Estudio y manejo de nódulos tiroideos por médicos no especialistas. Consenso SOCHED / Study and management of thyroid nodes by non specialist physicians: SOCHED consensus

The thyroid nodule is a frequent cause of primary care consultation. The prevalence of a palpable thyroid nodule is approximately 4-7%, increasing up to 67% by the incidental detection of nodules on ultrasound. The vast majority are benign and asymptomatic, staying stable over time. The clinical importance of studying a thyroid nodule is to exclude thyroid cancer, which occurs in 5 to 10% of the nodules. The Board of SOCHED (Chilean Society of Endocrinology and Diabetes) asked the Thyroid Study Group to develop a consensus regarding the diagnostic management of the thyroid nodule in Chile, aimed at non-specialist physicians and adapted to the national reality. To this end, a multidisciplinary group of 31 experts was established among university academics, active researchers with publications on the subject and prominent members of scientific societies of endocrinology, head and neck surgery, pathology and radiology. A total of 14 questions were developed with key aspects for the diagnosis and subsequent referral of patients with thyroid nodules, which were addressed by the participants. In those areas where the evidence was insufficient or the national reality had to be considered, the consensus opinion of the experts was used through the Delphi methodology. The consensus was approved by the SOCHED board for publication.

Colangiopatía asociada a hipertensión portal extrahepática: caso clínico / Cholangiopathy associated with portal hypertension: case report

Se comunica el caso clínico de una paciente portadora de cavernomatosis portal en la cual se pesquisaron alteraciones de la vía biliar de origen incierto. Los estudios diagnósticos determinaron la presencia de una colangiopatía asociada a la hipertención portal. Esta entidad ha sido bien caracterizada en sujetos con obstrucción de la vena porta y puede asociarse a un espectro de manifestaciones clínicas. Se discuten los aspectos más relevantes de esta entidad así como la literatura pertinente

Disección espontánea de la arteria mesentérica superior / Superior mesenteric artery spontaneous disection

La disección espontánea de la arteria mesentérica superior es una condición muy poco frecuente. Su etiopatogenia es aún desconocida. Se postula como causa entre otras necrosis quística de la túnica media, displasia fibromuscular, trauma abdominal cerrado, hipertensión arterial y ateroesclerosis. Su forma de presentación en la mayoría de los casos corresponde a dolor abdominal intenso o shock hipovolémico secundario a rotura de la arteria disecada. El método diagnóstico de mayor rendimiento es la angiografía, la que además permite efectuar procedimientos terapéuticos. En muchos casos, sin embargo se puede realizar un diagnóstico definitivo mediante tomografía computada (angio Tac), que permite obtener contraste adecuado a nivel de la arteria mesentérica superior. Se presenta un caso de un paciente de sexo masculino, 45 años, que ingresa al Servicio de Urgencia por un cuadro de dolor abdominal difuso. Se realiza una tomografía axial computada (TAC) demostrando este diagnóstico

Cirugía coronaria mínimamente invasiva / Minimally invasive coronary artery surgery

Background: There is a growing interest to perform a left internal mammary artery (LIMA) graft to the left anterior descending coronary artery (LAD) on a beating heart through a minimally invasive access to the chest cavity. Aim: To report the experience with minimally invasive coronary artery surgery. Patients and methods: Analysis of 11 patients aged 48 to 79 years old with single vessel disease that, between 1996 and 1997, had a LIMA graft to the LAD performed through a minimally invasive left anterior mediastinotomy, without cardiopulmonary bypass. A 6 to 10 cm left parasternal incision was done. The LIMA to the LAD anastomosis was done after pharmacological heart rate and blood pressure control and a period of ischemic pre conditioning. Graft patency was confirmed intraoperatively by standard Doppler techniques. Patients were followed for a mean of 11.6 months /7-15 months). Results: All patients were extubated in the operating room and transferred out of the intensive care unit on the next morning. Seven patients were discharged on the third postoperative day. Duplex scanning confirmed graft patency in all patients before discharge; in two patients, it was confirmed additionally by arteriography. There was no hospital mortality, no perioperative myocardial infarction and no bleeding problems. After follow up, ten patients were free of angina, in functional class I and pleased with the surgical and cosmetic results. One patient developed atypical angina on the seventh postoperative month and a selective arteriography confirmed stenosis of the anastomosis. A successful angioplasty of the original LAD lesion was carried out. Conclusions: A minimally invasive left anterior mediastinotomy is a good surgical access to perform a successful LIMA to LAD graft without cardiopulmonary bypass, allowing a shorter hospital stay and earlier postoperative recovery. However, a larger experience and a longer follow up is required to define its role in the treatment of coronary artery disease

