¿Está la cirugía académica en jaque? Visión acerca de los cirujanos/as del futuro

La cirugía académica requiere de un compromiso mayor comparado a la práctica quirúrgica fuera de centros académicos. Es mucho mas demandante por la carga docente y de investigación que involucra aparte de la labor asistencial, lo cual provoca conflictos en la relación laboral, familiar y desarrollo profesional integral. Las futuras generaciones tienen aspiraciones y visiones diferentes de cómo enfrentar el trabajo diario sin descuidar la calidad de vida. En este articulo se analizan los diferentes factores que afectan este equilibrio y como se espera que se manejará el escenario laboral en los próximos años.

Academic surgery requires a greater commitment compared to surgical practice outside academic centers. It is much more demanding due to the teaching and research load that it involves apart from the care work, which causes conflicts in the work, family relationship and comprehensive professional development. Future generations have different aspirations and visions of how to face daily work without neglecting quality of life. This article analyzes the different factors that affect this balance and how the labor scenario is expected to be managed in the coming years.

Novedades en la evaluación y tratamiento de la obstrucción intestinal alta

La obstrucción intestinal mecánica es un problema quirúrgico significativo en términos de prevalencia, morbimortalidad y costos económicos asociados. En los últimos años se han realizado avances en: detectar mecanismos fisiopatológicos del desarrollo de adherencias, optimizar el diagnóstico de pacientes aptos para manejo conservador, valorar la utilidad intraoperatoria de herramientas que definan la necesidad de resección intestinal y hallar terapias preventivas. El objetivo de esta revisión narrativa es sintetizar la evidencia científica actualizada, publicada referente al diagnóstico y tratamiento de una obstrucción intestinal alta mecánica.

Mechanical small bowel obstruction is a significant surgical problem in terms of prevalence, morbimortality, and associated economic costs. In recent years, advances have been made in: detection of physio pathological mechanisms of adhesion genesis, improvement in diagnosis of patients suitable for conservative treatment, assessment the efficacy of intraoperative tools that define the need for intestinal resection, and development of preventive therapies. The objective of this narrative review is to synthesize the updated scientific evidence published, regarding the diagnosis and treatment of mechanical small bowel obstruction.

CLINICAL AND SURGICAL DILEMMAS IN OCTOGENARIAN PATIENTS WITH SMALL BOWEL OBSTRUCTION.

BACKGROUND: Small bowel obstruction (SBO) is a major problem in emergencies. Comorbidities increase morbimortality, which is reflected in higher costs. There is a lack of Latin American evidence comparing the differences in postoperative results and costs associated with SBO management. AIMS: To compare the risk of surgical morbimortality and costs of SBO surgery treatment in patients older and younger than 80 years. METHODS: Retrospective analysis of patients diagnosed with SBO at the University of Chile Clinic Hospital from January 2014 to December 2017. Patients with any medical treatment were excluded. Parametric statistics were used (a 5% error was considered statistically significant, with a 95% confidence interval). RESULTS: A total of 218 patients were included, of which 18.8% aged 80 years and older. There were no differences in comorbidities between octogenarians and non-octogenarians. The most frequent etiologies were adhesions, hernias, and tumors. In octogenarian patients, there were significantly more complications (46.3 vs. 24.3%, p=0.007, p<0.050). There were no statistically significant differences in terms of surgical complications: 9.6% in <80 years and 14.6% in octogenarians (p=0.390, p>0.050). In medical complications, a statistically significant difference was evidenced with 22.5% in <80 years vs 39.0% in octogenarians (p=0.040, p<0.050). There were 20 reoperated patients: 30% octogenarians and 70% non-octogenarians without statistically significant differences (p=0.220, p>0.050). Regarding hospital stay, the average was significantly higher in octogenarians (17.4 vs. 11.0 days; p=0.005, p<0.050), and so were the costs, being USD 9,555 vs. USD 4,214 (p=0.013, p<0.050). CONCLUSIONS: Patients aged 80 years and older with surgical SBO treatment have a higher risk of medical complications, length of hospital stay, and associated costs compared to those younger.

