Pielopastia Laparoscópica: Técnica Robótica / Laparoscopic pyeloplasty: Robotic Technique

Múltiples series de pieloplastia laparoscópica han demostrado altos niveles de éxito y escasas complicaciones para población adulta. El uso de robótica facilita la reconstrucción pieloureteral debido a la superioridad en cuanto a visión estereoscópica, precisión de movimientos y filtros anti temblor . Lo que permite además del éxito quirúrgico, una ventaja en términos de técnica mínimamente invasiva y consecuentemente menor estadía hospitalaria. El objetivo del presente video es demostrar la técnica utilizada en nuestro centro para pieloplastia robótica y mostrar una sistematización que simplifica el procedimiento.AU

Multiple series of laparoscopic pyeloplasty have demonstrated high success levels and few complications in the adult population. The use of robotics facilitates pyeloureteral reconstruction due to the superiority in stereoscopic vision, movement precision and anti-tremor filters. The previous provides not only surgical success but also an advantage in terms of minimally invasive technique and consequently less hospital stay. The objective of this video is to demonstrate the technique used in our facilities in robotic pyeloplasty and to show a systematization that simplifies the procedure.

Frecuencia, susceptibilidad antimicrobiana y patrón de adherencia de Salmonella enterica aislada de carne de pollo, res y cerdo de la Ciudad de México / Frequency, antimicrobial susceptibility and adherence patterns of Salmonella enterica isolated from chicken meat, beef and pork from Mexico City

Resumen Introducción: Los alimentos de origen animal frecuentemente están implicados en brotes de salmonelosis. Objetivo: Evaluar la frecuencia de Salmonella enterica en carnes molidas de pollo, res y cerdo (un total de 2.592 muestras) obtenidas de mercados sobre ruedas y supermercados de la Delegación Iztapalapa en la Ciudad de México, determinar la susceptibilidad antimicrobiana y efectuar ensayos de adherencia en las cepas aisladas. Métodos: El aislamiento de S. enterica se hizo de acuerdo a la BAM-FDA, la susceptibilidad antimicrobiana de acuerdo con CLSI y el ensayo de adherencia en células HEp-2 conforme a Baffone y cols., 2001. Resultados: Salmonella enterica fue aislada en 511 del total de muestras analizadas (19,7%), de las cuales 244 (47,7%), 152 (29,7%) y 115 (22,5%) correspondieron a carne molida de pollo, res y cerdo, respectivamente. La mayor frecuencia de resistencia de S. enterica a antimicrobianos fue a ampicilina y cloranfenicol en pollo, perfloxacina y ampicilina en res y carbenicilina, ampicilina, cloranfenicol, cefotaxima y perfloxacina en cerdo. Noventa por ciento de las cepas mostraron un patrón de adherencia agregativo. Conclusión: La frecuencia de S. enterica en productos cárnicos es alta, por lo que es importante la adecuada cocción de la carne para disminuir el riesgo de una salmonelosis.

Background: Food of animal origin is often involved in salmonellosis outbreaks. Aim: To evaluate the frequency of Salmonella enterica in chicken, beef and pork ground meat (a total of 2,592 samples) obtained from travelling markets and supermarkets at the Iztapalapa area of Mexico City, in order to determine the antimicrobial susceptibility and adherence capacity of isolated strains. Methods: Isolation of S. enterica was carried out according to the BAM-FDA, the microbial susceptibility according with CLSI and adherence assay on HEp-2 cell line according with Baffone et al., 2001. Results: S. enterica was isolated from 511 of all the analyzed samples (19.7%), from which 244 (47.7%), 152 (29.7%) and 115 (22.5%) corresponded to chicken, beef and pork ground meat, respectively. The highest frequency of resistance of S. enterica to antimicrobials was to ampicillin and chloramphenicol in chicken, perfloxacin and ampicillin in beef and carbenicillin, ampicillin, chloramphenicol, cefotaxime and perfloxacin in pork. Ninety percent of the strains showed an aggregative adherence pattern on HEp-2 cells. Conclusion: The frequency of S. enterica on meat products is high, which is the reason why a proper cooking of these ground meats is important in order to reduce the risk of acquiring salmonellosis.

