Nutrición enteral precoz en pacientes con gastrectomía total por cáncer / Early enteral nutrition in patients subjected to a total gastrectomy

Background: Total parenteral nutrition has a high cost and frequency of complications. Enteral feeding is a feasible alternative that can be started early in the postoperative period. Aim: To assess digestive tolerance to early enteral feeding in cancer patients undergoing total gastrectomy and to compare early enteral feeding (EEF) with total parenteral nutrition plus enteral feeding (TPN+EF), initiated after overcoming postoperative ileus. Patients and methods: Subjects with a resectable gastric cancer were considered eligible for the study. During surgery a nasoenteral tube was placed and patients were prospectively randomized to EEF or TPN+EF. Digestive tolerance, effectiveness, complications and costs between both modalities of nutritional support were compared. Results: Twenty eight patients (15 male, aged 63ñ14 years old) were studied. Fourteen patients were randomized to EEF and 14 to TPN+EF. Diarrhea occurred in 14 and 29 percent of EEF and TPN+EF patients respectively, (p: NS). Patients with TPN+EF received an average of 28 Cal/kg/day and 1.1 g/kg/day proteins. Patients with EEF received an average of 29 Cal/kg/day and 0.8 g/kg/day proteins. At the eighth postoperative day, serum albumin was 3.9ñ0.7 and 3.2ñ0.5 g/dl in EEF and TPN+EF patients respectively (p <0.05), serum prealbumin was 16.9ñ5 and 12.3ñ4.3 mg/dl in EEF and TPN+EF patients respectively (p <0.05) and nitrogen balance was +2.4ñ1.5 and -1.6ñ0.6 g/24 h in EEF and TPN+EF patients respectively (p <0.05). Postoperative hyperglycemia was observed with a lower frequency and nutritional support costs and length of hospital stay were significantly lower in the EEF group. Conclusions: After total gastrectomy EEF is well tolerated, safe and effective, even during the early postoperative ileus. This therapeutic modality could be the first choice for nutritional support in these patients

Obesidad: factor de riesgo para esteatohepatitis y fibrosis hepática / Obesity as a risk factor for steatohepatitis and hepatic fibrosis

Background: Nonalcoholic fatty liver (NAFL) has been recognized as a cause of chronic liver disease. Its main risk factor is obesity. Aim: To describe the clinical and liver pathological findings in a group of patients who underwent surgery as obesity treatment. Patients and Methods: Sixty eight patients with severe or morbid obesity were subjected to surgery as obesity treatment. Each patient was evaluated with a complete clinical and laboratory medical assessment. A wedge of liver was excised during surgery. Liver biopsies were analyzed without knowledge of clinical and laboratory findings. The presence of steatosis, inflammation (portal or lobular), fibrosis and cirrhosis were recorded in the pathological analysis. Age and body mass index (BMI) were correlated with pathological data. Significance was set at a p value of less than 0.05. Results: Ninety one percent of patients had steatosis, 45 percent inflammation and 47 percent fibrosis. One patient had cirrhosis (1,4 percent). There was a statistically significant association between BMI and moderate or severe steatosis (p <0.03). There was also an association between BMI and portal (p=0.017) and lobular inflammation (p=0.034). A BMI over 40 kg/m2 (morbid obesity) was significantly associated with the presence of fibrosis (p=0.032). Moreover, the presence of moderate or severe steatosis was a risk factor for the development of hepatic fibrosis (p=0.026). Conclusions: Obesity is a major and independent risk factor for steatohepatitis and fibrosis. The degree of steatosis in the liver biopsy, is a risk factor for the development of fibrosis

Resultados preliminares de la esofagomiotomía por video laparoscopia en pacientes con acalasia esofágica / Laparoscopic esophagomyotomy for achalasia: preliminary results in 19 patients

Background: Laparoscopic esophagomyotomy is becoming a good alternative to pneumatic dilatation, injection of botulinic toxin or classical surgery in the treatment of achalasia. Aim: To report the results of laparoscopic esophagomyotomy in patients with achalasia. Patients and methods: Nineteen patients with achalasia, nine women, aged 9 to 66 years old, operated between 1996 and 2001 are reported. Results: There was no surgical mortality. One patient had a subphrenic abscess due to an unnoticed tear of the esophageal mucosa. During surgery, esophageal mucosa was perforated in 4 patients, that was sutured in three. One patient with an extensive tear of the mucosa required conversion to classical surgery. Patients were followed for 2 to 48 months. Radiological controls showed a significant increase in the diameter of gastroesophageal junction and a diameter reduction of the mid third esophageal segment. Lower esophageal pressure was significantly reduced. All patients experienced a weight increase and reduction of dysphagia. Conclusions: Laparoscopic esophagomyotomy is a safe an effective therapeutic alternative for achalasia

Resultados de la cirugía antirreflujo por videolaparoscopía en 108 pacientes / Videolaparoscopic antireflux surgery results in 108 patients

