Fístula aorto-duodenal primaria: caso clínico / Primary aorto-duodenal fistula: clinical case

Resumen Introducción Las fístulas aorto-entéricas (FAE) son una causa infrecuente de hemorragia digestiva. El pronóstico, generalmente ominoso, depende de una alta sospecha clínica y diagnóstico oportuno. Caso clínico Reportamos el caso de una mujer de 66 años intervenida por un aneurisma sacular aórtico abdominal (AAA) yuxtarrenal, con rotura contenida, fistulizado al duodeno. Presentó una hemorragia digestiva en el preoperatorio; sin embargo, el diagnóstico de la fístula se hizo en el intraoperatorio. La paciente fue sometida a reparación quirúrgica urgente con instalación de una prótesis aórtica bifemoral y resección duodenal. En el postoperatorio inmediato presentó una trombosis parcial de las ramas de la prótesis aórtica e isquemia de extremidades, siendo reintervenida exitosamente. Discusión La FAE es una causa potencialmente fatal de hemorragia digestiva. El diagnóstico continúa siendo un desafío debido a su presentación inespecífica y siempre debiese ser considerado frente a una hemorragia digestiva sin causa aparente. Existen varias opciones para el enfrentamiento quirúrgico que deben ser analizadas caso a caso, sin retrasar la reparación de la fístula. Es preferible la resección duodenal ante la simple duodenorrafia.

Introduction Aorto-enteric fistulae (AEF) are a rare cause of gastrointestinal bleeding. The prognosis tends to be ominous, depending greatly in a high level of clinical suspicion and prompt diagnosis. Clinical case We report a case of a 66-year-old female with a saccular juxta-renal abdominal aortic aneurysm (AAA), with a contained rupture. The patient was urgently submitted to surgical repair using an bifemoral aortic prosthesis. A duodenal partial resection was performed. During the immediate postoperative time she presented partial thrombosis of prosthesis and ischemia of lower extremities so she was reoperated successfully. Discussion AEF is a potentially fatal cause of gastrointestinal bleeding. Diagnosis is still troublesome due to its vague presentation and it should always be considered when facing gastrointestinal haemorrhage with no apparent cause. There are several surgical approaches that should be pondered case to case without delaying the repair of the defect.

El "paciente difícil" y profesionalismo médico / The "difficult patient" and medical professionalism

En el presente artículo se revisan las características que definen al "paciente difícil" entendiendo que esta realidad se comprende mejor como una "relación difícil médico-paciente". Bajo una mirada antropológica se repasan las bases que componen el encuentro entre el médico y un paciente, para transmitir algunas recomendaciones sobre cómo mejorar este singular encuentro, a fin de que se genere una mayor satisfacción y beneficio para ambos. Surge como recomendación considerar los elementos constitutivos del profesionalismo médico, teniendo especialmente presente la autonomía del paciente, la primacía del bienestar del mismo y una actitud de servicio y compasión por el enfermo, por parte del médico. Si a ello se une el esfuerzo por una mirada empática, se puede esperar una mejor relación entre este binomio.

This article reviews the features that characterize the "difficult patient", which is a concept defined on the basis of a "difficult physician-patient relationship". It reviews the fundamentals of the physician-patient relationship from an anthropological point of view and provides recommendations to improve it in a way that it is more beneficial and provides greater satisfaction for both parties. The article suggests physician should seek to achieve high levels of medical professionalism by respecting the patient's autonomy and seeking her well-being at all times, while showing compassion and a service attitude towards her. In addition to this, a more empathetic attitude towards the patient can also contribute to improving the relationship.

Calidad en cirugía: hacia una mejor comprensión de las complicaciones quirúrgicas / Quality assessment in surgery

This paper deals with quality from the perspective of structure, processes and indicators in surgery. In this specialty, there is a close relationship between effectiveness and quality. We review the definition and classification of surgical complications as an objective means of assessing quality. The great diversity of definitions and risk assessments of surgical complications hampered the comparisons of different surgical centers or the evaluation of a single center along time. We discuss the different factors associated with surgical risk and some of the predictive systems for complications and mortality. At the present time, standarized definitions and comparisons are carried out correcting for risk factors. Thus, indicators of mortality, complications, hospitalization length, postoperative quality of life and costs become comparable between different groups. The volume of procedures of a determinate center or surgeon as a quality indicator is emphasized.