Prostatectomía radical: técnica robotica / Radical Prostatectomy: robotic technique

INTRODUCCIÓN: El constante avance de la tecnología y el desarrollo de las técnicas mínimamente invasivas en cirugía robótica han dado mayores opciones de tratamiento quirúrgico a pacientes con Cáncer de Próstata. Debido a la complejidad anatómica y reducido espacio de la pelvis la cirugía robótica facilita realizar la prostatectomía . La superioridad técnica del sistema con robot en cuanto a visión, libertad de movimiento y precisión, permite una cirugía más segura además de mejorar resultados quirúrgicos, oncológicos y funcionales. El objetivo del presente video es demostrar la técnica utilizada en nuestro centro para prostatectomía radical robótica y mostrar una sistematización que simplifica el procedimiento. DESARROLLO: Se exponen las características del instrumento Madajet, así como su carga y armado. Se realiza el aislamiento y superficialización del conducto deferente derecho mediante técnica de tres dedos, en la cual el cirujano coloca sus dedos índice y medio en la cara posterior del escroto, fijando el deferente con el dedo pulgar en la cara anterior de la pared escrotal. Una vez aislado el deferente se realiza la anestesia local mediante del disparo del dispositivo sobre la pared anterior del escroto, repitiendo el proceso sobre el deferente izquierdo. Se realiza vasectomía sin bisturí mediante aislamiento del deferente en el rafe medio escrotal con clamp de anillo Li Brand®, con posterior punción y divulsión de la piel con pinza aguzada Li Brand® . Se efectúa la exteriorización del conducto deferente y posterior separación de éste de los vasos deferenciales, finalizando con la oclusión y sección del deferente. CONCLUSIONES: La vasectomía con técnica sin bisturí ­ sin aguja con dispositivo Madajet es una cirugía sencilla y reproducible que simplifica y disminuye los costos del procedimiento, lo que podría producir una mayor masificación de la vasectomía como método de control de fertilidad.(AU)

Edentulismo en adultos de Pachuca, México: aspectos sociodemográficos y socioeconómicos / Edentulism in Mexican adults: sociodemographic and socioeconomic aspects

Introducción La pérdida de dientes se ha convertido en un problema de salud pública bucal. Objetivo Determinar la prevalencia y distribución del edentulismo, así como las variables sociodemográficas y socioeconómicas asociadas en individuos de 35 años y más. Materiales y métodos Se realizó un estudio transversal en 656 sujetos seleccionados de forma aleatoria. En el estudio se incluyeron hombres y mujeres de 35 años y más, asistentes a las clínicas de atención dental de la Universidad Autónoma del Estado de Hidalgo (UAEH), una universidad pública de México. Para la realización de este estudio los examinadores fueron capacitados en la cumplimentación de los cuestionarios y estandarizados en el criterio diagnóstico de la pérdida de dientes. La variable dependiente fue el edentulismo. Los datos fueron analizados en Stata 11. Resultados El promedio de edad fue de 49,06 ± 10,33. Los individuos fueron principalmente mujeres (63,3%). La prevalencia general de edentulismo fue de 15,7% (IC 95%: 12,9-18,5); entre las mujeres fue de 17,6% y en los hombres de 12,5% (p = 0,081). La prevalencia de edentulismo fue mayor entre los sujetos de más edad (p < 0,001). Se observó que a mayor escolaridad (p < 0,001), a mejor nivel socioeconómico (p < 0,001) y en quienes tuvieron automóvil en el hogar (p < 0,05), la prevalencia de edentulismo fue menor. Conclusiones La prevalencia de edentulismo en adultos mayores de 35 años que acuden a las clínicas de esta universidad fue del 15,7%. Se observó diferencia de la prevalencia de edentulismo por edad, pero no por sexo. Se observaron diferencias socioeconómicas, sugiriendo ciertas desigualdades en salud bucal.

Introduction Tooth loss has become a problem of oral health. Objective To determine the prevalence and distribution of edentulism, as well as the associated sociodemographic and socioeconomic variables in subjects aged 35 and older. Materials and methods A cross-sectional study was conducted on 656 randomly selected subjects. The study included men and women aged 35 years and older attending dental care clinics at a public university in Mexico. Examiners were trained in filling out questionnaires and receiving training in order to standardise the criteria of tooth loss. The dependent variable was the presence of edentulism. The data were analysed using Stata 11. Results The mean age of the population was 49.06 ± 10.33 years, and the majority (63.3%) were women. The overall prevalence of edentulism was 15.7% (95% CI: 12.9-18.5%); the prevalence among women was 17.6% and the prevalence among men was 12.5% (P = .081). The prevalence of edentulism was higher among older subjects (P < .001). The prevalence of edentulism was lower among individuals with higher levels of education (P < .001), those with higher socioeconomic status (P < .001), and those who had a car at home (P < 0.05) Conclusions The prevalence of edentulism in adults over 35 years of age attending dental care clinics at this public university was 15.7%. Differences were observed in the prevalence of edentulism by age, but not by gender. Socioeconomic differences were observed, suggesting certain oral health inequalities.

