Nutrición enteral precoz en pacientes con gastrectomía total por cáncer / Early enteral nutrition in patients subjected to a total gastrectomy

Background: Total parenteral nutrition has a high cost and frequency of complications. Enteral feeding is a feasible alternative that can be started early in the postoperative period. Aim: To assess digestive tolerance to early enteral feeding in cancer patients undergoing total gastrectomy and to compare early enteral feeding (EEF) with total parenteral nutrition plus enteral feeding (TPN+EF), initiated after overcoming postoperative ileus. Patients and methods: Subjects with a resectable gastric cancer were considered eligible for the study. During surgery a nasoenteral tube was placed and patients were prospectively randomized to EEF or TPN+EF. Digestive tolerance, effectiveness, complications and costs between both modalities of nutritional support were compared. Results: Twenty eight patients (15 male, aged 63ñ14 years old) were studied. Fourteen patients were randomized to EEF and 14 to TPN+EF. Diarrhea occurred in 14 and 29 percent of EEF and TPN+EF patients respectively, (p: NS). Patients with TPN+EF received an average of 28 Cal/kg/day and 1.1 g/kg/day proteins. Patients with EEF received an average of 29 Cal/kg/day and 0.8 g/kg/day proteins. At the eighth postoperative day, serum albumin was 3.9ñ0.7 and 3.2ñ0.5 g/dl in EEF and TPN+EF patients respectively (p <0.05), serum prealbumin was 16.9ñ5 and 12.3ñ4.3 mg/dl in EEF and TPN+EF patients respectively (p <0.05) and nitrogen balance was +2.4ñ1.5 and -1.6ñ0.6 g/24 h in EEF and TPN+EF patients respectively (p <0.05). Postoperative hyperglycemia was observed with a lower frequency and nutritional support costs and length of hospital stay were significantly lower in the EEF group. Conclusions: After total gastrectomy EEF is well tolerated, safe and effective, even during the early postoperative ileus. This therapeutic modality could be the first choice for nutritional support in these patients

Tumores neuroendocrinos gástricos: presentación clínica, endoscópica y alternativas de tratamiento / Clinical and endoscopic presentation of gastric neuroendocrine tumors

Background: Gastric neuroendocrine tumors correspond to less than 1 percent of all gastric tumors. These tumors can be of three types. Seventy five percent are type I and are associated to chronic atrophic gastritis type A (CAG- A). Half of them are associated with pernicious anemia. Type II tumors are associated with Zollinger Ellison syndrome and type I multiple endocrine neoplasia. Type III are sporadic tumors. Aim: To report the clinical, endoscopical features and response to the treatment of gastric neuroendocrine tumors. Patients and methods: A retrospective study of eleven patients (seven male, aged 38 to 72 years old) with a pathological diagnosis of gastric neuroendocrine tumor. Their clinical presentation, associated diseases, treatment and follow up were reviewed. Results: Epigastric pain was present in eight patients, weight loss in three, epigastric pain and weight loss in one and post prandial abdominal pain in two. At endoscopy, multiple polyps in the fundus were observed in six, verrucose gastritis in one, polyps in the antrum in one, two subcardial polyps in 1, a fundus ulcer in one and a Bormann III type lesion in one. Chronic atrophic gastritis was diagnosed in seven patients and pernicious anemia in five. Serum gastrin levels were determined in 4 patients and were high in all. Four subjects were treated with endoscopic polipectomy only. A partial or total gastrectomy was done in seven patients. No complications or mortality occurred during the follow up. Conclusions: Abdominal pain is a common presentation of patients with gastric neuroendocrine neoplasia. Polyps predominantly in the fundus are the most common endoscopic finding. Surgical treatment or endoscopical polypectomy, depending of the extension of the disease, yield satisfactory results

Manejo actual de la acalasia del esófago: revisión crítica y experiencia clínica / Current management of achalasia of the esophagus

The therapeutic options for treatment of Achalasia of the esophagus include medical treatment, endoscopic and surgical procedures. The latter can be either conservative, such as cardiomyotomy or more aggressive, such as cardioplasty or esophageal resection. In this article, we discuss the early and long term results after the different therapeutic options. We also present the results of our recent surgical experience. The definitive results seem to be better after surgical treatment compared to medical management or endoscopic procedures

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

Hallazgo incidental de cáncer en saco herniario inguinal / Inguinal hernia sac cancer: report of 2 cases

The presence of cancer in a hernia sac is uncommon. The tumor can involve the hernia sac, the herniated mass or be external to the hernia sac. We report two cases with this condition. A 68 years old male was operated of a right inguinal hernia. During surgery, several white nodules were noted in the internal side of hernia sac. The same lesions were present in the mesentery. Pathological study revealed an adenocarcinoma. The primary tumor was not located and the patient died one and a half years after the procedure. A 62 years old male was operated due to an irreductible inguinal mass, seven months after a subtotal gastrectomy for gastric cancer. During the resection of the mass, metastasic implants in the mesenteric adipose tissue were noted. A mini laparotomy was performed and an extensive peritoneal tumor dissemination was found. The patient died two months after surgery