Clinical and surgical dilemmas in octogenarian patients with small bowel obstruction / Dilemas clínicos e cirúrgicos em pacientes octogenários com obstrução do intestino delgado

ABSTRACT BACKGROUND: Small bowel obstruction (SBO) is a major problem in emergencies. Comorbidities increase morbimortality, which is reflected in higher costs. There is a lack of Latin American evidence comparing the differences in postoperative results and costs associated with SBO management. AIMS: To compare the risk of surgical morbimortality and costs of SBO surgery treatment in patients older and younger than 80 years. METHODS: Retrospective analysis of patients diagnosed with SBO at the University of Chile Clinic Hospital from January 2014 to December 2017. Patients with any medical treatment were excluded. Parametric statistics were used (a 5% error was considered statistically significant, with a 95% confidence interval). RESULTS: A total of 218 patients were included, of which 18.8% aged 80 years and older. There were no differences in comorbidities between octogenarians and non-octogenarians. The most frequent etiologies were adhesions, hernias, and tumors. In octogenarian patients, there were significantly more complications (46.3 vs. 24.3%, p=0.007, p<0.050). There were no statistically significant differences in terms of surgical complications: 9.6% in <80 years and 14.6% in octogenarians (p=0.390, p>0.050). In medical complications, a statistically significant difference was evidenced with 22.5% in <80 years vs 39.0% in octogenarians (p=0.040, p<0.050). There were 20 reoperated patients: 30% octogenarians and 70% non-octogenarians without statistically significant differences (p=0.220, p>0.050). Regarding hospital stay, the average was significantly higher in octogenarians (17.4 vs. 11.0 days; p=0.005, p<0.050), and so were the costs, being USD 9,555 vs. USD 4,214 (p=0.013, p<0.050). CONCLUSIONS: Patients aged 80 years and older with surgical SBO treatment have a higher risk of medical complications, length of hospital stay, and associated costs compared to those younger.

RESUMO RACIONAL: A obstrução do intestino delgado (OID) é um grande problema em emergências. As comorbidades aumentam a morbimortalidade, o que se reflete no aumento dos custos. Há uma falta de evidência latino-americana comparando as diferenças nos resultados pós-operatórios e custos associados ao manejo da OID. OBJETIVOS: Comparar o risco de morbimortalidade cirúrgica e os custos de tratamento cirúrgico da OID em pacientes com idade inferior e superior a 80 anos. MÉTODOS: Análise retrospectiva de pacientes diagnosticados com OID no Hospital Clínico da Universidade do Chile entre janeiro de 2014 e dezembro de 2017. Pacientes com qualquer tratamento médico foram excluídos. Estatísticas paramétricas foram usadas: erro de 5% foi considerado estatisticamente significante, com intervalo de confiança de 95%. RESULTADOS: Um total de 218 pacientes foram incluídos, dos quais 18,8% tinham 80 anos ou mais. Não houve diferenças nas comorbidades entre octogenários e não octogenários. As etiologias mais frequentes foram aderências, hérnias e tumores. Nos pacientes octogenários houve significativamente mais complicações (46,3 vs. 24,3%, p=0,007, p<0,050). Não houve diferenças estatisticamente significativas quanto às complicações cirúrgicas: 9,6% em <80 anos e 14,6% em octogenários (p=0,390, p>0,050). Nas complicações médicas foi evidenciada diferença estatisticamente significativa com 22,5% em <80 anos vs. 39.0% em octogenários (p=0,040, p<0,050). Foram reoperados 20 pacientes: 30% octogenários e 70% não octogenários, sem diferenças estatisticamente significativas (p=0,220, p>0,050). Em relação ao tempo de internação, a média foi significativamente maior nos octogenários (17,4 v/s 11,0 dias; p=0,005, p<0,050). Da mesma forma, também foram os custos com 9.555 USD vs. 4.214 USD (p=0,013, p<0,050). CONCLUSÕES: Pacientes com 80 anos ou mais com tratamento cirúrgico de OID têm maior risco de complicações médicas, tempo de internação e custos associados em comparação aos mais jovens.

Enfrentamiento ante filtraciones de la esófagoyeyuno anastomosis

La filtración de la esófagoyeyuno anastomosis (FEYA) es una de las complicaciones más graves tras una gastrectomía total, ya que se asocia a un aumento de la morbimortalidad quirúrgica. El manejo óptimo de la FEYA aún es controversial, existiendo cada vez más opciones mínimamente invasivas, especialmente endoscópicas. El objetivo de la presente revisión es comparar la evidencia científica publicada y actualizada referente al tratamiento médico, endoscópico y quirúrgico de una FEYA y sus resultados a corto y largo plazo además de proponer un algoritmo de manejo que permita orientar la práctica clínica. Finalmente se presenta la experiencia nacional en relación a los avances presentados en los últimos años en torno manejo clínico de FEYA.