La cirugía laparoscópica antirreflujo es un procedimiento que puede tener ventajas sobre la cirugía laparotómica, siempre que los resultados sean similares. Objetivos: Evaluar los resultados de un protocolo prospectivo en pacientes con reflujo gastroesofágico crónico patológico (RGCP) sometidos a fundoplicatura y video laparoscopia. Se analizan 108 pacientes en los que se realizó un análisis clínico, endoscópico, manométrico y estudio de pH de 24 h, antes y después de la cirugía. La técnica en todas fue una fundoplicatura de 360º de 4 cm de largo, con cierre del hiatus y una fundoplicatura anterior. No hubo complicaciones intraoperatorias ni mortalidad. En el control alejado, en pacientes con Barrett corto, los resultados fueron buenos pero en Barrett extenso hubo una recidiva del 100 por ciento. En pacientes sin esófago de Barrett, hubo 85 por ciento de Visick I y II a 40 meses plazo. Los resultados de la cirugía laparoscópica son enteramente similares a la cirugía abierta, con evidentes ventajas en el postoperatorio inmediato

Resultados preliminares de la gastroplastía horizontal con anastomosis en Y de Roux como cirugía bariática en pacientes con obesidad severa y mórbida / Horizontal gastroplasty with Roux en Y anastomosis in morbidly obese patients: preliminary results

Background: morbidly obese subjects have a high incidence of complications. The poor results of dietary treatments, has prompted the search of new therapies for obesity and among these, surgical procedures. Aim: To report the long term results of horizontal gastroplasty with roux en Y anastomosis in morbidly obese subjects. Patients and methods: fifty patients with an initial body mass index of 41.3 ñ 6 kg/m2 have been subjected to a horizontal gastroplasty with roux en Y anastomosis. During the study period, surgical techniques were modified, reducing the gastric pouch size, adding a truncal vagotomy, cholecystectomy, and increasing the length of the roux en Y loop from 70 to 100 cm. Twenty five patients have been followed for two years. Results: There was no operative mortality and one patient had an anastomotic leak that required 35 days of hospitalization. During follow up, in one patient, the stapled suture line loosened. After two years of follow up, weight decreased from 112 ñ 19 to 77.2 ñ 14 kg. Conclusions: horizontal gastroplasty with roux en Y anastomosis achieved an adequate weight loss with a low rate of complications in this group of morbidly obese subjects

Evaluación subjetiva y objetiva de los resultados de la cirugía antirreflujo por video laparoscopía en pacientes con reflujo gastroesofágico / Subjective and objective assessment of the results of video laparoscopic anti-reflux surgery in patients with gastroesophageal reflux

Laparoscopic antireflux surgery is a minimally invasive procedure that should have similar results than classical surgical treatment. To report the results of a prospective study of laparoscopic antirelux surgery, 32 patients with gastroesophageal reflux and without Barret's esophagus, were subjected to endoscopy, amnometry and measurement of intraesophageal pH before and after laparoscopic surgery. Tehre were no postoperative deaths or complications. Gastroesophageal sphincter pressure and abdominal sphincter lenght increased from 9.1ñ3.9 to 13.0ñ3.5 mm Hg and from 8.1ñ6.2 to 13.5ñ5.4 cm after surgery (p<0.01). There was a decrease in acid reflux in 82 percent of patients. In conclusion, laparoscopic antireflux surgery reproduces exactly the results of open surgical procedures

Estudio prospectivo y randomizado de 2 tipos de anastomosis como método de reconstrucción después de gastrectomía total / Randomized and prospective study of 2 types of anastomosis as reconstruction method after total gastrectomy

Se realizó un estudio prospectivo y randomizado comparando los resultados inmediatos de 2 tipos de anastomosis después de gastrectomía total por cáncer gástrico. Hubo 37 pacientes seleccionados para una anastomosis esofagoyeyunal terminolateral simple y 43 pacientes para una anastomosis tipo Tomoda. No se observó diferencias significativas en ambos grupos en cuanto a características epidemiológicas. La duración de la operación, las complicaciones sépticas postoperatorias y la incidencia de fístulas anastomóticas fueron similares en ambos grupos al igual que la estadía postoperatoria. Falta evaluar los resultados a largo plazo para comprobar si hay diferencias entre ambas anastomosis

Comparación de la anastomosis esofagoyeyunal mecánica vs manual para gastrectomía total en pacientes con cáncer gástrico / Comparison between mechanical and manual esophagojejunal anastomosis for total gastrectomy in gastric cancer patients

Se realizó un estudio prospectivo en 53 pacientes con cáncer gástrico sometidos a gastrectomía total comparando la técnica manual frente a la mecánica, en la anastomosis esofagoyeyunal. En 35 pacientes se realizó la técnica manual y en 18 la técnica con stapler. No hubo mortalidad operatoria en la serie. El tiempo operatorio, la incidencia de fístula y otras complicaciones postoperatorias fueron similares en ambos grupos. La frecuencia de infección de la herida operatoria, la presencia de absceso subfrénico y la estadía postoperatoria fueron significativamente menores en pacientes sometidos a la técnica mecánica. Este procedimiento es fácil de realizar, es reproducible de un cirujano a otro, no requiere de gran experiencia previa como la técnica manual y es una buena alternativa cuando es necesario hacer una anastomosis esofagoyeyunal alta