Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter?

OBJECTIVE: To report our experience in POEM vs. LHM, with particular focus on myotomy extension. BACKGROUND: POEM has been adopted worldwide as a treatment for achalasia. While resolution of dysphagia is above 90%, postoperative reflux ranges from 10 to 57%. Myotomy length has been a controversial topic. METHODS: Thirty-five cases of POEM were prospectively analyzed and compared retrospectively to the last 35 patients that underwent LHM, from December 2010 to August 2016. Mean follow-up was 10 months (6/32) for POEM and 20 months (6/68) for LHM. All patients with LHM had a myotomy extension ≥3 cm on the gastric side. In POEM cases, extension was defined by direct vision (Hill type II) and never exceeded 2 cm. RESULTS: Follow-up was completed in 100% of patients. Efficacy (ES ≤ 3) was 33/35 (94.2%) for POEM and 32/35 (91.4%) for LHM in a short-term follow-up (p = 1.000) and 31/35 (88.6%) and 27/35 (77.1%), respectively, in a long-term follow-up (p = 1.000), with average ES drop from 9 to 1.2 (p = 0.0001) in POEM vs. 9.2 to 1.3 (p = 0.0001) in LHM. Major Postoperative complications occurred in 1 patient (leak) for LHM and 1 patient (massive capnothorax) in POEM. Hospital stay was shorter for POEM than for LHM (1.3 vs. 2.1, respectively) (p = 0.0001). Symptomatic reflux cases included 7/35 POEM (20%) vs. 6/35 LHM (17.1%) (p = 0.4620). Esophagitis signs in endoscopy appeared in 1/21 POEM (4.7%) vs. 1/22 LHM (4.5%) (p = 1.000). Patients requiring PPI included 8/35 POEM (22.8%) vs. 7/35 LHM (20%) (p = 0.6642). Further treatment (endoscopic dilation) was performed in 10/35 POEM (28.5%) vs. 8/35 LHM (22.8%). CONCLUSIONS: A shorter myotomy on the gastric side in POEM may contribute to an acceptable reflux rate with comparable relief of dysphagia. Although our follow-up for POEM is shorter than for LHM, the trends are promising and warrant future prospective studies to address this topic.

Urinary bladder matrix scaffolds strengthen esophageal hiatus repair.

BACKGROUND: Laparoscopic repair of the hiatal hernia is associated with a recurrence rate between 12% and 42% depending on the defect size. Although the impact of hiatal reinforcement on long-term recurrence remains controversial, the main limitation of this approach has been the risk of adverse events related with the use of synthetic materials in the vicinity of the esophagus. METHODS: A total of 14 female domestic pigs underwent laparoscopic primary hiatal hernia repair of a simulated defect in the esophageal hiatus. Seven of the hiatal repairs were reinforced with an extracellular matrix (ECM) scaffold, whereas the remaining seven served as primary repair controls. Animals were survived for 8 wk. At necropsy, after gross morphologic evaluation, samples were sent for mechanical testing and histology. RESULTS: The repaired defect site reinforced with ECM scaffolds showed a robust closure of the crura in all cases with a smooth peritoneal-like structure covering the entire repair. Average load at failure of the treated group was found to be significantly stronger than that of the controls (185.8 ± 149.7 g versus 57.5 ± 57.5 g, P < 0.05). Similarly, the stiffness was significantly higher in the treated animals (57.5 ± 26.9 g/mm versus 19.1 ± 17.5 g/mm; P < 0.01). Interestingly, there was no difference in elongation at failure (7.62 ± 2.02 mm versus 7.87 ± 3.28 mm; P = 0.44). CONCLUSIONS: In our animal survival model, we have provided evidence that the addition of an ECM to augment a primary hiatal repair leads to tissue characteristics that may decrease the possibility of early failure of the repair. This may translate to decreased recurrence rates. Further study is necessary.

Prevalencia de la composición química de uro litiasis en pacientes de clínicas privadas / Chemical composition prevalence of kidney stones in private clinic patients

Introducción: La litiasis urinaria, también denominada urolitiasis, es una enfermedad causada por la presencia de cálculos o litos en el interior de los riñones o de las vías urinarias (uréteres, vejiga). Los cálculos renales se componen de sustancias normales de la orina, pero por diferentes razones se han concentrado y solidificado en fragmentos de mayor o menor tamaño. Es una condición frecuente que afecta a más del 10% de la población, en la edad media de la vida y es más frecuente en los hombres. Predomina en personas con hábitos sedentarios o en personas con gran exposición al calor y deshidratación. El análisis por disolución de los cálculos renales nos permite evaluar la composición química del mismo y así tomar las medidas clínicas adecuadas para prevenir su formación y recurrencia. Objetivo: Describir cual es la composición química más frecuente de los litos urinarios en una clínica privada de la ciudad de Guatemala. Describir la frecuencia de presentación entre géneros y su prevalencia en los grupos de edad. Metodología: Diseño descriptivo, transversal. Se realizó el análisis por disolución del cálculo a 80 pacientes de una clínica privada. Se tomaron datos de género y edad de los pacientes. Resultados: De los 80 pacientes analizados se encontraron 75 litos urinarios compuestos por oxalato de calcio (93.75%), 4 de ácido úrico (5%) ,1 de cistina (1.25%) y 0 litos de estruvita (0%). En el estudio participaron 62 pacientes se sexo Masculino (77.5%) y 18 femeninas (22.5%), con un rango de edades de 18 a 80 años y una edad promedio de 41.4 años. Conclusión: La gran mayoría de los litos analizados en el estudio estaban compuestos de Oxalato de Calcio, lo cual concuerda con las estadísticas de la NHANES donde se afirma que aproximadamente el 80% están compuestos de este material. En esta serie se encontró que el 93.75% de los litos examinados eran de oxalato de calcio. El 76% de los pacientes con litos de oxalato de calcio son de sexo masculino y presentan una edad promedio de 46.4 años; en los litos compuestos por ácido úrico se encontró una prevalencia del 5% y el 100% de estos eran varones. Los conformados por cistina comprende solo el 1.25% encontrados en el 100% de estos en varones. No se encontraron litos de estruvita. Se concluyó que los pacientes de sexo masculino presentan mayor prevalencia en la formación de litos urinarios