Leakage of the esophagojejunostomy (LEY) is one of the most serious complications after total gastrectomy, as it is associated with increased surgical morbidity and mortality. The optimal management of LEY is still controversial, with increasing minimally invasive options, especially endoscopic ones. The aim of this review is to compare the published and updated scientific evidence regarding the medical, endoscopic and surgical treatment of LEY and its short and long-term results, in addition to propose a management algorithm that allows guiding clinical practice. Finally, the national experience is presented in relation to the advances presented in recent years regarding clinical management of LEY.

TOMOGRAPHIC SARCOPENIA PREDICTS ANASTOMOTIC LEAKS AND LONG-TERM SURVIVAL IN GASTRIC CANCER PATIENTS OPERATED WITH CURATIVE INTENT.

BACKGROUND: The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field. AIMS: This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent. METHODS: This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool "propagate segmentation", and all muscle seen in the image was manually adjusted. RESULTS: We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76-0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04-8.15). CONCLUSIONS: Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.

Tomographic sarcopenia predicts anastomotic leaks and long-term survival in gastric cancer patients operated with curative intent / Sarcopenia tomográfica prevê fístulas de anastomoses e sobrevida a longo prazo em pacientes com câncer gástrico operados com intenção curativa

ABSTRACT BACKGROUND: The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field. AIMS: This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent. METHODS: This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool "propagate segmentation", and all muscle seen in the image was manually adjusted. RESULTS: We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76-0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04-8.15). CONCLUSIONS: Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.

RESUMO RACIONAL: O estado nutricional pré-operatório tem valor prognóstico pós-operatório. A densidade tomográfica e a área do músculo psoas é uma ferramenta validada para o estado nutricional. Existem poucos estudos avaliando a utilidade da tomografia de estadiamento em pacientes com câncer gástrico neste campo. OBJETIVOS: Determinar a influência da sarcopenia, medida por tomografia computadorizada de estadiamento pré-operatório, na morbimortalidade pós-operatória e sobrevida em longo prazo em pacientes operados de câncer gástrico com intenção curativa. MÉTODOS: Estudo retrospectivo de 2007 a 2013. A definição de sarcopenia radiológica foi pela medida da área (PA) e densidade do músculo psoas (PD) a nível de L3 (Terceira vertebra lombar), em um corte axial de tomografia computadorizada abdominopélvica (na seleção sem meio de contraste intravascular). O Software utilizado foi o OsirixX v 10.0.2, com a ferramenta "propagar segmentação", ajustando manualmente todos os músculos vistos na imagem. RESULTADOS: Foram incluídos 70 pacientes, 77% homens, PA média em L3: 16,6 cm2 (desvio padrão+6,1), PD média em L3: 36,1 mean muscle density (desvio padrão+7,1). Os cânceres avançados foram de 86, 28,6% tinham células em anel de sinete, 78,6% necessitaram de gastrectomia total, a morbidade e mortalidade cirúrgica pós-operatória foi de 22,8 e 2,8%, respectivamente, a sobrevida global de 5 anos a longo prazo (SV5) foi de 57,1%. Na análise multivariada, PA falhou em prever morbidade cirúrgica (p=0,4) e sobrevida global de 5 anos (p=0,34), enquanto PD foi capaz de prever fístulas anastomóticas (p=0,009; OR 0,86; IC95% 0,76-0,96) e SV5 (p=0,04; OR 2,9; IC95% 1,04-8,15). CONCLUSÕES: O diagnóstico tomográfico de sarcopenia por desvio padrão é capaz de predizer fístulas anastomóticas e sobrevida a longo prazo em pacientes com câncer gástrico tratados com intenção curativa.