Citodiagnóstico de lesiones focales hepáticas mediante punción con aguja fina dirigida por imágenes / Cytodiagnosis of hepatic focal injuries by punction with fine needle controlled by images

Two hundred two aspirates, obtained in 201 patients were studied. Procedures were performed under ultrasound guidance in 77.9 percent of cases and under CT scan guidance in 22.1 percent. Cytological diagnoses was compared with definitive pathological diagnosis in 136 patients and with clinical follow up in 66. Cytology was positive for malignant cells in 81.2 percent of cases, negative for malignant cells in 15.3 percent inconclusive in 1 percent and the sample was inadequate in 2.5 percent. Cytology was false negative for malignant lesions in 17 cases and there were no false positives. It had a sensitivity of 90.6 percent, a specificity of 100 percent, a positive predictive value of 100 percent and a negative predictive value of 55.3 percent. The histological types of malignant lesions were adenocarcinoma in 48.2 percent of cases, hepatocellular carcinoma in 16.5 percent and non specific carcinoma in 20.7 percent. The main sites of the primary tumors were the liver in 24.4 percent of cases, gallbladder and biliary tract in 20.9 percent, intestine in 15,1 percent. Cytological diagnosis of fine needle aspirates of the liver obtained under image guidance are a valuable support in the diagnosis of focal liver lesions

Rol diagnóstico de la combinación tomografía computada - angiografía en lesiones traumáticas de la aorta torácica / Diagnostic role of the combination of computed tomography and angiography in traumatic injury of thoracic aorta

Aim: To assess tha diagnostic value of the combination of computed tomography and angiography in aptients with blunt thoracic trauma and suspicion of aortic injury. Patients and methods: restrospective analysis of six patients, aged 22 to 72 years old, with traumatic thoracic aorta injury secondary to severe trauma, specially car accidents, seen between 1985 and 1994. Results: an early diagnosis was done in 3 patients. One patient, in whom diagnosis was delayed, died before surgery. In 3 cases, CAT scan showed indirect evidence of aortic rupture, consisting in alterations of aortic outline. In other 3 patients, it showed hemomediastinum, associated to a left hemothorax in one case. Angiography confirmed the diagnosis, localized and characterized yhe injury in all patients. Conclusions: the delay in the diagnosis of aortic injury may be fatal. The combination of CAT scan and angiography has a high sensitivity and specificity to localize and characterize lesions of the aorta or its branches or associated organs, essential step for surgical planning. CAT scan restrict the use of angiography, avoiding false negative studies, but cannot be used as the sole diagnostic procedure

Disolución de cálculos vesiculares de colesterol por infusión percutánea transhepática con Metil-Tert-Butil-Eter / Gallstones dissolution with metil-butil-eter via percutaneous transhepatic infusion

Se evaluó el tratamiento de colelitiasis sintomática de cálculos de colesterol o mixtos con escaso contenido de calcio, mediante infusión directa de metil-tert-butil-éter (MTBE) a través de colecistostomía transhepática en 10 pacientes con extracción complementaria de fragmentos residuales en 3 de ellos. La colecistostomía se realizó por vía transhepática bajo visión ecográfica o fluoroscópica. Se infundió MTBE durante 2 a 15 horas, en uno a cinco días, hasta lograr disolución de todos los cálculos, controlando el procedimiento con colecistografía directa, determinación colorimétrica de colesterol en el líquido recuperado y ecografías horarias. Se logró disolución completa en 7 pacientes (70 ciento por ciento). En los 3 restantes, portadores de cálculos que contenían calcio, se extrajeron fragmentos residuales con canastillo de Dormia. Sólo hubo complicaciones menores durante el procedimiento en 2 pacientes (náuseas y vómitos), que cedieron espontáneamente al suspender la infusión. A todos los pacientes se les indicó tratamiento de mantención con ácido Ursodeoxicólico. Se realizó seguimiento ecográfico cada 3 meses por un período de 10 meses, sin observar recurrencias. Esta técnica demuestra ser efectiva y de baja morbilidad en pacientes con indicaciones específicas, aunque su rol como tratamiento definitivo está aún por dilucidar