Resultados preliminares de la esofagomiotomía por video laparoscopia en pacientes con acalasia esofágica / Laparoscopic esophagomyotomy for achalasia: preliminary results in 19 patients

Background: Laparoscopic esophagomyotomy is becoming a good alternative to pneumatic dilatation, injection of botulinic toxin or classical surgery in the treatment of achalasia. Aim: To report the results of laparoscopic esophagomyotomy in patients with achalasia. Patients and methods: Nineteen patients with achalasia, nine women, aged 9 to 66 years old, operated between 1996 and 2001 are reported. Results: There was no surgical mortality. One patient had a subphrenic abscess due to an unnoticed tear of the esophageal mucosa. During surgery, esophageal mucosa was perforated in 4 patients, that was sutured in three. One patient with an extensive tear of the mucosa required conversion to classical surgery. Patients were followed for 2 to 48 months. Radiological controls showed a significant increase in the diameter of gastroesophageal junction and a diameter reduction of the mid third esophageal segment. Lower esophageal pressure was significantly reduced. All patients experienced a weight increase and reduction of dysphagia. Conclusions: Laparoscopic esophagomyotomy is a safe an effective therapeutic alternative for achalasia

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

Alimentación, tabaquismo e historia reproductiva como factores de riesgo del cáncer de cuello del útero / Diet, smoking and reproductive history as risk factors for cervical cancer

Background: Epidemiological studies have suggested that smoking, nutrition and sexual patterns are major risk factors for cervical cancer. Aim: To study the association between food consumption patterns, smoking and sexual behavior and the risk of cervical cancer. Material and methods: A matched case control study of 170 cases and 340 controls. Food and nutrient intakes were assessed by a food frequency questionnaire considering 58 antioxidant rich food items. Median daily intake of vegetables, fruits, antioxidant vitamins and fiber was calculated. A conditional logistic regression model was used to determine odds ratios associated with variations in nutritional intake and no nutritional factors (age at first delivery, parity, body mass index, family history of cancer and smoking). Results: High intakes of vegetables, fruits, beta carotene, vitamin C, E and fiber were associated with a lower risk of cervical cancer (Odds ratios ranging from 0.56 to 0.78). The risk for cancer was inversely associated with the age at first delivery and directly associated with the total number of pregnancies and smoking. Multivariate analysis model showed a protective effect for vegetable and vitamin E consumption (odds ratio of 0.6 with confidence intervals of 0.5 to 0.8 p<0.001) and a higher risk associated to smoking (odds ratio 2.8, confidence intervals 1.5-5.5 p<0.002) and a younger age at the first delivery (odds ratio 3.37 confidence intervals 2-5.3 p<0.001). Conclusions: Cervical cancer is associated with reproductive and food consumption behaviors. A higher intake of vegetables and foods rich in vitamin E can reduce its risk

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

Cirugía de la obesidad mórbida / Surgery of the morbid obesity

Surgical treatment of obesity is indicated speciallity in individuals with morbid obesity or in those with a BMI>35 Kg/m² with comorbidities. More than 30 different techniques have been described, being the most widely used those based on the restriction of gastric capacity with or without a decreased nutrient absorption in the intensive. In this paper it shown the Chilean experience with more than a hundred subjects operated with a new technique, involving a subtotal gastrectomy (95 percent) with gastroyeyuno anastomosis with circular stapler

Atributos del médico tratante: estudio desde el punto de vista del paciente / Physician attributes: a study on patient point of view

Los atributos del médico en su práctica profesional han sido definidos como virtudes de alto valor moral y ético. Sin embargo, éstas representan la perspectiva de los propios médicos respecto a sus pares. Mediante un estudio de encuesta a 104 pacientes adultos con patología quirúrgica no cancerosa, en etapa de diagnóstico se objetivó características deseables en el médico tratante desde el punto de vista del paciente, en relación a ciertas características personales y comunicacionales. El 56 por ciento de la muestra manifestó su opción por médicos con un rango etario definido y de ellos, el 90 por ciento lo prefiere entre 35 y 50 años. Más del 95 por ciento atribuye gran importancia a la seguridad del médico en sí mismo y a la capacidad de escuchar atentamente al paciente y de explicar detalladamente a éste su enfermedad y posibles tratamientos. El 83 por ciento le asignó gran importancia a la presentación personal y de ellos, el 56 por ciento prioriza el aseo personal por sobre el tipo de vestuario o el uso de delantal blanco. Menor importancia se atribuye a la simpatía y la puntualidad. Los pacientes prefieren la seguridad en sí mismo y la capacidad de comunicación como las variables más importantes en su relación con el médico

Resultados de la colecistectomía a 10 años plazo / Clinical status of patients subjected to cholecystectomy 10 years after