Nefrolitectomía endoscópica transpiélica durante pieloplastía laparoscópica asistida por robot: Combinación de técnicas endourológicas para la resolución de un caso de estenosis pieloureteral asociado a nefrolitiasis / Endoscopic nephrolithotomy transpielic during a robot assisted laparoscopic pyeloplasty: Combination of endourological techniques for solving a case of pelvi-ureter stenosis associated with nephrolithiasis

La estenosis pieloureteral (EPU) puede predisponer al desarrollo de nefrolitiasis debido a estasis urinaria. Inicialmente la endopielotomía percutánea fue la alternativa mínimamente invasiva de elección frente a la cirugía abierta para la resolución de los casos de EPU con nefrolitiasis concomitante. Sin embargo, el bajo éxito de la endopielotomía percutánea ha favorecido el uso de la laparoscopía convencional o asistida por robot para el tratamiento de las EPU. Se han reportado casos de pieloplastías laparoscópicas en los cuales se ha introducido un nefroscopio flexible a través de un trócar para resolver la nefrolitiasis por vía transpiélica. Acá reportamos nuestra experiencia en un caso.(AU)

The pelvi-ureter stenosis may predispose to the development of nephrolithiasis due to urinary stasis. Initially, a percutaneous endopyelotomy was minimally invasive alternative of choice versus open surgery for resolving cases of EPU with concomitant nephrolithiasis. However, the low success of percutaneous endopyelotomy has favored the use of conventional laparoscopy or robot-assisted treatment of the pelvi-ureter stenosis. There have been reports of laparoscopic pyeloplasty in which a flexible nephroscope is inserted through a trocar to solve nephrolithiasis by a transpielic via. Here we report our experience in one case.(AU)

Gravedad de caries empleando un criterio del tamaño de la lesión y variables asociadas en una muestra de escolares mexicanos / Caries severity using a criterion according to size of lesion among Mexican schoolchildren

Objetivo: Determinar la gravedad de caries (tamaño de la lesión) y las variables asociadas en niños escolares mexicanos. Materiales y Métodos: Se realizó un estudio transversal en 1373 escolares de 6 a 12 años de edad inscritos en escuelas públicas de Campeche, México. Se distribuyeron cuestionarios para determinar una serie de variables sociodemográficas, socioeconómicas y conductuales. Se realizó un examen bucal a cada niño para establecer el tamaño de las lesiones de caries de acuerdo al índice llamado "criterio de magnitud de la lesión cariosa" y asignarlo de acuerdo al número de lesiones presentes a uno de 4 grupos de riesgo para desarrollar caries, en donde el primer grupo representa a los menos afectados. Se generó un modelo multivariado de regresión logística multinomial. Resultados: Los grupos de riesgo a caries quedaron distribuidos de la siguiente manera: 598 (43.6%) fueron del grupo 1; 261 (19.0%) se asignaron al grupo 2; 316 (23.0%) estuvieron en el grupo 3; y 198 (14.4%) en el grupo 4. Comparando con el grupo menos afectado por lesiones cariosas, las variables asociadas en los diferentes grupos de gravedad en el modelo multivariado fueron: grupo de riesgo 2: edad, sexo y defectos de desarrollo del esmalte; grupo de riesgo 3: atención dental en el último año, actitud de la madre hacia la salud bucal y defectos de desarrollo del esmalte; grupo de riesgo 4: edad, atención dental en el último año, actitud de la madre hacia la salud bucal y defectos de desarrollo del esmalte. Conclusión: La gravedad de caries está influenciada por variables demográficas, conductuales y clínicas.

Objective: To determine the severity of caries (lesion size) and associated variables in Mexican schoolchildren. Material and Methods: A cross-sectional study was conducted in 1373 schoolchildren 6-12 years old enrolled in public schools in Campeche, Mexico. Questionnaires were distributed to determine demographic, socioeconomic and behavioral variables. Dental examination was performed to each child to establish the size of caries lesions according "Criterion of carious lesion magnitude" index and to allocate according to the number of lesions present to one of four risk groups for developing cavities wherein the first group represents the least affected. A multivariate multinomial logistic regression model was generated. Results: Caries risk groups were distributed as follows: 598 (43.6%) were in group 1; 261 (19.0%) were assigned to group 2; 316 (23.0%) were in group 3; and 198 (14.4%) in group 4. Comparing with the least affected group by carious lesions, associated variables for severity in the multivariate model were "Risk Group 2": age, sex and developmental enamel defects; "Risk Group 3": dental care in the past year, mother's attitude toward oral health and developmental enamel defects; "Risk Group 4": age, dental care in the past year, mother's attitude toward oral health and developmental enamel defects. Conclusion: Severity of decay is influenced by demographic, behavioral and clinical variables.