Introduction: Urinary stones, also known as urolithiasis, is a disease caused by the presence of stones or calculi inside the kidneys or urinary tract (ureters, bladder). Kidney stones are made up of normal substances in the urine, but for different reasons they concentrate and solidified as fragments of various sizes. It is a common affection in more than 10% of the population in their middle age and is more common in men. Urinary stones are more prevalent in people with sedentary habits or those with high exposure to heat and dehydration. The analysis by dissolving kidney stones allows us to evaluate its chemical composition and thus take appropriate measures to prevent recurrence. Objective: The main objective was to analyze the chemical composition of urinary calculi in patients from a private clinic and find out the frequency of its occurrence between genders and age groups. Methodology: Descriptive, transversal study. Urinary calculi analysis of 80 patients performed. Gender and age data recorded. Results: Out of 80 samples analyzed, 75 urinary calculi composition was calcium oxalate (93.75%), 4 of uric acid (5%), 1 cystine (1.25%) and none of struvite (0%) found. The groups were composed of 62 males (77.5%) and 18 female (22.5%) with an age range between 18 and 80 years and an average age of 41.4 years. Conclusion: The baste majority of calculi analyzed in the study were composed of calcium oxalate, which is consistent with statistics from NHANES where approximately 80% of calculi are composed of calcium oxalate. In this study 93.75% of calculi examined were composed of calcium oxalate. Seventy-six (76%) of patients with calcium oxalate calculi are male with a median age of 46.4 years. Uric acid calculi were present in 5% and 100% of those found in males. Cystine calculi found had a prevalence of 1.25% with 100% in males and the struvite calculi were not found. It was concluded that male patients have a higher prevalence in formation of urinary calculi and oxalate ones predominate

Surgical management of gastroesophageal junction tumors.

Surgical resection remains the mainstay of potentially curative therapy for gastroesophageal junction (GEJ) tumors. However, because of the location of the tumor at the boundary between the esophagus and stomach, GEJ tumors have been a source of controversy in regard to their definition, classification, staging and surgical management. The definition of GEJ tumors was addressed with the development of the three-tiered Siewert's classification scheme. There remain many controversies regarding the appropriate surgical approach and the extent of the lymphadenectomies for these tumors. For locally advanced, resectable GEJ tumors, an aggressive surgical resection should be considered and the approach predicated by tumor location as defined by the Siewert's classification. Limited resections for earlier stage tumors have also been evaluated.

Drenaje laparoscópico de linfocele post-trasplante renal / Laparoscopic drainage of lymphocele following renal transplantation

El trasplante renal es el tratamiento ideal para lospacientes con insuficiencia renal crónica, el cual, como todo procedimiento tiene una incidencia de complicaciones entre las que se mencionan el linfocele osea, la acumulación de líquido linfático peri-renal misma que se reporta entre el 2-10 por ciento. Complicación que si no se trata tempranamente puede causar disfunción del injerto. El presente reporte tiene como finalidzad presentar nuestra experiencia inicial en la Unidad de Trasplante Renal del Instituto Guatemalteco de Seguridad Social para el manejo de linfocele mediante una ventana peritoneal por videolaparoscopía. Se presentan 2 casos resueltos adecuadamente por esta vía; actualmente 1 año pos-trasplante con función renal adecuada

Esternotomía mediana: vía de abordaje alternativa para la cirugía pulmonar / Median sternotomy: alternative approach for pulmonary surgery

Se presentan 33 casos de resecciones pulmonares simples, combinadas y ampliadas, efectuadas por esternotomía mediana como vía de abordaje. Se analiza la esternotomía como incisión alternativa en la cirugía pulmonar, sus vantajes y desventajas y se presentan los resultados y la experiencia obtenidos

Esternotomía mediana: vía de abordaje alternativa para la cirugía pulmonar / Median sternotomy: alternative approach for pulmonary surgery

Se presentan 33 casos de resecciones pulmonares simples, combinadas y ampliadas, efectuadas por esternotomía mediana como vía de abordaje. Se analiza la esternotomía como incisión alternativa en la cirugía pulmonar, sus vantajes y desventajas y se presentan los resultados y la experiencia obtenidos (AU)