Cirugía de Ross en Chile: Tasa libre de reoperación y supervivencia global en una cohorte de más de 10 años de seguimiento

Antecedentes: El autoinjerto de válvula pulmonar (VP) u operación de Ross (OpR) tiene excelentes resultados a largo plazo. Es superior a otros tipos de reemplazo valvular en jóvenes adultos, aunque no el estándar de primera línea. Un tiempo quirúrgico prolongado o alta morbimortalidad son importantes preocupaciones. Objetivos: Establecer la morbimortalidad asociada a la OpR por un período >10 años, considerando el tiempo quirúrgico, tasa de reoperación y supervivencia global (SG). Métodos: Cohorte prospectiva (1996-2012), en seguimiento hasta agosto-2023. La SG fue estimada desde la OpR hasta la última consulta o deceso. Mediante regresión de Cox (Hazard Ratio, HR) se estimaron factores asociados a la SG. Resultados: La serie consta de 161 pacientes: 118 de etiología congénita (73.3%), 17 infecciosa (10.6%), 26 reumática (16.1%). La lesión fue estenótica en 79 (49.1%), insuficiencia en 40 (24.8%), mixta en 42 (26.1%). La OpR fue urgente en 11 (6.8%). The median time of ECC and the operation was 149 y 232 minutos, respectivamente. Veintisiete pacientes requirieron reoperación (16.8%). Con una mediana de 19.7 años (17.2-22.2), 23 pacientes fallecieron (14.3%): 1/23 asociado a OpR, 17/23 por causa cardiovascular y 5/23 por causas no cardiovasculares. La lesión mixta se asoció a mayor mortalidad (HR 3.07; IC 95% 1.11-8.47; p=.029). Conclusiones: La OpR es un procedimiento con baja morbimortalidad. La lesión mixta es un factor de riesgo independiente de mayor mortalidad. Sin embargo, la mediana de tiempo de CEC y quirúrgico es prolongado frente a otras técnicas de reemplazo valvular.

Background: Pulmonary valve (PV) autograftor reoperation or Ross surgery (RS), presents excellent long-term results. It is superior to other types of PV replacement in young adults, although it is not the first-line gold standard. A longer operative time or high morbidity and mortality rates are important concerns. Aim: To establish the morbidity and mortality associated with RS for >10 years, considering operative time, reoperation rate and overall survival (OS). Methods: Prospective cohort (1996-2012), with a follow-up until August/2023. The OS was estimated from RS to the last consultation/death. Factors associated to OS were estimated using Cox regression (Hazard Ratio, HR) Results: 161 patients were included: the etiology was congenital (118, 73%), infectious (17, 10.6%), and rheumatic (26,16.1%). The lesion was stenotic in 79 (49.1%), heart failure in 40 (24.8%), mixed in 42 (26.1%). RS was urgent in 11 (6.8%). Extracorporeal circulation (ECC) and operative times were 149 and 232 minutes, respectively. Twenty-seven patients required reoperation (16.8%). With a median follow up of 19.7 years (17.2-22.2), 23 patients died (14.3%): 1/23 associated with RS, 17/23 due to cardiovascular causes, and 5/23 due to non-cardiovascular causes. Mixed injury was associated with higher mortality (HR 3.07; 95% CI 1.11-8.47; p=.029). Conclusions: RS is a procedure with low morbidity and mortality. Mixed injury is an independent risk factor for increased mortality. However, the median ECC and operative times were higher compared to other valvular replacement techniques.

Tratamento das estenoses esofágicas benignas simples com dilatadores de Savary-Gilliard: ainda é necessária a regra de três? / Treating simple benign esophageal strictures with savary-gilliard dilators: is the rule of three still necessary?

