Rol actual de la adrenalectomía bilateral en el manejo del síndrome de cushing ectópico / Current role of bilateral adrenalectomy in the management of ectopic Cushing's syndrome

Objetivo: Describir las característicasclínicas y los resultados perioperatorios de la adrenalectomía bilateral laparoscópica (ABL) en 5 pacientestratados con diagnóstico de Síndrome de Cushing Ectópico (SCE).Material y método: Se realizó un estudio retrospectivo y descriptivo de todos los pacientes con SCEsometidos a una ABL, entre enero de 2009 y junio de2017. Todos los pacientes fueron evaluados por unequipo multidisciplinario que decidió conjuntamente elmomento más adecuado para la cirugía. Fueron analizados los siguientes datos protocolares: edad, sexo, origen del tumor secretor, duración del hipercortisolismo,motivo de internación, manejo terapéutico inicial, datosbioquímicos (cortisol sérico preoperatorio, ACTH plasmática y cortisol libre urinario), datos quirúrgicos (vía deabordaje, tiempo quirúrgico, tipo de cirugía, necesidadde conversión a cirugía abierta), datos perioperatorios (tiempo de internación postoperatoria, complicacionessegún la escala de Clavien-Dindo, mortalidad, tasa decuración clínica y tasa de curación bioquímica, tiempode seguimiento).Resultados: Cinco pacientes fueron sometidos a ABL.El abordaje fue mínimamente invasivo, ya sea transperitoneal (n=3) o retroperitoneoscópico posterior (n=2). Eltiempo de internación fue de 23,4 días (r=4-81). Ningún paciente falleció por complicaciones quirúrgicas, ytodos lograron la curación bioquímica y clínica de suhipercortisolismo después de la cirugía.Conclusiones: ABL es un procedimiento de rescateeficaz para controlar los síntomas asociados al hipercortisolismo en pacientes con SCE refractario al tratamiento médico.(AU)

Objectives: The aim of this paper is todescribe the clinical features and the perioperative results of the bilateral laparoscopic adrenalectomy (BLA) ofsalvaje in 5 patients treated for an Ectopic Cushing Syndrome (CS) who were refractory to medical treatment.Material and methods: We performed a retrospective analysis of the clinical records of our institution.Five BLAs were performed in patients with Ectopic CSrefractory to medical treatment during the period fromJanuary 2009 and June 2017. All patients were evaluated by a multidisciplinary team that jointly decidedthe most appropriate time for surgery. The followingprotocol data were analyzed: age, sex, location of the secreting tumor, duration of hypercortisolism, reason forhospitalization, initial therapeutic management), biochemical data (pre-op serum cortisol, plasma ACTH andfree urinary cortisol), surgical data (surgical approach,surgical time, type of surgery, need for conversion toopen surgery), perioperative data (post op surgical stay,post op complications according to the Clavien-Dindoscale 14, mortality, clinical cure rate and biochemicalcure rate, follow up time).Results: Five patients underwent BLA. The approachfor the BLA was minimally invasive, either trans peritoneal (n=3) or posterior retroperitoneoscopic (n=2). Meanhospitalization time was 23.4 days (r=4-81). None ofthe patients died because of surgical complications, andall of them achieved biochemical and clinical remissionof their hypercortisolism after surgery.Conclusions: BLA is an effective salvage alternativeto control the symptoms associated with overproductionof corticosteroids in patients with ectopic CS refractoryto medical treatment.(AU)

[Current role of bilateral adrenalectomy in Ectopic Cushing syndrome.] / Rol actual de la adrenalectomía bilateral en el manejo del síndrome de Cushing Ectópico.

OBJECTIVES: The aim of this paper is to describe the clinical features and the perioperative results of the bilateral laparoscopic adrenalectomy (BLA) of salvaje in 5 patients treated for an Ectopic Cushing Syndrome (CS) who were refractory to medical treatment. MATERIALS AND METHODS: We performed a retrospective analysis of the clinical records of our institution. Five BLAs were performed in patients with Ectopic CS refractory to medical treatment during the period from January 2009 and June 2017. All patients were evaluated by a multidisciplinary team that jointly decided the most appropriate time for surgery. The following protocol data were analyzed: age, sex, location of the secreting tumor, duration of hypercortisolism, reason for hospitalization, initial therapeutic management), biochemical data (pre-op serum cortisol, plasma ACTH and free urinary cortisol), surgical data (surgical approach, surgical time, type of surgery, need for conversion toopen surgery), perioperative data (post op surgical stay, post op complications according to the Clavien-Dindo scale 14, mortality, clinical cure rate and biochemical cure rate, follow up time). RESULTS: Five patients underwent BLA. The approach for the BLA was minimally invasive, either trans peritoneal (n=3) or posterior retroperitoneoscopic (n=2). Mean hospitalization time was 23.4 days (r=4-81). None of the patients died because of surgical complications, and all of them achieved biochemical and clinical remission of their hypercortisolism after surgery. CONCLUSIONS: BLA is an effective salvage alter native to control the symptoms associated with overproduction of corticosteroids in patients with ectopic CS refractory to medical treatment.

