Estudio comparativo de precisión diagnóstica preoperatoria y la confirmación laparoscópica de hernia hiatal / Comparative study of preoperative diagnostic precision and laparoscopic confirmation of hiatal hernia

Resumen Introducción: La hernia hiatal (HH) de tipo I por deslizamiento es el tipo más frecuente, siendo difícil de definir objetivamente, por lo que el principal foco de controversia es su diagnóstico. El objetivo del presente trabajo es reportar los resultados respecto de la precisión diagnóstica del estudio preoperatorio y confirmarlo con el diagnóstico laparoscópico de este tipo de HH. Materiales y Método: Estudio prospectivo descriptivo de serie que incluyen pacientes con síntomas típicos de enfermedad por reflujo gastroesofágico, los cuales se sometieron a estudio con esófago-gastro-duodenoscopía, estudio manométrico y radiológico de esófago, estómago y duodeno con bario. Se incluyen sólo los pacientes en los cuales la endoscopía revela la existencia de HH por deslizamiento ≪ 5 cm. Estos pacientes se sometieron a tratamiento quirúrgico confirmándose o no la existencia de HH al momento de la exploración laparoscópica. Resultados: El valor predictivo positivo y sensibilidad para manometría fue de un 51,2% y 70%, para la radiología 91,7% y 80,5% y para endoscopia 80,3% y 70,7% respectivamente. Conclusión: Para el diagnóstico confiable de HH antes del tratamiento, las tres investigaciones mencionadas deben ser obligatorias antes de la cirugía.

Introduction: Being type I hiatal hernia (HH) the most frequent, is difficult to define objectively and therefore, the main focus of controversy is the diagnosis. The aim of this paper is to report the results regarding the diagnostic accuracy of the preoperative study and to confirm it with the laparoscopic diagnosis of hiatal hernia. Materials and Method: This descriptive and prospective study includes patients with typical symptoms of gastroesophageal reflux disease who underwent esophageal-gastro-duodenoscopy, manometry and radiological study of esophagus with barium swallow. Only patients in whom endoscopy reveals the existence of HH by sliding ≪ 5 cm are included. These patients underwent surgical treatment confirming or not the existence of HH at the time of laparoscopic exploration. Results: The positive pre- dictive value and sensibility for manometry was 51.2% and 70%, for radiology 91.7% and 80.5%, and for endoscopy 85.3% and 70.7% respectively. Conclusion: For the reliable diagnosis of HH before treatment, the three mentioned investigations must be mandatory before the surgery.

Peritonitis esclerosante primaria y secundaria: estudio comparativo / Primary and secondary sclerosing peritonitis: comparative study

Resumen Introducción: Existen dos tipos de peritonitis esclerosante (PE): primaria o idiopática y secundaria, generalmente a diálisis peritoneal (DP), y con menor frecuencia a otras patologías abdominales o sistémicas. Su mortalidad es alta. Objetivo: Comparar las características clínicas, estudios diagnósticos y tratamiento de pacientes con Peritonitis Esclerosante Primaria y Secundaria, definir si existen diferencias y determinar los principales elementos clínicos e imagenológicos que permitan hacer un diagnóstico precoz y mejorar los resultados terapéuticos. Material y Métodos: Se analizan 18 casos de PE diagnosticados en nuestro hospital, entre los años 2001-2014. Incluye una serie retrospectiva de 15 casos de PE secundaria (13 por diálisis peritoneal y 2 por cirrosis hepática). Se compara con un estudio prospectivo que incluye 3 pacientes con PE primaria. Resultados: Las principales diferencias se evidencian en la presentación clínica: PE primaria: se presenta con cuadro de obstrucción intestinal y baja de peso de distinta magnitud. PE secundaria: predominan el dolor abdominal, peritonitis recurrente y la falla de ultrafiltración. La tomografía computada de abdomen es útil, sobre todo cuando hay obstrucción intestinal. Ha hecho posible el diagnóstico preoperatorio. Conclusiones: Se requiere un alto índice de sospecha para el diagnóstico precoz de PE, sobre todo para la forma primaria. Debe sospecharse en todo paciente con dolor abdominal, vómitos recurrentes y baja de peso de cualquier magnitud; y en aquellos en diálisis peritoneal durante 5 años o más, que presenten dolor abdominal y/o peritonitis recurrente y/o falla de ultrafiltración.