ABSTRACT BACKGROUND: Bougies dilation is considered an effective technique for the treatment of simple benign esophageal strictures. The "rule of three" has been advocated to prevent reported adverse events such as bleeding and perforation. However, adherence to this rule has increased the cost and duration of treatment. OBJECTIVE: To demonstrate the safety and long-term benefits of progressive bougie dilations until reaching 15 mm (45Fr) in one single session endoscopy with non-adherence to the rule of three. METHODS: A retrospective analysis of a prospectively collected data of patients with simple benign esophageal strictures treated with multiple progressive bougie dilators until reaching 15 mm (45Fr) in one single session. RESULTS: The median age was 58 years (range 28-89), and 83.3% of patients were female. The main presenting symptom was dysphagia for solids in 11/12 cases (91.6%). The cause of their simple benign esophageal stricture was distributed as follows: 7/12 esophageal webs, 2/12 peptic stenosis, 2/12 Schatzki rings and one caustic injury. 75% required only one session for clinical success. No serious adverse events were described. No recurrence of symptoms was noted in a median follow-up of 20 months. CONCLUSION: The rule of three in patients with simple benign esophageal strictures secondary to esophageal webs, Schatzki rings and peptic strictures treated with Savary-Gilliard dilators is not necessary, showing good clinical results. Prospective studies with more patients are necessary.

RESUMO CONTEXTO: A dilatação por velas é considerada uma técnica eficaz para o tratamento de estenoses esofágicas benignas simples. A "regra de três" tem sido defendida para prevenir eventos adversos relatados, como sangramento e perfuração. No entanto, a adesão a esta regra aumentou o custo e a duração do tratamento. OBJETIVO: Demonstrar a segurança e os benefícios de longo prazo das dilatações progressivas por velas até chegar a 15 mm (45Fr) em uma única sessão de endoscopia com não adesão à regra de três. MÉTODOS: Uma análise retrospectiva de dados coletados prospectivamente de pacientes com estenoses esofágicas benignas simples tratadas com múltiplos dilatadores de velas progressivas até atingir 15 mm (45Fr) em uma única sessão. RESULTADOS: A mediana de idade foi de 58 anos (variação de 28-89) e 83,3% dos pacientes eram do sexo feminino. O principal sintoma de apresentação foi a disfagia para sólidos em 11/12 casos (91,6%). A causa da estenose esofágica benigna simples foi distribuída como segue: 7/12 membranas esofágicas, 2/12 estenose péptica, 2/12 anéis de Schatzki e um ferimento cáustico. 75% necessitaram apenas de uma sessão para o sucesso clínico. Não foram descritos eventos adversos graves. Nenhum retorno dos sintomas foi anotado em uma continuação mediana de 20 meses. CONCLUSÃO: A regra de três em pacientes com as estenoses esofágicas benignas simples secundárias às membranas esofágicas, os anéis de Schatzki e as estenoses péptica tratadas com os dilatadores de Savary-Gilliard não é necessária, mostrando bons resultados clínicos. Estudos prospectivos com mais pacientes são necessários.

Fibrobroncoscopía en pacientes onco-hematológicoscon infiltrados pulmonares, estudio transversal / Fibrobronchoscopy in onco-hematological patients with pulmonary infiltrates, cross-sectional study

Introducción: Las enfermedades infecciosas y masas pulmonares son una causa importante de mortalidad en los pacientes onco-hematológicos. El objetivo del presente estudio fue determinar la sensibilidad y especificidad de la fibrobroncoscopía (FBC) en el diagnóstico temprano de pacientes hemato-oncológicos. Métodos: El presente estudio descriptivo transversal se realizó en pacientes onco-hematológicos con hallazgos anormales en imágenes de tórax que fueron sometidos a FBC en el Instituto Oncológico de Solca-Guayaquil entre el periodo enero 2014 -diciembre 2016. Resultados: Ingresaron al estudio 98 pacientes: 54 mujeres (55.1%), de 61 ±18 años, 39 (39.8 %) con tumores sólidos, 76 (77.6 %) con síntomas respiratorios, 88 (89.8 %) con alta sospecha de lesión maligna. La sensibilidad del diagnóstico con líquido bronquial fue del 62.5 %; con cepillado, 88 % y del esputo post FBC fue de 14.3 %. La especificidad del diagnóstico con líquido bronquial fue del 89.7 %; con cepillado, 73.9 % y del esputo post FBC fue de 93.3 %. Conclusiones: En el presente estudio existe mayor sensibilidad con el cepillado bronquial comparativamente al líquido bronquial y el esputo post FBC para el diagnóstico de lesiones malignas