OBJETIVO: Describir las características clínicas y los resultados perioperatorios de la adrenalectomía bilateral laparoscópica (ABL) en 5 pacientes tratados con diagnóstico de Síndrome de Cushing Ectópico (SCE).MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo y descriptivo de todos los pacientes con SCE sometidos a una ABL, entre enero de 2009 y junio de 2017. Todos los pacientes fueron evaluados por un equipo multidisciplinario que decidió conjuntamente el momento más adecuado para la cirugía. Fueron analizados los siguientes datos protocolares: edad, sexo, origen del tumor secretor, duración del hipercortisolismo, motivo de internación, manejo terapéutico inicial, datos bioquímicos (cortisol sérico preoperatorio, ACTH plasmática y cortisol libre urinario), datos quirúrgicos (vía de abordaje, tiempo quirúrgico, tipo de cirugía, necesidad de conversión a cirugía abierta), datos perioperatorios (tiempo de internación postoperatoria, complicaciones según la escala de Clavien-Dindo, mortalidad, tasa de curación clínica y tasa de curación bioquímica, tiempo de seguimiento). RESULTADOS: Cinco pacientes fueron sometidos a ABL. El abordaje fue mínimamente invasivo, ya sea transperitoneal (n=3) o retroperitoneoscópico posterior (n=2). El tiempo de internación fue de 23,4 días (r=4-81). Ningún paciente falleció por complicaciones quirúrgicas, y todos lograron la curación bioquímica y clínica de su hipercortisolismo después de la cirugía. CONCLUSIONES: ABL es un procedimiento de rescate eficaz para controlar los síntomas asociados al hipercortisolismo en pacientes con SCE refractario al tratamiento médico.

Treatment for postchemoradiotherapy hypopharyngeal stenosis: Pharyngoesophageal bypass using an anterolateral thigh flap-A case report.

Radiation-induced pharyngoesophageal stenosis is a frequent and unwanted consequence of nonsurgical treatment of hypopharyngeal carcinomas. Current treatment mainly includes endoscopic dilatations, but a poor response to this modality and/or a severe stenosis may lead to a radical resection (pharyngolaryngectomy) and reconstruction with tubed flaps, which allow oral feeding but fail to preserve speech. In this report, we present a case of radiation-induced hypopharyngeal stenosis treated with a pharyngoesophageal bypass using an anterolateral thigh (ALT) flap with the intention of preserving the larynx. We describe the case of a 59-year-old male with severe pharyngoesophageal stenosis after chemoradiotherapy due to a squamous cell carcinoma, where conventional dilatation treatment failed to restore pharyngoesophageal passage of solids or liquids. Since the patient rejected a pharyngolaryngectomy due the loss of speech entailed, a pharyngoesophageal bypass was performed using an ALT flap. The flap measured 13 × 20 cm, which ensured a 4-cm-diameter tube and enough length to communicate the lateral pharyngeal wall with the cervical esophagus. Endoscopy did not reveal flap failure, and during the immediate postoperative period, the patient had a small cervical leak detected only by imaging that did not affect the skin and resolved with antibiotic treatment. The patient also required a tracheostomy on day 4 and initially had no passage of saliva through the bypass; we attributed this to edema that resolved spontaneously after 1 month with complete liquid and solid passage and laryngeal competence that led to tracheal decannulation. Good functional results were achieved both for speech and swallowing at 5-year follow-up. We believe that this procedure may be considered before performing a pharyngolaryngectomy for the treatment of a persistent benign stenosis in patients with a functional larynx.

Pneumo-PET-CT: Initial Results of This Novel Technique on the Evaluation of Esophageal and Gastric Tumors with Anatomic-Surgical Correlation.

We present the initial results of a novel hybrid scanning-based technique that combines pneumo-computed tomography (PNCT) with positron emission tomography (PET) using 2-(fluorine-18) fluoro-2-deoxy-D-glucose (FDG). We denominate it pneumo-PET-CT. The focus of our discussion will be on the description of the pneumo-PET-CT technique and the interpretation criteria with emphasis on its benefits and applications in the presurgical and postneoadjuvant therapy evaluation of esophageal, esophagogastric junction (EGJ), and gastric tumors.