Introduction: There are two types of sclerosing peritonitis (SP): primary or idiopathic and secondary, generally to peritoneal dialysis, and less frequently, to other abdominal or systemic pathologies. Mortality related to this is high. Objective: To compare the clinical feature, diagnostic studies and treatment of patients with Primary and Secondary Sclerosing Peritonitis, to define whether there are any differences and to establish the main clinical and imaging elements allowing for an early diagnosis and improving the therapeutic results. Material and Methods: An analysis of 18 SP cases diagnosed at our hospital between 2001-2014 was carried out. This includes a retrospective series of 15 cases of secondary SP (13 to peritoneal dialysis and 2 to liver cirrhosis). This is compared against a prospective study that includes 3 patients with primary SP. Results: The main differences became evident in the clinical presentation: Primary SP: occurs in an intestinal obstruction and a loss of weight scenario of varying degrees. Secondary SP: abdominal pain and recurrent peritonitis as well as ultrafiltration failure prevail. CT of the abdomen has proven to be useful, in particular in those cases where there is intestinal obstruction. It has made preoperative diagnostic possible. Conclusions: A high degree of suspicion is required for an SP early diagnosis, especially for the primary form. All patients presenting abdominal pain, recurrent vomiting and any degree of weight loss and those with five or more years of peritoneal dialysis presenting abdominal pain and/or recurrent peritonitis and/or ultrafiltration failure should raise a diagnosis suspicion.

Retención de cápsula endoscópica en enfermedad de Crohn ¿cómo manejarla? / Retained capsule endoscopy in Crohn´s disease: how to manage it?

Capsule endoscopy is a technique that allows the study of the small intestine, through a device that is swallowed by the patient, capturing images as it travels through the digestive tract. Capsule retention is the most serious complication. We report the case of a 69 year-old male presenting with iron deficiency anemia, with normal upper endoscopy and colonoscopy; but obscure gastrointestinal bleeding was diagnosed and therefore a study with capsule endoscopy was requested. The patient evolves with retained capsule in the small intestine with ulcerated stenosis as shown by imaging. This finding was confirmed by enteroscopy with biopsy, without being able to extract the capsule. Medical management with corticosteroids was indicated for intestinal obstruction secondary to inflammatory stenosis in the context of Crohn's disease: The capsule was expelled after 21 days of ingestion, with a positive outcome

La cápsula endoscópica es una técnica que permite el estudio del intestino delgado, mediante un dispositivo que es deglutido por el paciente y captura imágenes en su recorrido por el tubo digestivo. La complicación más grave es la retención de la cápsula. Se reporta el caso de un paciente de sexo masculino, de 69 años con anemia ferropénica, con endoscopia alta y colonoscopia normal; planteándose sangrado gastrointestinal de origen oscuro por lo que se solicita estudio con cápsula endoscópica. El paciente evoluciona con retención de la cápsula en intestino delgado, visualizándose en las imágenes la presencia de estenosis ulcerada, hallazgo que se confirma mediante enteroscopia con toma de biopsias, sin lograr extraer la cápsula. Se indica manejo médico con corticoides por obstrucción intestinal secundario a estenosis inflamatoria en contexto de enfermedad de Crohn, expulsando espontáneamente la cápsula al día 21 de su ingestión, sin complicaciones.

Resultados de la cirugía bariátrica en pacientes diabeticos con índice de masa corporal mayor a 35Kg/m2 / Results of bariatric surgery in diabetic patients with body mass index greater than 35kg/35m2

Obesity and diabetes mellitus II (DMII) are closely related and have high prevalence around the world as in Chile. The term “diabesity” defines the DMII as a result of physiopathologic,metabolic and inflammatory events depending of obesity. This article summarizes the results of bariatric surgery in diabetic patients with BMI > 35 kg/M2. It makes a review of results in our hospital and compares them with International Literature. Although the bariatric surgery in diabetic patients is a field of constant investigation, the International and National literaturehave shown excellent results in patients with BMI > 35 kg/m2. Therefore it is important to continue the investigations concerning these diseases in order to determine all variables that are related to the final results. Bariatric surgery is the recommended therapeutic option foradults with BMI > 35, specially, if their DMII is difficult to control with medical treatment. These diabetic patients who undergo bariatric surgery need a close follow up and clinical and metabolic support during their life. This type of patients needs an integral and multidisciplinary treatment, including the education which plays a transcendental role to get optimal results.