Disección submucosa endoscópica en cáncer gástrico incipiente: experiencia inicial en el Hospital Clínico de la Pontificia Universidad Católica de Chile / Endoscopic submucosal dissection in early gastric cancer: Experience in 16 patients

Background: Endoscopic submucosal dissection (ESD) is a minimally invasive procedure that allows curative treatment of early gastric cancer (EGC) in selected patients. Aim: To report our initial experience with ESD. Material and Methods: Analysis of prospective data from 16 patients aged 61 to 84 years, who underwent ESD between December 2011 and June 2014. Tumor type, operative time, hospitalization length, oncologic outcomes, complications and short-term follow up were registered. Results: En-block resection was achieved in all cases. The median operative time was 135 min (range: 50-320 min). Specimens' median size was 3.5 cm (range: 3-10). All the resections were R0. In 14 patients ESD was considered curative. In two patients, ESD was considered potentially non-curative due to the presence pathological risk factors for lymph-node metastases in the biopsy specimen. Both patients underwent laparoscopic gastrectomy with lymph-node dissection. There was one case of gastric wall perforation that was repaired by laparoscopic suture. There was no mortality. The median follow-up time was 15 months (range: 2-30 months). Conclusions: ESD is a feasible and safe procedure in our institution with good results in this initial experience.

Experiencia de 18 años de cirugía de obesidad en la Pontificia Universidad Católica de Chile / Results of bariatric surgery. Experience over 18 years

Background: Bariatric surgery is the gold-standard treatment for morbid obesity because it has low morbidity rates in high-volume centers and generates long term sustained weight loss. Aim: To describe our experience in bariatric surgery since the creation of our bariatric program in 1992. Material and Methods: Retrospective analysis of all patients subjected to bariatric surgery from 1992 to December 2010. Data was obtained from the electronic institutional registry. The Procedures per-formed were open and laparoscopic Roux-en-Ygastric bypass (BPGA and BPGL, respectively), laparoscopic adjustable gastric band (BGAL) and laparoscopic sleeve gastrectomy (GML). Results: A total of 4943 procedures were performed, 768 (16%) BPGA, 2558 (52%) BPGL, 199 (4%) BGAL and 1418 (29%) GML. The number of procedures progressively increased, from 100 cases in 2000 to over 700 cases in 2008. Proportion of femóles and preoperative mean body mass Índex fluctuated between 69 and 79% and 35 and 43 kg/m², respectively, among the different procedures. Early and late complications fluctuated between Oto 1% (higher on BPGA) and 3 to 32.7% (higher on BGAL), respectively. The excess weight lost atfiveyears was 76.1 % in BPGA, 92.5%o in BPGL and 53.7% in BGAL. The figure for GML at three years was 73.7%. Conclusions: The complication rates ofthis series of patients are similar to those reported in large series abroad. BPGL is still the most effective procedure; however GML is an attractive alternative for less obese patients.

Obtención de cultivos primarios de estroma prostático benigno y tumoral mediante explantes de tejido desde biopsias por punción / Obtaining primary cultures of bening and tumoral prostatic stromal tissue through explants from needle biopsias

La progresión del cáncer de próstata (CaP) es regulada por el microentorno tumoral,el cual tiene como principal componente el estroma asociado al carcinoma (CAS). Sin embargo, los métodos experimentales usando cultivos primarios para modelar el comportamiento del estroma tumoral han sido insatisfactorios debido a la dificultad de obtener cultivos primarios de células estromales prostáticas humanas (Hpscs) con alta proporción de CAS. Así, el objetivo de este estudio consistió en estandarizar una metodología que permita ta obtención de cultivos primarios de HPSCs con alta proporción de CAS. Métodos: se recolectaron biopsias prostáticas de 10 pacientes,5 de ellos con CaP localmente avanzado y/o metastásico, y 5 sin evidencia de neoplasia. Se evaluó la proporción estromal por estudios histológicos y se estandarizó la obtención de cultivos primarios de HPScs mediante explantes de tejido. Los culilvos se caracterizaron por curvas de crecimiento y proliferación Resultados: El tejido obtenido desde biopsias prostáticas por punción de pacientes con CaP localmente avanzado y/o metastásico presentan alta proporción de CAS. La técnica explantes de tejido permite la obtención de cultivos primarios de HPSC desde biopsias, indicando además que cultivos primarios de CAS presentan un patrón de crecimiento y proliferación, superior a las células obtenidas de tejido benigno (BAS). Discusión: Nuestro estudio demuestra que a través de la técnica explantes de tejido es posible obtener cultivos primarios de HPSCs con CaP invasor, debido a que estos presentan zonas con alta proporción de CAS...