Venous Malformation of the Esophagus.

Venous malformations are an extremely infrequent condition in the gastrointestinal tract, particularly in the esophagus. We report a rare case of an adult with an asymptomatic mass located in the mediastinum and in whom the diagnosis and treatment of a venous malformation of the esophagus was performed through a thoracoscopic approach. When dealing with a hypervascularized submucosal esophageal tumor, venous malformations can be among the differential diagnoses.

Intussusception as a complication of bariatric surgery in pregnant patients: report of one case and revision of the literature.

Occlusive complications after a laparoscopic Roux-in Y gastric bypass (LRYGB), appear mainly as fibrous membranes of wounds, internal hernias or intussusception. Intussusception after a bariatric surgery occurs in 0.1-0.3% of the cases. We present a case of intussusception in a pregnant patient after a LRYGB.

Esophageal adenocarcinoma five years after laparoscopic sleeve gastrectomy. A case report.

INTRODUCTION: Laparoscopic sleeve gastrectomy has become the most popular bariatric procedure worldwide. However, postoperative gastroesophageal reflux disease appearance is a matter of concern. Only two cases of esophageal adenocarcinoma after gastric sleeve have been described, none of them with preoperative endoscopic evaluation. PRESENTATION OF CASE: We report a case of a 48-year-old male with morbid obesity and normal preoperative endoscopy and esophagram who underwent a laparoscopic sleeve gastrectomy and developed an esophageal adenocarcinoma five years later. DISCUSSION: Despite promising results in terms of weight loss and resolution of comorbidities, the onset or worsening of gastroesophageal reflux and its related complications, such as Barrett's esophagus or esophageal adenocarcinoma, is a matter of concern and need further study. CONCLUSION: We present a case of an esophageal adenocarcinoma five years after a laparoscopic sleeve gastrectomy for morbid obesity. There is need to better determine the relationship between sleeve gastrectomy and gastroesophageal reflux disease in order to prevent its related complications, such as esophageal adenocarcinoma.

Manejo clínico y quirúrgico de los feocromocitomas y paragangliomas / Clinical and surgical management of pheochromocytomas and paragangliomas

Los feocromocitomas y paragangliomas (Feo/PGL) son tumores neurendocrinos raros con diferentes presentaciones clínicas, asociados a alta morbimortalidad. Reconocer los signos y síntomas es el paso diagnóstico inicial. Las metanefrinas fraccionadas urinarias tienen una excelente sensibilidad y especificidad. La tomografía computarizada (TC) es el método de elección para su localización. La tomografía por emisión de positrones (PET) con F18-fluordeoxiglucosa (F18-FDG) es el método funcional recomendado para detectar metástasis. La resección quirúrgica constituye la única opción curativa en estos pacientes. La adrenalectomía laparoscópica es la vía de abordaje para la mayoría los Feo/PGL. El tratamiento farmacológico, 7 a 14 días previos con alfabloqueantes y betabloqueantes, tiene como objetivo normalizar la presión arterial y prevenir complicaciones cardiovasculares periquirúrgicas. Se conoce que al menos un tercio de los pacientes presentan una mutación genética germinal. El estudio genético debe estar orientado a las características sindrómicas, formas de presentación, localización y fenotipo bioquímico del tumor. Se recomienda el abordaje interdisciplinario en centros especializados con experiencia en esta patología poco frecuente. (AU)

Pheochromocytomas and paragangliomas are rare neuroendocrine tumors with different clinical manifestation associated with high morbidity and mortality. Recognize signs and symptoms is the first step in diagnosis. Urinary fractionated metanephrines have an excellent specificity and sensitivity. Computed Tomography (CT) is the first-choice imaging modality for location. F18-DG positron tomography (PET)/CT scanning is the functional modality of choice for metastatic disease. Surgery is the only curative treatment. Minimally invasive adrenalectomy is the surgical approach for most adrenal pheochromocytomas. Perioperative alpha and beta blockade for 7 to 14 days normalize blood pressure and prevent perioperative cardiovascular complications. Is recognize that at least one-third of the patients have disease-causing germline mutations. Genetic testing must be orientated to syndromic features, presentation, localization and biochemical profile of these tumors. Multidisciplinary teams at centers with appropriate expertise are recommended to ensure a favorable outcome. (AU)

Management of early-stage esophageal neoplasia (MESEN) consensus.