Endoscopic ablation combined with fundoplication plus acid suppression-duodenal diversion procedure for long segment barrett´s esophagus: early and long-term outcome / Ablação endoscópica combinada com fundoplicatura associada a diversão duodenal no esôfago de barrett longo: resultados precoce e de longo prazo

ABSTRACT BACKGROUND: The addition of endoscopic ablative therapy plus proton pump inhibitors or fundoplication is postulated for the treatment of patients with long-segment Barrett´s esophagus (LSBE); however, it does not avoid acid and bile reflux in these patients. Fundoplication with distal gastrectomy and Roux-en-Y gastrojejunostomy is proposed as an acid suppression-duodenal diversion procedure demonstrating excellent results at long-term follow-up. There are no reports on therapeutic strategy with this combination. AIMS: To determine the early and long-term results observed in LSBE patients with or without low-grade dysplasia who underwent the acid suppression-duodenal diversion procedure combined with endoscopic therapy. METHODS: Prospective study including patients with endoscopic LSBE using the Prague classification for circumferential and maximal lengths and confirmed by histological study. Patients were submitted to argon plasma coagulation (21) or radiofrequency ablation (31). After receiving treatment, they were monitored at early and late follow-up (5-12 years) with endoscopic and histologic evaluation. RESULTS: Few complications (ulcers or strictures) were observed after the procedure. Re-treatment was required in both groups of patients. The reduction in length of metaplastic epithelium was significantly better after radiofrequency ablation compared to argon plasma coagulation (10.95 vs 21.15 mms for circumferential length; and 30.96 vs 44.41 mms for maximal length). Intestinal metaplasia disappeared in a high percentage of patients, and histological long-term results were quite similar in both groups. CONCLUSIONS: Endoscopic procedures combined with fundoplication plus acid suppression with duodenal diversion technique to eliminate metaplastic epithelium of distal esophagus could be considered a good alternative option for LSBE treatment.

RESUMO RACIONAL: A adição de terapia ablativa endoscópica associado a inibidores da bomba de prótons ou fundoplicatura tem sido postulada para o tratamento de pacientes com esôfago de Barrett de segmento longo (EBSL), no entanto, essa conduta não evita o refluxo ácido/biliar nesses pacientes. A fundoplicatura com gastrectomia distal e gastrojejunostomia em Y de Roux (FGD-Y) foi proposta como procedimento de supressão de ácido, demonstrando excelentes resultados no seguimento a longo prazo. Não há relatos na literature com a combinação dessa estratégia terapêutica. OBJETIVOS: Determinar os resultados precoces e a longo prazo observados em pacientes com EBSL com ou sem dysplasia de baixo grau, submetidos a FGD-Y, combinado com terapia endoscópica. MÉTODOS: Estudo prospectivo incluindo pacientes com EBSL, empregando a classificação de Praga, sendo o comprimento circunferencial (C) e máximo (M) e confirmado por estudo histológico. Os pacientes foram submetidos à coagulação com plasma de argônio (CPA, 21 pacientes) ou ablação por radiofrequência (ARF, 31 pacientes). Após o tratamento, eles foram seguidos precoce e tardiamente (5-12 anos), mediante avaliação endoscópica e histológica. RESULTADOS: Foram observadas poucas complicações após o procedimento (úlcera ou estenose). Re-tratamento foi necessário em ambos os grupos de pacientes. A redução do comprimento do epitélio metaplásico foi significativamente melhor após ARF em comparação com CPA (10,95 versus 21,15 mm para C e 30,96 versus 44,41 mm para M). A metaplasia intestinal desapareceu em elevada porcentagem de pacientes, e os resultados histológicos a longo prazo foram bastante semelhantes em ambos os grupos. CONCLUSÕES: Procedimentos endoscópicos combinados com fundoplicatura e gastrectomia distal e gastrojejunostomia em Y de Roux, para eliminar o epitélio metaplásico do esôfago distal podem ser considerados uma boa opção alternativa para o tratamento da EBSL.

LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION.

BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

RISK FACTORS FOR REOPERATION, MORBIDITY, AND MORTALITY IN PATIENTS WITH SMALL BOWEL OBSTRUCTION SUBMITTED TO SURGICAL TREATMENT.