Tumor microenvironment plays a critical role in the progression of prostate cancer (CaP), which main component ¡s the ®carcinoma associated stroma¼ (CAS).However, the in vitro models utilizing human prostate stroma cells (HPSCs) as primary cultures have failed in recapitulate the human prostate microenvironment due to the unfeasibility to obtain primary cultures of HPSCs with a pure population of CAS. The aim of this study was to standardize a new methodology that allow to obtain primary cultures of HPSCs with high proportion of CAS. Methods: Primary cultures of HPSCs were obtained from explants of human needle biopsies from 5 benign and 5 locally advances and/or metastatic human prostate tissues. The primary cell cultures were characterized by proliferation rates and growth curves. Locally advanced and/or metastatic prostate needle biopsies exhibit a high presence of CAS. The analysis of human primary cultures isolated from benign and malignant prostate tissue explants revealed distinctive populations of HPSCs that can be distinguishable by proliferation rates and growth curves. Discussion: our studies demonstrated for the first time that prostate explants from needle biopsy, represents a feasible technique to obtain primary cultures of stromal cells from benign and malignant tissues, and represents in more accurate way the complexity of the tumor microenvironment...

Experiencia con el colgajo graso hipotenar en el manejo del síndrome del túnel del carpo recidivante / Hypothenar fat flap in the management of recidives of carpal tunnel syndrome

Introducción: el síndrome del túnel del carpo es la neuropatía compresiva más frecuente en la práctica clínica y muy a menudo requiere una liberación quirúrgica. Para el manejo de la recidiva de esta patología existen numerosas técnicas quirúrgicas de interposición de tejido blando alrededor del nervio mediano para evitar la fibrosis. Materiales y métodos: se realizó un estudio retrospectivo tipo serie de casos para evaluar los resultados de los pacientes con síndrome del túnel del carpo recidivante manejados con neurolisis del mediano más colgajo graso hipotenar entre los años 2001 y 2008. El seguimiento de los pacientes se realizó con medición periódica de la fuerza de agarre y de la pinza lateral, presencia del signo de Tinel y escala numérica del dolor. Resultados: se incluyeron 18 procedimientos realizados en 16 pacientes que estuvieron en un grupo de edad entre 42 y 55 años (promedio de 49,3 años). La reaparición de los síntomas luego de la intervención quirúrgica inicial se dio en un periodo entre 8 y 36 meses (mediana de 18 meses). Al cuarto mes posoperatorio se encontró una ganancia de fuerza de agarre promedio de 4,78 kg. El dolor desapareció en el 61% de los pacientes y el 78% presentaron una mejoría significativa. Discusión: el colgajo grasonhipotenar es una alternativa quirúrgica que puede ofrecer una mejoría de los síntomas a los pacientes con síndrome del túnel del carpo recidivante.

Resultados del tratamiento quirúrgico de las metástasis hepáticas por cáncer colorrectal / Outcome of surgical treatment of liver metastasis from colorectal cancer

Background: Surgical resection is the only treatment associated with long-term cure in patients with liver metastasis from colorectal cancer, achieving a 30% to 40% five years survival. Aim: To evaluate the results of liver resection for metastatic colorectalcancer in our centre. Patients and methods: Retrospective study. Epidemiological, perioperative and follow up data of patients undergoing liver resection for metastatic colorectalcancer between January 1990 and July 2007 were assessed. We compared the results between two periods; period 1 (1990-1997) and period 2 (1998-2007). Results: Sixty six patients aged61±12 years (46 males) underwent 75 resections. An anatomical excision was performed in 54 (72%) cases, a right hepatectomy in 18, an extended right hepatectomy in 11, a left hepatectomy in 1, and a segmentectomy in 24. In 24 (32%) patients the liver resection wassimultaneous with the colorectal cancer resection. Operative time was 221±86 min. Hospital stay was 11±5 days. Postoperative morbidity was 35% and surgical mortality was 0%. Resectionmargin was free of tumor in 53 (80%) patients. Five years overall and hepatic disease-free survival was 38% and 23%, respectively. In period 2, more anatomical resections than in period1 were performed (77% and 55%, respectively, p =0.04), without an increase in complications (35% and 34%, respectively; p =ns), but with a better five years survival (45% and 21%, respectively, p =0.04). Conclusions: Five years survival for excision of liver metastatic colorectal cancer in our center is similar to that reported abroad. During the second period there has been a trend toward more extensive resections which was associated with a better survival, without an increase in complications or mortality.