BACKGROUND: Treatment of esophageal adenocarcinoma often involves surgical resection. Newer technologies in interventional endoscopy have led to a substantial paradigm shift in the management of early-stage neoplasia in Barrett's esophagus comprising high-grade dysplasia (HGD), intramucosal carcinoma, and, in some cases, submucosal carcinoma. However, there has been no consensus regarding the indications for esophageal preservation in these cases. In this work, consensus guidelines were established for the management of early-stage esophageal neoplasia considering clinically relevant aspects (age, comorbidities, and social environment) in each scenario. METHODS: Seventeen experts were invited to participate based on their background and clinical expertise at high-volume centers. A questionnaire was created that included four clinical scenarios covering a wide range of situations within HGD and/or early esophageal neoplasia, particularly where controversies are likely to exist. Each of the clinical scenarios was open to discussion subdivided by patient age (20, 50, and 80 s). For each clinical scenario an expert was chosen to defend that position. Each defense triggered a subsequent discussion during a consensus meeting. Conclusions of that discussion together with an accompanying literature analysis allowed experts to confirm or change their original choices and served as the basis for the recommendations stated in this article. RESULTS: There was 100 % consensus supporting esophageal preservation in patients with HGD, independent of patient age or Barrett's length. In patients with T1a adenocarcinoma, consensus for preservation was not reached (65 %) for young and middle-aged individuals but was supported for elderly patients (100 %). For T1b adenocarcinoma, consensus was reached for surgical resection (90 %), leaving organ preservation for patients with very low risk of nodal invasion or poor surgical candidates. CONCLUSION: Advances in endoscopic imaging and therapy allow for organ preservation in most settings of early-stage neoplasia of the esophagus, provided that the patient understands the implications of this decision.

Pneumo-CT assessing response to neoadjuvant therapy in esophageal cancer: Imaging-pathological correlation.

Pneumo-computed tomography (PnCT) is a technique primarily developed and used to study stenotic lesions of the esophagus, gastroesophageal junction and stomach for pre-surgical planning. It helps to define both upper and lower borders of neoplasms located in the aforementioned areas. It achieves maximum lumen distension with CO2 highlighting thickened areas of the esophageal wall, thus allowing an accurate quantification of their extents. Although there are other alternatives for distension (oral contrast agents, water and effervescent granules), they may be suboptimal. Patients with locally advanced esophageal cancer have a dismal prognosis despite surgical resection. Therefore, neoadjuvant treatment strategies using radiation therapy and chemotherapy were developed to improve survival. Neoadjuvant therapy improves esophageal tumor prognosis in a substantial proportion of patients, and the use of imaging techniques is mandatory to detect their response. PnCT combined with virtual endoscopy and multiplanar reconstruction enhances morphologic details in esophageal cancer, and thus would allow an improved assessment of response to neoadjuvant treatment. Therefore, more information could be provided to assess the efficacy of pre-surgical treatment. We describe the potential use of PnCT to assess the response to neoadjuvant therapy in esophageal cancer with an imaging pathologic correlation.

Outcomes of esophageal surgery, especially of the lower esophageal sphincter.

This paper includes commentaries on outcomes of esophageal surgery, including the mechanisms by which fundoduplication improves lower esophageal sphincter (LES) pressure; the efficacy of the Linx™ management system in improving LES function; the utility of radiologic characterization of antireflux valves following surgery; the correlation between endoscopic findings and reported symptoms following antireflux surgery; the links between laparoscopic sleeve gastrectomy and decreased LES pressure, endoscopic esophagitis, and gastroesophageal reflux disease (GERD); the less favorable outcomes following fundoduplication among obese patients; the application of bioprosthetic meshes to reinforce hiatal repair and decrease the incidence of paraesophageal hernia; the efficacy of endoluminal antireflux procedures, and the limited efficacy of revisional antireflux operations, underscoring the importance of good primary surgery and diligent work-up to prevent the necessity of revisional procedures.

Esophageal cancer characterization with pneumo-64-MDCT.

Early diagnosis and accurate staging of esophageal cancer are both essential for therapeutic strategy planning. Endoscopic ultrasound, CT, and positron emission tomography have all been used in the preoperative staging of esophageal cancer separately or in various combinations. Each imaging method has its strengths and weaknesses. Depiction of the tumor's anatomic location conditions the surgical strategy. Endoscopic ultrasound and PET have important advantages but neither provides information for surgical planning. CT scans have some limitations for hollow organ assessment in the absence of lumen distension, since the organ wall may be collapsed. Therefore, optimal esophageal distension could be very useful to overcome these limitations. This potential drawback is crucial at the level of the GE junction, a typically difficult region to evaluate. In order to optimize tumor visualization in the esophageal wall and in the GE junction, we developed a technique named pneumo-64-MDCT. We achieve maximum lumen distension, which better highlights the thickened areas in relation to the normal esophageal wall. At the present time, we have performed 200 studies with this technique and it proved useful, safe and accurate to identify esophageal wall thickening and to stage esophageal cancer. The additional stomach distension led to an adequate definition of both the upper and lower borders of the lesion in tumors located in the GE junction, which in turn was helpful to design the surgical approach.