Lucas Sierra y los inicios de la cirugía biliar en Chile: a 130 años de la colecistectomía de Langenbuch / Lucas Sierra and early biliary surgery in Chile: 130 year after Langenbuch cholecystectomy

Through the communication of the first cholecystectomy performed in Chile by Dr. Lucas Sierra Mendoza in 1899, is reviewed the surgical setting of the time and highlights the features of this distinguished surgeon. Referring to Langenbuch initial experience, we illustrate the pathogenic conceptions of biliary gallstone disease and walk the path of cholecystectomy in the following century.

A través de la comunicación de la primera colecistectomía efectuada en Chile por el doctor Lucas Sierra Mendoza en 1899, se revisa el contexto quirúrgico de la época y se destacan las características de este distinguido cirujano. Con referencia a la experiencia inicial de Langenbuch, se expone la concepción etiopa-togénica de la enfermedad biliar litiásica y se recorre el camino de la colecistectomía en la centuria siguiente.

Hepatocarcinoma en hígado no cirrótico / Hepatocellular carcinoma in a non cirrhotic liver

Background: The appearance of hepatocellular carcinoma in non-cirrhotic livers is uncommon. Material and Method: We report a 62 years old woman presenting with a liver mass that was subjected to a left hepatectomy. Results: The pathology report disclosed a poorly to moderately differentiated hepatocellular carcinoma. The surrounding liver tissue was normal. Immunohistochemistry identified intracytoplasmic a-1 antitrypsin granules, confirming the suspicion of a-1 antitrypsin deficiency.

Introducción: El Carcinoma Hepatocelular (HCC), tumor hepático primario más frecuente, se presenta en general en hígados cirróticos. Un porcentaje menor se desarrolla en pacientes sin cirrosis, en los cuales deben buscarse otras etiologías. Paciente y Método: Se presenta un caso clínico y las características anato-mopatológicas de una paciente con hepatocarcinoma e hígado no cirrótico tratada en nuestro centro. Mujer de 62 años, con historia de dolor abdominal y baja de peso. Estudio por imágenes revela masa hepática de aproximadamente 8 cm de diámetro mayor, en segmentos II, III y IV, sugerente de HCC. Resultados: Se realiza hepatectomía izquierda. Evoluciona de forma satisfactoria en el postoperatorio. La biopsia muestra un HCC moderada a pobremente diferenciado. El tejido no tumoral es normal, con gránulos intracitoplasmáticos Pas y Pas diastasa (+). Inmunohistoquímica identifica gránulos intracitoplasmáticos de antitripsina, con lo que se confirma la sospecha diagnóstica de déficit de a-1 antitripsina.

La incorporación de la mujer en la cirugía chilena / The incorporation of women in Chilean surgery

It has been observed an increasing number of women studying medicine. However, the incorporation of women to surgery remains low. In Chile we do not have information on this topic. Our goal was to collect information to provide the figures and trends in this regard. Information was obtained from the Society of Surgeons of Chile (SCCH), the Chilean Chapter of the American College of Surgeons (CCh CAC), the Autonomous National Commission of Medical Specialties (CONACEM) and the Superintendent of Health of Chile (SS), until June 2011. The SCCH has 854 partners and 64 were women (7.5 percent). The Chilean Chapter of the CCh CAC has 162 members and 4 women (2.5 percent). At CONACEM, 1.070 persons have been certified as surgeons, 80 are women (7.5 percent). In the register of SS there are 1.177 surgeons, 8.4 percent female. In 1959 the first women joined SCCH. Since then, the number has been progressive, growing mainly in the last two decades to reach the 7.5 percent now. Nevertheless, in all consulted sources, the percentage of women in surgical practice, still less than 10 percent. It seems that woman is trying to increase participation in the surgical field. However, the "surgeon's lifestyle" collides with compatibility between work and family life. We believe there is room for qualitative research in this field, to better understand motivations and challenges of women in order to access the surgical world nowadays.