Morbilidad y mortalidad operatoria de la gastrectomía subtotal y total por cáncer gástrico 2004 a 2010: parte I de un estudio prospectivo / Complications and mortality of total and subtotal gastrectomy for gastric cancer

Background: Surgery for gastric cancer may have high rates of complications and mortality. Aim: To analyze operative mortality of total and subtotal gastrectomy in the period 2004-2010. Material and Methods: Prospective study 345 patients with gastric cancer, mean age 62 years, 64 percent males, subjected to a total or subtotal R0, R1 or R2 gastrectomy. All patients were assessed in the postoperative period and all complications were recorded. Results: Total and subtotal gastrectomies were performed in 224 and 69 patients respectively. Postoperative complications consisted in anastomotic leaks, duodenal stump leaks, hemoperitoneum, pulmonary infections and intestinal obstruction. Mortality of total gastrectomy R1 or R2 was 2.1 percent whereas palliative gastrectomy, to improve quality of life, had 15 percent mortality. Subtotal gastrectomy had 1.4 percent mortality. Conclusions: There has been a reduction in operative mortality of gastrectomy for gastric cancer, however the rate of complications has not changed.

Objetivos: Analizar la morbilidad y mortalidad operatoria de la gastrectomía total y subtotal en el período 2004-2010 y compararlo con las cifras publicadas en los últimos 40 años. Material y Método: El presente estudio prospectivo incluye a los pacientes sometidos a gastrectomía total o subtotal R0 R1 o R2 entre mayo de 2004 y diciembre de 2010. Se evaluaron la morbilidad y la mortalidad postoperatoria. Resultados: La gastrectomía total se realizó en 244 pacientes y la subtotal en 69 pacientes. La morbilidad postoperatoria correspondió a filtración de la anastomosis, filtración del muñón duodenal, hemoperitoneo, infecciones pulmonares y obstrucción intestinal. La mortalidad de la gastrectomía total R0 o R1 fue de 2,1 por ciento, mientras que la gastrectomía de aseo tuvo un 15 por ciento de mortalidad. La gastrectomía subtotal presentó una mortalidad de 1,4 por ciento. Conclusiones: Como consecuencia de todos los adelantos técnicos y materiales en la cirugía del cáncer gástrico, que significó una baja muy importante en la mortalidad operatoria, las complicaciones postoperatorias no han variado estos últimos 40 años.

Optimización de cultivos de hepatocitos humanos para estudios de citotoxicidad / Optimization of human hepatocyte cultures for citotoxicity studies

Los cultivos de hepatocitos entregan un valioso acercamiento al estudio de las funciones metabólicas específicas del hígado, evaluación de citotoxicidad. No existen líneas humanas inmortales con función normal. La inmortalización de hepatocitos humanos con el método UCHT1(medio de cultivo condicionado por células tumorales de tiroides) permitirá prolongar la sobrevida y función de estos, siendo útil para evaluar funcionalidad y citotoxicidad. Objetivo: Optimizar el cultivo de hepatocitos humanos. Metodología: En cultivos primarios de hepatocitos humanos, se agregó medio UCHT1 cultivando en superficies de colágeno, polilisina, gelatina y matrigel. Como control positivo, se utilizó línea Gherschenson (GER) para evaluar curva de crecimiento y producción de Glucógeno (PAS). Se evaluó citotoxicidad (LIVE/DEAD) en hepatocitos GER expuestos a Metotrexato (10, 100 y 1000 mM) a 24, 48 y 72 hrs. Resultados: Se realizó 3 cultivos primarios. Fue efectiva la utilización de Polilisina y Colágeno. Duración 8 meses. No se ha realizado la curva de crecimiento, ni evaluación de funcionalidad en hepatocitos humanos. La línea GER tiene un crecimiento exponencial (tiempo duplicación: 36 hrs). Se observó producción de glucógeno en condiciones de diferenciación hasta 120 hrs. La citotoxicidad por Metotrexato tiene una curva dosis dependiente, significativa en todas las concentraciones (p<0,001) (CL50 a 1000 mM a 24 hrs). Conclusiones: Se logró establecer una línea primaria de hepatocitos humanos. La polilisina y el colágeno han optimizado el establecimiento de cultivos primarios. El método PAS permitió evaluar producción de glucógeno (diferenciación). Los valores de citotoxicidad demostraron un efecto dosis dependiente en las condiciones experimentales. Logrando estandarizar el método para evaluación futura de líneas celulares humanas.