La melatonina reduce la respuesta de cortisol al ACTH en humanos / Melatonin reduces cortisol response to ACTH in humans

Background: Melatonin receptors are widely distributed in human tissues but they have not been reported in human adrenal gland. Aim: To assess if the human adrenal gland expresses melatonin receptors and if melatonin affeets cortisol response to ACTH in dexamethasone suppressed volunteers. Material and methods: Adrenal glands were obtained from 4 patients undergoing unilateral nephrectomy-adrenalectomy for renal cáncer. Expression of mRNA MT1 and MT2 melatonin receptors was measured by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). The effect of melatonin on the response to intravenous (i.v.) ACTH was tested (randomized cross-over, double-blind, placebo-controlled tríal) in eight young healthy males pretreated with dexamethasone (1 mg) at 23:00 h. On the next day at 08:00 h, an i.v. Une was inserted, at 08:30 h, and after a blood sample, subjeets ingested 6 mg melatonin or placebo. At 09:00 h, 1-24 ACTH (Cortrosyn, 1µg/1.73 m² body surface área) was injected, drawing samples at 0, 15, 30, 45 and 60 minutes after. Melatonin, cortisol, cortisone, progesterone, aldosterone, DHEA-S, testosterone and prolactin were measured by immunoassay. Results: The four adrenal glands expressed only MT1 receptor mRNA. Melatonin ingestión reduced the cortisol response to ACTH from 14.6+1.45µg/dl at 60 min in the placebo group to 10.8+1.2µg/dl in the melatonin group (p <0.01 mixed model test). It did not affect other steroid hormone levels and abolished the morningphysiological decline of prolactin. Conclusions: The expression ofMTl melatonin receptor in the human adrenal, and the melatonin reduction of ACTH-stimulated cortisol production suggest a direct melatonin action on the adrenal gland .

Sobrevida alejada de pacientes operados por cáncer gástrico incipiente / Long term survival of patients operated for early gastric cancer

Background: Early gastric cancer involves mucosa and submucosa, independent of lymph node involvement. Radical gastrectomy is the standard treatment. Aim: To assess long term survival of patients operated for an early gastric cancer. Material and methods: Retrospective Rev iew of medical and pathology records of patients subjected to a gastrectomy for an early gastric cancer, between 1975 and 2002. All were treated using a standardized protocol and staged according to 2002 TNM classification of the American Joint Committee of Cáncer (AJCC). Demographic and pathologic features, operation performed and long term survival were recorded. Survival was analyzed using Kaplan-Meier method. Results: The series is comprised by 64 males and 41 females aged 61 + 1 years. Tumor was located in the upper third of the stomach on 33 subjects and a total gastrectomy was performed in 53. Pathology showed an intestinal type adenocarcinoma in 82 and a diffuse type in 23. In patients with involvement of mucosa and submucosa, 24 ± 14 and 22 ± 14 lymph nodes were excised, respectively. Lymph node involvement was present in 8 percent and 22 percent of patients with involvement of mucosa and submucosa, respectively. Five years survival was 94 percent and 78 percent in patients without and with lymph node involvement, respectively. Survival among patients in stage IA and IB was 94 percent and 76 percent, respectively. Multivariate analysis showed that the lymph node involvement was an independent mortality risk factor. Conclusions: Total gastrectomy in patients with early gastric cancer is associated with a good survival. Lymph node involvement is a mortality risk factor.

Adenocarcinoma gástrico treinta y dos años post linfoma gástrico / Gastric adenocarcinoma appearing 32 years after the resection of a gastric lymphoma: report of one case

The association of gastric lymphoma and gastric adenocarcinoma in the same patient is uncommon. We report a 76 year-old male with a previous history of massive upper gastrointestinal bleeding who required a subtotal gastrectomy with Billroth II reconstruction in 1974. Pathology demonstrated a gastric ¡ympho-histiocytic non-Hodgkin's lymphoma. The patient received complementary radiotherapy and was followed with annual endoscopies for 23 years. In 2006, he presented with fatigue. An upper gastrointestinal endoscopy showed an ulcerated and proliferative lesión at the gastric stump. Biopsy demonstrated a gastric adenocarcinoma. Gastric stump resection with lymph node dissection was perfomed. Pathology of the excised specimen showed a moderately differentiated tubular adenocarcinoma of the gastrojejunal anastomoses which infiltrated up to the subserosa. Additionally lymphatic permeations were observed and 10 of the 16 excised lymph nodes were invaded by the tumor.