Background: The post cholecystectomy syndrome comprises a series of vague symptoms referred by patients subjected to this surgical procedure. These symptoms are unspecific and their association with the operation is dubious. Aim: To assess the frequency of digestive symptoms among patients subjected to a cholecystectomy ten years ago. Patients and methods: One hundred patients subjected to a cholecystectomy between 1987 and 1990, were contacted by mail. They were invited to a clinical interview and to an abdominal ultrasound examination. Results: Two invited patients had died of an acute myocardial infarction. Therefore, 98 patients (78 women), aged 30 to 85 years old, were assessed. Seventy two percent had diverse dyspeptic symptoms, 90 percent had no food intolerance and 94 percent had gained weight after the operation. Ninety six percent was satisfied with the surgical results, 3 percent had severe symptoms due to gastroesophageal reflux or depression. One patient had a residual choledocholithiasis and refused any treatment. Conclusions: Cholecystectomy is well tolerated and has good long term results

Efecto de la vagotomía asociada a cirugía antirreflujo sobre la secreción gástrica de ácido en pacientes con reflujo gastroesofágico patológico / Effect fo the super selective vagotomy associated to antireflux surgery on acid gastric secretion in patients with pathologic gastroesophageal reflux

Se estudió la secreción gástrica basal (BAO) y la secreción gástrica máxima estimulada (PAO) en 3 grupos de pacientes con reflujo GE crónico sometidos a cirugía. a) 18 casos con calibración cardial y gastropexia posterior, asociado a vagotomía suprasectiva; b) 22 casos sometidos a switch duodenal y vagotomía supraselectiva y, c) 23 casos con vagotomía y gastrectomía parcial, 11 de ellos analizados 8 a 10 años después de la cirugía. La secreción ácida basal (BAO) se redujo en cerca de 60 por ciento en los pacientes sometidos a vagotomía supraselectiva y en 96 por ciento después de vagotomía-gastrectomía. La secrección máxima (PAO) se redujo en 50 por ciento en los casos con vagotomía supraselectiva y en 89 por ciento después de vagotomía-gastrectomía. Estos resultados explican en parte la alta recurrencia del reflujo ácido en pacientes con esófago de Barrett sometidos a cirugía antirreflujo con vagotomía supraselectiva. Por el contrario, después de vagotomía-gastrectomía, esta recurrencia es muy baja

Prevalencia de lesiones de la vía biliar durante colecistectomía laparoscópica en el período inicial de esta técnica, agosto 1990 a noviembre 1995: estudio cooperativo de 26 hospitales / Prevalence of biliary duct injuries during laparoscopic cholecystectomy in initial period of this technique 1990 to 1995: cooperative study of 26 hospitals

Se realizó una encuesta retrospectiva en 26 hospitales chilenos referente a la prevalencia de lesiones de vía biliar durante colecistectomía laparascópica en la primera etapa inicial de aprendizaje de esta técnica (1990-1995). Hubó un total de 25.007 pacientes operados con una ocurrencia de 78 lesiones de la vía biliar, lo que representa una prevalencia de 0,3 por ciento. La mayoría de los hospitales comenzaron con este procedimiento durante 1992. Las lesiones más frecuentes fueron las de tipo II, seguidos de las tipo I y III. En el 57 por ciento de los casos el cirujano se dio cuenta de esta lesión durante la misma operación y procedió a repararla de inmediato. En 43 por ciento los pacientes evolucionan con dolor abdominal, distensión y un biliperitoneo que fue reoperado entre el 2º y 10º día. No hubo mortalidad operatoria. En el seguimiento a corto plazo (15 meses) los pacientes permanecían asistomáticos. El mejor tratamiento es la prevención de la ocurrencia de estas lesiones, mediante una cuidadosa técnica quirúrgica y el uso criterioso de la colangiografía intraoperatoria

Perímetro del cardias en pacientes con reflujo gastroesofágico patológico crónico / Cardia perimeter in patients with chronic gastroesophageal reflux

Introducción: antecedentes anatómicos y clínicos sugieren que el cardias de los pacientes con reflujo gastroesofágico patológico está dilatado. El objetivo de este trabajo fue confirmar este hallazgo y correlacionarlo con el grado de progreso y gravedad de la enfermedad, sugiriendo una relación fisiopatológica. Material y método: se midió durante la cirugía el perímetro de la unión gastroesofágica o cardias en sujetos controles (n=25) y pacientes con esofagitis por reflujo (n=45), esófago de Barrett corto (n=17) y Barret largo (n=15). Resultados: el perímetro del cardias promedio en controles fue de 6,3 cm, en pacientes con esofagitis por reflujo fue 8,9 cm, en pacientes con esófago de Barrett corto 13,8 cm y en pacientes con esófago de Barrett largo fue de 13,1 cm. Conclusión: el perímetro del cardias en sujetos controles es significativamente menor (p<0,001) que el perímetro de los pacientes con esofagitis y esófago de Barrett. El perímetro del cardias es mayor cuando más avanzada es la enfermedad. No hubo diferencias en los perímetros entre esófago de Barrett corto y largo