Background: Hepatocyte cultures are a valuable tool to study specific metabolic liver functions and cytoxicity. Human hepatocyte cell lines with normal function do not exist. Immortalization of human hepatocytes with a rat thyroid cell line (UCHT1) allows long-term survival and function of these cells, becoming useful to evaluate functionality and cytotoxicity. Aim: To optimize long-term culture of human hepatocytes. Material and Methods: UCHT1 media was added to primary cultures of human hepatocytes, seeding in collagen, gelatin, matrigel and polilisine surfaces. Gherschenson cell line (GER) was used as a positive control to evaluate the growth curve and Glycogen production (PAS). Cytotoxicity was evaluated (LIVE/ DEAD) in GER hepatocytes exposed to Metotrexate (10, 100 and 1000 µM) 24, 48 and 72 hrs. Results: Three primary cultures were made. The use of Polilisine and Collagen was effective. Cultures were kept for 8 months. Growth curves or evaluation of functionality in human hepatocytes, were not carried out. GER cell line had an exponential growth (duplication time: 36 hrs). Production of glycogen in differentiation conditions was observed up to 120 hrs. Cytotoxicity by Metotrexate had a dose dependent curve with a 50% lethal dose calculated as 1000 µM at 24 hrs. Conclusions: A primary line of human hepatocytes was obtained. Polilisine and collagen optimized the establishment of primary cultures. PAS method allowed the evaluation of glycogen production (differentiation). Cytotoxicity demonstrated a dose dependent effect in experimental conditions.

Reoperaciones por fracaso tardío de la cirugía bariátrica: reporte de 5 casos clínicos / Reoperation due to late failure or complications of bariatric surgery: report of five cases

En el presente trabajo hacemos una revisión y análisis descriptivo de 5 casos clínicos de pacientes operados por obesidad mórbida, que se presentaron en el Hospital Clínico de la Universidad de Chile en el período de junio del 2003 a septiembre del 2005 en los que se detectó fallas de algunos de estos procedimientos manifestadas por síntomas y reganancia de su peso.

Alteraciones de la tolerancia a la glucosa y frecuencia de síndrome metabólico en pacientes con enfermedad por hígado graso no alcohólico / Glucose tolerance alterations and frequency of metabolic syndrome among patients with non alcoholic fatty liver disease

Background: Non alcoholic fatty liver disease (NAFLD) is associated to diabetes mellitus, obesity, disturbances in serum lipid levels, insulin resistance and metabolic syndrome. Aim: To assess glucose tolerance and the presence of metabolic syndrome among patients with biopsy proven NAFLD. Patients and methods: Serum lipid levels, hepatic function tests were measured and an oral glucose tolerance test was performed in 46 patients (mean age 45±12 years, 36 females) without history of diabetes mellitus and with steatosis in a liver biopsy. Results: Mean body mass index of the sample was 37±12 kg/m². Seventeen percent had pure steatosis, 78 percent had steatohepatitis with or without fibrosis and 50 percent had fibrosis in the liver biopsy. Glucose intolerance and diabetes was found in 57 percent and 15 percent of cases, respectively. The presence of steatohepatitis was higher in diabetics, compared with subjects with glucose intolerance or a normal glucose response (43, 38 and 8 percent, respectively, p <0.0001). Ninety three percent had a metabolic syndrome and the proportion of biopsies with fibrosis was higher among subjects with more than three diagnostic criteria for metabolic syndrome compared with those with three or less criteria (59 and 46 percent, respectively, p <0.05). Conclusions: Glucose intolerance, diabetes and metabolic syndrome are common among patients with NAFLD, even when they are not obese.

Riesgo perioperatorio del bypass gástrico reseccional en pacientes con obesidad mórbida: Estudio prospectivo de 684 pacientes / Perioperative risk among morbid obese patients subjected to gastric bypass

Background: Bariatric surgery is a complex procedure not exempt of complications. Aim: To assess mortality and complications of excisional gastric bypass among morbidly obese subjects. Material and methods: Prospective analysis of 684 morbid obese patients (age range 14-70 years, 525 females) subjected to an excisional gastric bypass. Major postoperative complications and mortality were registered. Results: Mean body mass index (BMI) of the subjects was 43.7 kg/m2. One hundred sixty two patients had a BMI between 35 and 39.9 kg/m2, 419 had a BMI between 40 and 49.9 kg/m2 and 103 had a BMI over 50 kg/m2. Two patients with a BMI of 52 and 56 kg/m2 respectively, died in the postoperative period (0.3%). Thirty six patients had major complications. Anastomotic fistula was the most common complication in 12 patients (1.7%). Fourteen patients required a new operation due to complications. None of these died. The mean operative volume of the surgical team was 124 patients per year. Conclusions: Excisional gastric bypass has a low rate of mortality and complications, if the surgical team operates a large volume of patients.