Radio-quimioterapia postoperatoria en cáncer gástrico localmente avanzado / Postoperative radio-chemotherapy in locally advanced gastric cancer

Background: Overall 5 years survival for surgically excised gastric cancer is 30 percent. Adjuvant treatment may improve the surgical results. Aim: To assess treatment results and toxicity in patients with surgically excised gastric cancer, treated with adjuvant radiotherapy and concomitant continuous 5-Fluorouracil (5-FU). Material and Methods: Forty one patients aged 32 to 73 years (29 males) with stage II-IVA gastric cancer, subjected to a total or subtotal gastrectomy and D2 nodal dissection between 1997 to 2006, were studied. They received adjuvant radiotherapy to the gastric bed and draining lymphatic nodes in a total dose of 50.4 Gy in 28 fractions and chemotherapy with continuous infusión 5-FU, 200 mg/m²/day. Results were compared to historical controls matched according to demographic parameters and tumor characteristics. Results: Eighteen patients were in stage II, 10 in stage IIIA, nine in stage IIIB and four in stage IVA. Twelve patients had an NO nodal status, 15 were NI, nine were N2 and five were N3. After a mean follow up of 32 months, 26 patients (63 percent) were alive. Five year overall survival was 49.6 percent for surgery plus radiochemotherapy compared to 30.7 percent for the historical group subjected only to surgery (p =0.002). Radiotherapy was associated with grade 1-2 toxicity and treatment was completed without interruptions in all patients. Chemotherapy was delayed temporarily in 3 patients. Conclusions: Adjuvant radio-chemotherapy improved overall survival in gastric cancer, compared to historical controls subjected only to surgical treatment.

Resultados inmediatos y tardíos de la miotomía de Heller laparoscópica en pacientes con acalasia esofágica / Laparoscopic Heller myotomy for esophageal achalasia

Background: Achalasia is characterized by an incomplete relaxation of the lower esophageal sphincter. The best treatment is surgical and the laparoscopic approach may have good results. Aim: To assess the results of laparoscopic Heller myotomy among patients with achalasia. Material and methods: Prospective study of patients subjected to a laparoscopic Heller myotomy between 1995 and 2004. Clinical features, early and late operative results were assessed. Results: Twenty seven patients aged 12 to 74 years (12 females) were operated. All had disphagia lasting for a mean of 32 months. Mean lower esophageal sphincter pressure ranged from 18 to 85 mmHg. Eight patients received other treatments prior to surgery but symptoms persisted or reappeared. The preoperative clinical score was 7. No patient died and no procedure had to be converted to open surgery. In a follow up of 21 to 131 months, all patients are satisfied with the surgical results and the postoperative clinical score is 1. Only one patient with a mega esophagus maintained a clinical score of six. Conclusions: In this series of patients, laparoscopic Heller myotomy was an effective and safe treatment for esophageal achalasia.

Gastrectomía laparoscópica en cáncer gástrico: Experiencia preliminar / Laparoscopic gastrectomy in gastric cancer: Experience in four patients

Background: The development of the laparoscopic surgery has allowed its incorporation to the surgical treatment of gastric cancer. Aim: To evaluate the feasibility and safety of laparoscopic gastrectomy in gastric cancer in our institution. Patients and methods: Prospective data in four patients who underwent laparoscopic gastrectomy for gastric cancer from May to August of 2005 was reviewed. Demographic data, clinical characteristics and postoperative results were registered. Patients were staged according to TNM-AJJC staging system. Results: Four patients aged 48 to 80 years (three males), underwent a completely laparoscopic R0 gastrectomy with lymph node dissection. Two patients underwent total gastrectomy. A subtotal Billroth II gastrectomy was performed in the other two patients. The mean operative time was 260 minutes (Range 180-330). There were no conversions to open surgery. The mean postoperative hospital stay was 6.5 days (Range 6-7 days). There were no complications. According to pathology, one patient presented carcinoma in stage IA, two patients in stage IB and one patient in stage IIIB. The mean number of lymph nodes dissected was 40 (Range 35-54). Conclusions: Laparoscopic gastrectomy is a feasible procedure with good postoperative results in this preliminary experience.

Trombo tumoral en aurícula derecha en tumor de Wilms / Tumoral thrombus in right auricle in Wilms tumor

En el tumor de Wilms (TW) el trombo cavo atrial (TCA) es < 5 por ciento, siendo rareza el compromiso auricular derecho. Revisamos los abordajes quirúrgicos del TCA en el TW. Materiales y métodos: Paciente de 3 años y medio con tumor renal derecho de 10 cm, un cava inferior ocupada por trombo tumoral hasta la aurícula derecha. Además tumor en la vena renal izquierda y cava infra renal. Se utiliza quimioterapia preoperatoria previa biopsia por punción. Resultados: seis semanas de quimioterapia y un TAC demostró reducción 10 por ciento del tumor y menor TCA. Se realizó nefrectomía radical derecha con trombectomía cava abdominal y renal izquierda combinada con trombectomía cava toráxica y auricular, con paro cardiopulmonar, circulación extracorpórea e hipotermia. Evolucionó sin complicaciones, la biopsia no demostró tumor en el riñón o TCA. Se catalogó TW etapa III sin anaplasia y entró en un protocolo DD4A del NWTSG. A 1 mes de la cirugía el TAC mostró ausencia de tumor. Conclusiones: El compromiso tumoral de la cava y aurícula derecha es excepcional en TW. Los mejores resultados y menor morbilidad están asociados a quimioterapia preoperatoria y buena planificación de la vía de abordaje.

