Primary drainage success  94.1% 
Mean surgery duration  177min (90-350) 
Mean surgical bleeding  151ml (20-300) 
Complications  5.9% 
Days of postoperative hospital stay  6.8 days (2-18) 
Recurrence  0% 
Follow-up  40 months 
Mortality  0% 

AP: acute pancreatitis; PP: pancreatic pseudocyst

Discussion

This is the largest published case series to date in a Mexican population on the laparoscopic surgical treatment of PPs. In 2004 Dávila-Cervantes et al. reported complications of 20% and 0% recurrence in 22 months of follow-up on 10 Mexican patients with PP treated through laparoscopic internal drainage.15

Our data show that the minimally invasive technique for treating patients with PP employed at our hospital center is a feasible, safe, and effective option in our medical environment and the results are comparable to those published in the largest and most recent article on laparoscopic drainage of PP. In that case series by Palanivelu et al., which included 108 patients, they reported a mean postoperative hospital stay of 5.6 days and conversion, morbidity, mortality, and recurrence rates of 0, 8.3, 0, and 1%, respectively.16

It is important to point out that in contrast to the other case series published in the international literature that use different types of laparoscopic internal drainage (transgastric cystogastroscopies, cystojejunoscopies, etc.), only one laparoscopic technique (posterior cystogastrostomy) is used at our hospital, which facilitates the teaching/learning process and the reproducibility of the technique.

Minimally invasive management (laparoscopic and endoscopic) of PPs is currently gaining ground over the open approach.12 In 2013, Varadarajulu et al. published a randomized, prospective study that compared a minimally invasive approach (endoscopic drainage) with the conventional surgical approach, showing that in select cases, endoscopic management achieves the same success rates as conventional surgical treatment, but with fewer days of hospital stay and a lower economic cost.17

It remains to be established whether one minimally invasive treatment modality is superior to another. In 2009 Melman conducted a retrospective study comparing laparoscopic drainage with endoscopic drainage. He concluded that the primary success rate for PP drainage was statistically superior with the surgical approach.5

Conclusions

The results obtained with the laparoscopic posterior cystogastrostomy technique at our hospital center showed that this approach in our environment is feasible, safe, and effective, and in skilled hands, should be considered a treatment option for patients with PP. Our technique has the added advantage of being standardized and thus facilitates the teaching/learning process of the procedure, making our hospital a human health resource formation center for the minimally invasive treatment of this pathology in the Mexican population.

Ethical responsibilitiesProtection of persons and animals

The authors declare that no experiments were performed on humans or animals for this study.

Data confidentiality

The authors declare that they have followed the protocols of their work center in relation to the publication of patient data.

Right to privacy and informed consent

The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This document is in the possession of the corresponding author.

Financial disclosure

No financial support was received in relation to this study/article.

Conflict of interest

The authors declare that there is no conflict of interest.

References
[1]
A. Brun, N. Agarwal, C.S. Pitchumonl.
Fluid collections in and around the pancreas in acute pancreatitis.
J Clin Gastroenterol., 45 (2011), pp. 614-625
[2]
P. Banks, T. Bollen, C. Dervenis, et al.
Classification of acute pancreatitis-2012: Revision of the Atlanta classification and definitions by international consensus.
[3]
M.D. Johnson, R.M. Walsh, J.M. Henderson.
Surgical versus nonsurgical management of pancreatc pseudocysts.
J Clin Gastroenterol., 43 (2009), pp. 586-590
[4]
C.V. Cheruvu, M.G. Clarke, M. Prentice, et al.
Conservative treatment as an option in the management of pancreatic pseudocyst.
Ann R Coll Surg Engl, 85 (2003), pp. 313-316
[5]
L. Melman, R. Azar, K. Beddow.
Primary and overall success rates for clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts.
Surg Endosc., 23 (2009), pp. 267-271
[6]
K.E. Behrns, K. Ben-David.
Surgical therapy of pancreatic pseudocysts.
J Gastrointest Surg., 12 (2008), pp. 2231-2239
[7]
R. Jedlica.
Eine neue operations methode der pankreascysten (pancreatogastrostomie).
Zentral Chir, 50 (1923), pp. 132
[8]
V. Gumaste, C.S. Pitchumoni.
Pancreatic pseudocyst.
Gastroenterologist., 43 (1996), pp. 3-43
[9]
A. Park, R. Scwartz.
Laparoscopic pancreatic surgery.
Am J Surg., 177 (1999), pp. 158-163
[10]
M. Morino, C. Garrone, C. Locatelli.
Laparoscopic management of benign pancreatic cystic lesions.
Surg Endosc., 9 (1995), pp. 625
[11]
M. Aljarabah, B.J. Ammori.
Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: A systematic review of published series.
Surg Endosc., 21 (2007), pp. 1936-1944
[12]
Y. Khaled, D. Malde, J. Parker, et al.
Laparoscopic versus open cystgastrostomy for pancreatic pseudocysts: A case-matched comparative study.
J Hepatobiliary Pancreat Sci, 21 (2014), pp. 818-823
[13]
H. Van Santvoort, M. Besselink, O. Bakker, et al.
A step-up approach or open necrosectomy for necrotizing pancreatitis.
N Engl J Med, 362 (2010), pp. 16
[14]
B. Crisanto, M. Rojano, L. Cárdenas, et al.
Drenaje laparoscópico de un seudoquiste pancreático: reporte de caso.
Rev Gastroenterol Mex., 77 (2012), pp. 148-152
[15]
A. Dávila-Cervantes, F. Gomez, C. Chan.
Laparoscopic drainage of pancreatic pseudocysts.
Surg Endosc., 18 (2004), pp. 1420-1426
[16]
C. Palanivelu, K. Senthilkumar, M.V. Madhankumar.
Management of pancreatic pseudocyst in the era of laparoscopic surgery–experience from a tertiary centre.
Surg Endosc., 21 (2007), pp. 2262-2267
[17]
S. Varadarajulu, J. Young, B. Sutton, et al.
Equal efficacy of endoscopic and surgical gastrostomy for pancreatic pseudocyst drainage in a randomized trial.
Gastroenterology, 145 (2013), pp. 583-590

Please cite this article as: Crisanto-Campos BA, Arce-Liévano E, Cárdenas-Lailson LE, Romero-Loera LS, Rojano-Rodríguez ME, Gallardo-Ramírez MA, et al. Manejo laparoscópico de los seudoquistes pancreáticos: experiencia de un hospital general en la Ciudad de México. Revista de Gastroenterología de México. 2015;80:198–204.

Copyright © 2015. Asociación Mexicana de Gastroenterología
Idiomas
Revista de Gastroenterología de México

Subscribe to our newsletter

Article options
Tools
es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.