Se ha observado un aumento del número de mujeres que estudia medicina. No obstante, la incorporación de la mujer a la cirugía sigue siendo baja. En Chile no conocemos de información sobre este tema. Nuestro objetivo fue recopilar información que proporcionara cifras y tendencias en este sentido. Se obtuvo información de la Sociedad de Cirujanos de Chile (SCCh), del Capítulo Chileno del Colegio Americano de Cirujanos (CCh CAC), de la Comisión Nacional Autónoma de Especialidades Médicas (CONACEM) y de la Superintendencia de Salud de Chile (SS), hasta junio de 2011. La SCCh tiene 854 socios y 64 corresponden a mujeres (7,5 por ciento). El Capítulo Chileno del CAC tiene 162 miembros y 4 son mujeres (2,5 por ciento). Ante CONACEM se han certificado 1.070 cirujanos, de los cuales 80 son mujeres (7,5 por ciento). En el registro de la SS hay 1.177 cirujanos, 8,4 por ciento de sexo femenino. El año 1959 se incorporó la primera mujer a la SCCh. Desde ahí, el número ha sido progresivo, aumentando principalmente en las dos décadas recientes hasta alcanzar el 7,5 por ciento actual. No obstante este aumento, en todas las fuentes consultadas el porcentaje de mujeres en práctica quirúrgica es inferior al 10 por ciento. Pareciera ser que la mujer intenta realmente una mayor participación en el campo quirúrgico. Sin embargo, el "estilo de vida del cirujano", choca con una compatibilización mayor entre vida laboral y familiar. Creemos que hay espacio para investigaciones cualitativas en este campo, que reflejen mejor las motivaciones y dificultades de la mujer por acceder al mundo quirúrgico en nuestro medio.

Condrosarcoma tóraco-abdominal / Thoraco-abdominal chondrosarcoma

Chondrosarcomas represent the third primary malignant bone tumor. Costal location occurs in 12 percent, being the most common tumor of the ribs. It affects most frequently in the second and fifth decades of life. This tumor is histologically classified into grades 1, 2 and 3 in descending order of differentiation. For grade 2, with oncologic resection, there is a 10-year survival of 64 percent, and a 10 percent risk for metastasis. Radiotherapy has a limited therapeutic role and chemotherapy has not shown benefits. We report a case of a 45 years old woman, who presented with a symptomatic growing mass in the right rib cage, of three months of evolution, whose evaluation by magnetic resonance imaging and computed tomography shows a sarcomatous tumor with involvement of ribs, muscles, diaphragm, pleura, peritoneum and liver. A small amount of intraperitoneal free fluid was observed. A block resection was made, resulting a 16.8 cm long at the widest point chondrosarcoma, grade 2, with involvement of all layers of the wall, tumor microfoci in the liver capsule and malignant tumor cells in peritoneal fluid.

Los condrosarcomas representan la tercera neoplasia ósea maligna primaria. La ubicación costal representa el 12 por ciento, siendo el tumor más frecuente de las costillas. Se presenta con mayor frecuencia en la segunda y quinta décadas de la vida. Este tumor se clasifica histológicamente en grados 1, 2 y 3 en orden decreciente de diferenciación. Para el grado 2, resecado oncológicamente, se observa una sobrevida a 10 años del 64 por ciento; existiendo un 10 por ciento de riesgo de metástasis. La radioterapia tiene un escaso rol terapéutico y la quimioterapia no ha demostrado beneficios. Presentamos el caso de una mujer de 45 años que consultó por un aumento de volumen sintomático de la parrilla costal derecha, de tres meses de evolución, cuya evaluación a través de tomografía axial y resonancia magnética permitió delinear un tumor sarcomatoso de la pared con afectación de costillas, músculos, diafragma, pleura, peritoneo e hígado. Además se observaba escasa cantidad de líquido libre intraperitoneal. Fue resecado en block un condrosarcoma de 16,8 cm de eje mayor, grado 2, con compromiso de todos los planos de la pared, microfocos tumorales en cápsula hepática y células neoplásicas malignas en líquido peritoneal.

La increíble empresa de Sarmiento de Gamboa y su triste fin: Posibles causas de la tragedia en el Estrecho de Magallanes en el siglo XVI / The possible causes of the tragedy of “Port Famine” in the Strait of Magellan

The attempts to colonize the Strait of Magellan soon followed the discovery of this route. PeDro Sarmiento de Gamboa, a Spanish sailor, established human settlements to fortify those lands and control the transit of vessels, especially those of English corsairs, which devastated Chilean and Peruvian coasts. During the summer of 1584, approximately 500 soldiers, artisans, priests, women and children established two villages called “Nombre de Jesús” and “Rey Don Felipe”. From the beginning, these settlers had leadership and communication problems and difficulties to obtain food. After three winters only 17 to 18 people survived according to the testimony of one of the survivors, that was rescued by an English sailor named Cavendish, which renamed the village “Rey Don Felipe” as “Port Famine”. When he observed the scenes of abandonment and death, he supposed that the settlers died due to lack of food. Other factors that facilitated the desolation were hypothermia, execution, anthropophagy and lesions caused by natives. There is also a possibility that intoxication by red tide (harmful algal bloom) could explain in part the finding of unburied corpses in the strait beaches.