Introduction: In the tumor of Wilms (TW) the thrombus cava atrial (TCA) it is < 5%, being exceptional the atrial right involvement. We check the surgical routes of access of the TCA in the TW. Materials and methods: 3-year-old patient with renal right tumor of 10 cm, a inferior vena cava occupied by tumor thrombus up to the right auricle. Also tumor in the renal left vein and vena cava under the kidney. We use preoperative chemotherapy previous biopsy for puncture. Results: 6 weeks of chemotherapy and a TAC demonstrated reduction 10% of the tumor and decrease TCA. We realized radical right nephrectomy with thrombectomy abdominal cava and renal left combined with thrombectomy thorax cava and atrial right, with cardiopulmonar unemployment, extracorporeal circulation and hypothermia. She evolved without complications, the biopsy did not demonstrate tumor in the kidney or TCA. TW catalogued stage the IIIrd without anaplasia and she entered a protocol DD4A of the NWTSG. To 1 month of the surgery the TAC showed absence of tumor. Conclusions: The tumor commitment of the vena cava and right auricle is exceptional in TW. The best results and minor morbidity are associated with preoperative chemotherapy and good planning of the routes of access.

Estrategias efectivas para aumentar la cobertura del Papanicolaou en el programa de detección del cáncer cervicouterino / Effective strategies to increase the papanicolau coverage in the cervicouterine cancer detection program

El aumento de las coberturas del Papanicolaou depende de múltiples factores donde se destaca la motivación de los equipos de salud, en especial de la profesional matrona, así como de una red de apoyo interdisciplinario y comunitaria destinada a captar mujeres, y el concepto de auto-cuidado que tenga internalizado cada mujer. El objetivo de este trabajo es dar a conocer estrategias de salud pública que permitieron aumentar la cobertura del Papanicolaou (Pap) vigente en mujeres beneficiarias en un 12 y 8% en los Servicios de Salud Valdivia y Metropolitano Norte. Las estrategias de salud pública probadas en este estudio como efectivas fueron: a)fomento de la informática con: la instalación del cito-expert en la atención primaria, planilla de cálculo de coberturas y estadística mensual, planilla de contra-referencia de pacientes atendidas en la UPC y envío vía e-mail cada tres días; b) Captación de monitoras de Pap en la comunidad;c) Investigación operativa y capacitación permanente a matronas, médicos y monitoras de Pap.d) Implementación de un banco de proyectos de promoción. Esto traducido en el efecto en la salud de la mujer ha significado diagnosticar NIE III cuatro veces más que en 1993, detectar el cáncer invasor en etapas iniciales (etapas I y II), y descender consecuentemente la mortalidad por esta enfermedad, alcanzando actualmente a una tasa de 4,6 por 100.000 mujeres mayores de 15 años en el Servicio de Salud de Valdivia.

The increase in Papanicolau coverage depends on multiple factors, in which the motivation of health teams stands out, specially that of the professional midwife, aided by an interdisciplinaryand community support network destined to attract women, and the concept of self care that each woman has internalized. The objective of this work is that of making available public health strategies allowing to bring about an increase in Papanicolau (PAP) coverage in beneficiary women by a 12 percent and 8% in the Valdivia and North Metropolitan Health Services respectively. The public health strategies proved as effective in this study were: a) promotion of the informative aspect, with installation of the cito-expert in primary attention, statements of coverage calculations and monthly statistics, counter-reference statement of patients attended at the Cervical Pathology Unit (UPC) and e-mail dispatch every three days; b) winning over of Pap monitors in the community; c) operative research and permanent training of midwives, physicians and Pap monitors; d) implementation of a promotion projects bank. This, translated into the effect on women’s health, has implied diagnosing intraepithelial neoplasia III (NIE III) four times as much as in 1993 and invasive cancer in its initial stages (stages I and II) and, consequently, decreasing mortality from this disease which, at present, reaches a rate of 4.6 per 100.000 women over 15 years of age in the Valdivia Health Service.