Introduction:Infectious diseases and lung masses are an important cause of mortality in onco-hematological patients. The aim of this study was to determine the sensitivity and specificity of Fiber Optic Bronchoscopy (FOB) in the early diagnosis of haemato-oncological patients. Methods:The present descriptive cross-sectional study was performed in onco-hematological patients with abnormal findings in chest images that were submitted to BCF in the Oncology Institute of Solca-Guayaquil between the period January 2014 to December 2016. Results: 98 patients, 54 women (55.1 %), 61 ± 18 years old, 39 (39.8 %) with solid tumors, 76 (77.6 %) with respiratory symptoms, 88 (89.8%) with high suspicion of malignant injury, entered the study. The sensitivity of the diagnosis with bronchial fluid was 62.5 %, with brushing 88 % and sputum post FOB was 14.3 %. The specificity of the diagnosis with Bronchial fluid was 89.7 %, with Brush 73.9 % and sputum post FOB was 93.3 %. Conclusions: In the present study there is greater sensitivity with Bronchial Brush comparatively to bronchial fluid and sputum post FOB.

Agenesia de vesícula biliar: presentación de caso y revisión de la literatura / Gallbladder agenesis: case report and a literature review

La agenesia de vesícula biliar es una enfermedad rara cuya sintomatología emula patología biliar. Está presente entre el 0,007 al 0,027% de aquellos en quienes se practica una colecistectomía. Luego de la misma, su evolución es asintomática. Se presenta el caso de una paciente femenina de 19 años con cuadro clínico compatible con colelitiasis. La ecografía revela vesícula escleroatrófica. Se realizó colecistectomía electiva, sin hallarse vesícula biliar. Tanto en el posoperatorio, como en el seguimiento anual, el curso fue asintomático. Además, se realizó una revisión de casos a partir de publicaciones de casos clínicos obtenidos de Medline. Catorce pacientes fueron incluidos en la revisión de casos, comparándose con otros cinco estudiados en una serie de casos. No existió diferencia significativa entre ambos grupos. La agenesia de vesícula biliar se presenta comúnmente entre los 40 y 64 años, con dolor en cuadrante superior derecho y diagnóstico ecográfico de colelitiasis. Es poco probable llegar a un diagnóstico preoperatorio. De intervenirse, es preferible limitarse a la exploración laparoscópica. La evolución ulterior será asintomática, sin estar claro aún el por qué.

Gallbladder agenesis is a rare disease, which its symptomatology emulates biliary pathology. It is presented between 0.007 to 0.027% of those patients in whom a cholecystectomy is performed. After it, its evolution is asymptomatic. We present the case of a 19 years old female patient with clinical presentationof cholelithiasis. Ultrasound reveals scleroatrophic vesicle. Elective cholecystectomy was performed,but the gallbladder was not found. The patient presented an asymptomatic evolution in the postoperative period and in the annual follow-up. In addition, we performed a case review from clinical case reports obtained from Medline. Fourteen patients were included in the review of cases, compared to another five studied in a series of cases. There was no significant difference between the two groups. Gallbladder agenesis usually happens between 40 and 64 years, with pain in the upper right quadrant and ultrasound diagnosis of cholelithiasis. It is unlikely to reach a preoperative diagnosis. If it is intervened, it is preferable to limit to laparoscopic examination. The following evolution will be asymptomatic, althoughthe cause of it is not known yet.