Resecabilidad y mortalidad operatoria de la gastrectomía subtotal y total en pacientes con cáncer gástrico avanzado, entre 1969 y 2004 / Evolution of resectability and mortality rates of total and subtotal gastrectomy for gastric cancer

Background: The only curative treatment for gastric cancer is its surgical excision associated to a lymph node dissection. Aim: To study the evolution of resectability and operative mortality of total and subtotal gastrectomy for gastric cancer, in a period of 35 years. Material and methods: Review of medical records of 3000 patients with gastric cancer, operated between 1969 and 2004. Resectability and mortality of total and subtotal gastrectomy was compared in four successive periods (1969 to 1979, 1980 to 1989, 1990 to 1999 and 2000 to 2004). Results: In the four periods there was a steady and significant increase in resectability rate from 49 to 85%. Mortality of total and subtotal gastrectomy decreased significantly from 17 to 2% and from 25 to 1%, respectively. Conclusions: Resectability and mortality rates of total and subtotal gastrectomy have improved with time. Probably a better pre and postoperative care and the experience of the surgical team have an influence in this favorable change.

Cirugía bariátrica y embarazo / Bariatric surgery and pregnancy

El número de pacientes sometidos a cirugía bariátrica ha aumentado rápidamente en el mundo. Esta revisión pretende describir la literatura publicada relativa a las deficiencias nutricionales posteriores a la cirugía bariátrica y su importancia en el embarazo.

Síndrome de Bouveret: caso clínico y revisión de la literatura / Bouveret syndrome: report of one case

El síndrome de Bouveret es una rara entidad clínica consistente en una obstrucción duodenal secundaria al paso de cálculos desde la vesícula biliar al duodeno, a través de una fístula colecisto o colédoco-duodenal. La presentación clínica es más bien inespecífica, siendo difícil el diagnóstico preoperatorio. La ecografía y TAC abdominal, como la endoscopia digestiva alta son los exámenes diagnósticos más útiles, siendo, en ocasiones, terapéutico. Este trabajo reporta el caso de un paciente de 76 años, que consulta por un cuadro compatible con una obstrucción intestinal causada por litiasis biliar y cáncer.

Evolución de comorbilidades metabólicas asociadas a obesidad después de cirugía bariátrica / Effects of gastric bypass on weight, blood glucose, serum lipid levels and arterial blood pressure in obese patients

Background: Type 2 diabetes, hypertension and serum lipid abnormalities are common among obese people and they should improve with weight reduction. Aim: To study the outcome of these abnormalities after bariatric surgery in morbid obesity patients. Material and methods: Two hundred thirty two morbid obese patients subjected to gastric bypass, were evaluated in the preoperative period and every three months after surgery, during a minimum of 12 months. Clinical evolution, blood glucose, serum insulin, insulin resistance measured with the homeostasis model assessment (HOMA) and serum lipid levels were analyzed. Results: In the preoperative period, 17% had type 2 diabetes, 49% had abnormal serum lipid levels and 25% had high blood pressure. Sixty six percent had at least one of these abnormalities and 20% had more than one. During follow up, body mass index decreased from 44 to 29.3 kg/m2. Total and HDL cholesterol, blood glucose and insulin resistance significantly decreased from the third month after surgery. Diabetes disappeared in 97% of diabetic subjects, blood pressure normalized in 53% of subjects with hypertension and serum lipid levels returned to normal in 88% of subjects with dyslipidemia. Conclusions: Gastric bypass in morbid obese patients achieves a significant and important weight reduction that results in significant reductions in the frequency of diabetes, dyslipidemia and hypertension among operated obese subjects.