Evaluación de los Programas de Formación en Cirugía General: encuesta a los alumnos de postítulo / Resident evaluation of general surgery training programs

Background: The profile of the general surgeon has changed, aiming to incorporate new skills and to develop new specialties. Aim: To assess the quality of postgraduate General Surgery training programs given by Chilean universities, the satisfaction of students and their preferences after finishing the training period. Material and methods: A survey with multiple choice and Likert type questions was designed and applied to 77 surgery residents, corresponding to 59 percent of all residents of general surgery specialization programs of Chilean universities. Results: Fifty five per cent of residents financed with their own resources the specialization program. Thirty nine percent disagreed partially or totally with the objectives and rotations of programs. The opportunity to perform surgical interventions and the support by teachers was well evaluated. However, 23 percent revealed teacher maltreatment. Fifty six percent performed research activities, 73 percent expected to continue training in a derived specialty and 69 percent was satisfied with the training program. Conclusions: Residents considered that the quality and dedication of professors and financing of programs are issues that must be improved. The opportunity to perform surgical interventions, obtaining a salary for their work and teacher support is considered of utmost importance.

A propósito de la muerte de Cano de Aponte y los accidentes ecuestres / On the death of Gabriel Cano de Aponte

Gabriel Cano de Aponte was Governor of Chile since 1717 and util his death in 1733, being 68 years old. As a soldier, he was an experimented horse rider. The sequence ofevents that caused his death three months after an equestrian accident are unclear. A systematic clinical analysis of the later is the main objective of this review. Historians have documented Cano de Aponte's "inclination for unbridled fun and equestrian exercises". During a holiday Cano de Aponte suffered a horse fall and subsequent crushing by the latter. It has been stated that a spinal lesion caused by the accident kept him bedridden for a period of three months, clear in reason and with intense pain, before his death. However, there is no evidence on historie data that conveys any typical sign associated to spinal injury following the accident. Therefore we suggest that Cano de Aponte suffered a complex pelvic ring fracture. The fact that he was prostrated, lucid, but suffered and intense pain best sustains the hypothesis of a pelvic fracture. After the initial period, one ofthe most common causes of death resulting from a pelvic fracture is deep venous thrombosis with secondary pulmonary thromboembolism. This must have been the sequence ofevents that most probably caused Cano de Aponte's death).

Ivan IV, el Terrible, ¿padeció de un síndrome del lóbulo temporal? / The possible temporal lobe syndrome of Ivan IV the Terrible

Ivan IV "The Terrible" was the first Tsar of all Russias and was crowned in 1547. He extended Russian territories and opened the route to Siberia in successful campaigns against Tartars. He increased his personal power to the point of generating an autocracy that isolated him progressively from the council of Boyars. He had a complex personality and his acts were impregnated by a profound religiousness, episodes of rage, mood changes and a sense of "personal fate". All these traits configure the controversial "temporal lobe personality". The possible association between these personality traits and the eventual epilepsy that Ivan IV could suffer, is discussed. This association is called "temporal lobe syndrome". Considering the mood changes, with severe irritability and episodes of control loss alternated with feelings of guilt, sadness and isolation, another possibility is that the Tsar had an affective bipolar disorder or, less probably, a personality disorder.

Aneurisma de la arteria esplénica: Diagnóstico diferencial y alternativas terapéuticas / Splenic artery aneurysm: Case report

Splenic artery aneurysms are rare and occur predominantly in women. Most of them are asymptomatic until rupture. We report a previously healthy 73 year-old woman who presented with non specific symptoms: dyspepsia and constipation. Laboratory tests were normal. Subsequent examinations (ultrasound and CT) showed a large aneurysm of the splenic artery without any sign of rupture. Endovascular treatment remained successfully performed using coil embolization. During a 12-months follow-up period, the patient was asymptomatic and no evidences of complications or splenic infarction were observed on CT scans.