Ileocolic intussusception due to intestinal metastatic melanoma. Case report and review of the literature.

The small intestine is a frequent site of melanoma metastases and the most common cause of secondary intestinal tumors. Even though, its presentation with intestinal obstruction due to intussusception is very rare. We present a 47-year-old woman with a medical history of facial melanoma operated 17 years ago and recently diagnosed of cervical recurrence who complained of abdominal pain of one week duration accompanied with vomiting and abdominal distension. Computed tomography (CT) scan revealed marked distension of the small intestine with features suggesting intussusception of the distal ileum. At laparoscopic exploration a massive ileocolic intussusception was found with invagination of the last 60 cm of ileum inside the cecum and ascending colon. Surgical reduction revealed a tumor of approximately 2 cm in the distal end of the intussuscepted intestine acting as the lead point. Resection of non-viable ileum along with the tumor and end-to-end anastomosis was performed. Many other lesions of smaller size were found distantly in the proximal small bowel but were not treated. The patient had a full recovery and was discharged three days after surgery. Pathological examination showed metastatic melanoma and a positron emission tomography (PET) scan confirmed disseminated disease with brain metastasis. The patient died three months after surgery. Intestinal occlusion due to metastatic disease is a rare condition but should be taken into account particularly in patients with history of cancer. Surgical intervention with a mini-invasive laparoscopic approach is feasible. Intestinal resection and anastomosis is mandatory for either curative or palliative intentions providing a satisfactory treatment.

[Gastrointestinal bleeding and intestinal perforation due to polyarteritis nodosa in a patient with celiac disease. A case report]. / Hemorragia digestiva y perforación intestinal secundarias a panarteritis nodosa en un paciente con enfermedad celiaca. Presentación de un caso.

Complications of celiac disease could present with intestinal perforation and rarely, gastrointestinal bleeding, which are usually secondary to nongranulomatous ulcerative jejunoileitis or T-cell lymphoma. We describe the case of a 66-year-old male patient with an 8-year history of celiac disease (CD) who presented with recurrent abdominal pain and gastrointestinal bleeding. Several tests were performed to find out possible complications associated to CD. Due to an overt gastrointestinal bleeding, an arteriography was performed and signs of polyarteritis nodosa were found. Vascular disease was aggressive, and despite multiple medical and surgical treatments the patient died. As arteriography is not usually performed for the study of the complications of CD, it is possible that the association between CD and PAN has been underdiagnosed.

[Usefulness of Pneumo-64-MDCT in the presurgical evaluation of esophageal cancer]. / Utilidad de la neumotomografia multislice 64 en la evaluación prequirúrgica del cáncer esofágico.

BACKGROUND: Pre-surgical characterization and staging of esophageal and esophagogastric union cancer with only one imaging method could be useful for the therapeutic strategy. OBJECTIVE: 1) To evaluate the sensitivity of Pneumo-64-MSCT (PnCT64) in the diagnosis of esophageal-cardial wall thickening in correlation with anatomopathological and postsurgical findings. 2) To evaluate the usefulness of gastric distension in the presurgical planning of esophageal cancer, especially those located in the gastroesophageal junction. METHODS: Twenty-four patients with endoscopic diagnosis of esophageal and cardial cancer were prospectively studied with PnCT64 before surgery. CT's were performed with a 64 row CT scanner and in order to achieve esophageal distension, CO2 was instilled with an automated insufflator through a Foley catheter. Mural thickening was evaluated as well as its scope, shape and anatomic location by using different type of reconstructions. PnCT64 findings were correlated with anatomopathological staging. RESULTS: In 21 patients an asymmetric wall thickening was observed with a sensitivity of 86.4% in correlation with anatomopathological findings. Adequate gastroesophageal distension defining the limits of the lesions was achieved in all patients. CONCLUSION: PnCT64 showed high sensitivity in the diagnosis of esophageal and cardial thickening. Gastric distension proved to be useful for the presurgical evaluation defining both upper and lower borders of the tumors located in the gastroesophageal junction.