Utilidad de la diferencia de temperatura axilo-rectal en apendicitis aguda: estudio retrospectivo / Utility of axillo-rectal temperature difference in acute appendicitis: retrospective study

La apendicitis aguda (AP) es la causa más frecuente de intervención quirúrgica en servicios de urgencia. Aproximadamente el 25 por ciento de los pacientes que concurren a éstos por dolor abdominal la presentan. En su diagnóstico frecuentemente se utiliza la diferencia de temperatura axilo-rectal (DAR) como signo clínico, siendo ampliamente aceptado que esta diferencia es mayor a 1 °C en AP. Al revisar la literatura médica no se encuentra evidencia que avale esta conducta. Se diseño un estudio para evaluar la DAR en AP. Se revisaron retrospectivamente 169 casos de AP, con registro de temperatura axilar y rectal al ingreso en urgencia. Se encontró que la DAR promedio fue de 0,8 °C. En AP con perforación apendicular la temperatura axilar rectal se encontraron aumentadas en forma estadísticamente significativa, pero la DAR se mantuvo sin cambios. Se concluye que la DAR no aporta al diagnóstico inicial de apendicitis aguda.

Diálisis con albúmina MARS (Molecular Adsorbent Recirculating System) como puente para el trasplante hepático en insuficiencia hepática fulminante: presentación de 3 casos / Albumin dialysis MARS (Molecular Adsorbent Recirculating System) in acute liver failure, before liver transplantation: report of three cases

The most successful therapy for acute liver failure is liver transplantation. However, due to the low number of donors, organ support therapies need to be used as a bridge to liver transplantation. Molecular Adsorbents Recirculating System (MARS) is a dialysis treatment that uses a recirculating dialysate containing albumin. This allows the removal of both hydrosoluble and albumin-related substances. This system improves hepatic encephalopathy, renal dysfunction and some clinical parameters in acute liver failure, but there is no clear decrease in mortality. We report three women aged 23, 21 and 61 years, that were subjected to liver transplantation, in whom this therapy was successfully used.

Utilidad de la proteína C reactiva en apendicitis aguda / Utility of the C reactive protein in acute appendicitis

El objetivo de este trabajo es evaluar el rol de Proteína C reactiva (PCR) como marcador de inflamación en el diagnóstico de la apendicitis aguda y relacionarlo con la histopatología de una serie de pacientes intervenidos por sospecha de apendicitis aguda. Pacientes y métodos: 36 pacientes consecutivos fueron operados por sospecha de apendicitis aguda. A todos ellos como parte del estudio se les solicitó en forma preoperatoria PCR. Una vez apendicectomizados, las biopsias fueron estudiadas en el Isntituto de Anatomía del Hospital y correlacionadas con el valor de la PCR. Resultados: Del total de pacientes, en 33 de 36 la sospecha clínica fue confirmada como apendicitis aguda y 3 biopsias fueron informadas normales. PCR se encontró elevada en 31 casos y en 5 con valores bajo los 5 mg/dl. Al analizar los resultados histopatológicos con PCR se encuentra que en el 87,8 por ciento de los casos que tuvieron apendicitis, la PCR se encontraba elevada y de los casos que tenían elevación de la PCR un 93,5 por ciento tenían apendicitis. Conclusiones: La elevación de la PCR tiene un alto valor predictivo positivo (93,5 por ciento) apendicitis aguda en ausencia de otra causa de inflamación sistémica. Puede ser utilizada como ayuda diagnóstica en los casos donde la clínica no puede aclarar el diagnóstico.

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

Reflujo gastroesofágico patológico en pacientes con obesidad severa, mórbida e hiper obesidad / Pathological gastroesophageal reflux in patients with severe, morbid and hyper obesity

Background: Overweight can be a risk factor for pathological gastroesophageal reflux or hiatal hernia. Aim: To study the prevalence of gastroesophageal reflux in patients with severe obesity. Patients and methods: Sixty seven patients, 51 female, aged 17 to 56 years old with a body mass index over 35 kg/m2, were studied. An upper gastrointestinal endoscopy was performed in all, esophageal manometry was done in 32 and 24 h pH monitoring was done in 32 patients. Results: Seventy nine percent of patients complained of heartburn and 66 of regurgitation. In 16 patients, endoscopy was normal. An erosive esophagitis was found in 33 patients, a short columnar epithelium in 12 and a Barret esophagus with intestinal metaplasia in six. Normal endoscopic findings and erosive esophagitis were present with a higher frequency in women. No association between the degree of obesity and esophageal lesions was observed. Lower esophageal sphincter pressure and abdominal length were significantly higher in subjects with a body mass index over 50 compared to those with a body mass index between 35 and 39.9 kg/m2. No differences were observed in 24 h pH monitoring. Conclusions: A high proportion of severely obese patients had symptoms and endoscopical findings of pathological gastroesophageal reflux

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