AIM: Small bowel obstruction (SBO) is a frequent cause of emergency department admissions. This study aimed to determine risk factors of reoperations, postoperative adverse event, and operative mortality (OM) in patients surgically treated for SBO. METHODS: This is a retrospective study conducted between 2014 and 2017. Exclusion criteria include gastric outlet obstruction, large bowel obstruction, and incomplete clinical record. STATA version 14 was used for statistical analysis, with p-value <0.05 with 95% confidence interval considered statistically significant. RESULTS: A total of 218 patients were included, in which 61.9% were women. Notably, 88.5% of patients had previous abdominal surgery. Intestinal resection was needed in 28.4% of patients. Postoperative adverse event was present in 28.4%, reoperation was needed in 9.2% of cases, and a 90-day surgical mortality was 5.9%. Multivariate analysis determined that intestinal resection, >3 days in intensive care unit (ICU), >7 days with nasogastric tube (NGT), pain after postoperative day 3, POAE, and surgical POAE were the risk factors for reoperations, while age, C-reactive protein, intestinal resection, >3 days in ICU, and >7 days with NGT were the risk factors for POAE. OM was determined by >5 days with NGT and POAE. CONCLUSIONS: Postoperative course is determined mainly for patient's age, preoperative level of C-reactive protein, necessity of intestinal resection, clinical postoperative variables, and the presence of POAE.

Risk factors for reoperation, morbidity, and mortality in patients with small bowel obstruction submitted to surgical treatment / Fatores de risco para reoperação e morbimortalidade em pacientes com obstrução de intestino delgado submetidos a tratamento cirúrgico

ABSTRACT - BACKGROUND: Small bowel obstruction (SBO) is a frequent cause of emergency department admissions. AIM: This study aimed to determine risk factors of reoperations, postoperative adverse event, and operative mortality (OM) in patients surgically treated for SBO. METHODS: This is a retrospective study conducted between 2014 and 2017. Exclusion criteria include gastric outlet obstruction, large bowel obstruction, and incomplete clinical record. STATA version 14 was used for statistical analysis, with p-value <0.05 with 95% confidence interval considered statistically significant. RESULTS: A total of 218 patients were included, in which 61.9% were women. Notably, 88.5% of patients had previous abdominal surgery. Intestinal resection was needed in 28.4% of patients. Postoperative adverse event was present in 28.4%, reoperation was needed in 9.2% of cases, and a 90-day surgical mortality was 5.9%. Multivariate analysis determined that intestinal resection, >3 days in intensive care unit (ICU), >7 days with nasogastric tube (NGT), pain after postoperative day 3, POAE, and surgical POAE were the risk factors for reoperations, while age, C-reactive protein, intestinal resection, >3 days in ICU, and >7 days with NGT were the risk factors for POAE. OM was determined by >5 days with NGT and POAE. CONCLUSIONS: Postoperative course is determined mainly for patient's age, preoperative level of C-reactive protein, necessity of intestinal resection, clinical postoperative variables, and the presence of POAE.

RESUMO - RACIONAL: A obstrução do intestino delgado (OID) é uma causa frequente de admissões ao Serviço de Emergência. OBJETIVO: Determinar os fatores de risco de reoperações, eventos adversos pós-operatórios e mortalidade operatória (MO) em pacientes com OID tratados cirurgicamente. MÉTODOS: Estudo retrospectivo entre 2014 e 2017. Critérios de exclusão: obstrução da saída do estômago, obstrução do intestino grosso e história clínica incompleta. O STATA 14 foi utilizado para análise estatística, considerando significância estatística p<0,05 com IC de 95%. RESULTADOS: Duzentos e dezoito pacientes foram incluídos, 61,9% mulheres, 88,5% dos pacientes tinham cirurgia abdominal anterior. A ressecção intestinal foi necessária em 28,4% dos pacientes. O evento adverso pós-operatório (EAPO) esteve presente em 28,4%, a reoperação foi necessária em 9,2% dos casos e a mortalidade cirúrgica em 90 dias foi de 5,9%. A análise multivariada determinou que a ressecção intestinal, > 3 dias em UTI, > 7 dias com sonda nasogástrica (SNG), dor após o 3º dia de pós-operatório, EAPO cirúrgico foram fatores de risco para reoperações, enquanto idade, proteína C reativa, ressecção intestinal, > 3 dias em UTI, > 7 dias com SNG foram fatores de risco para EAPO. A MO foi determinada em > 5 dias com SNG e EAPO. CONCLUSÕES: A evolução pós-operatória é determinada principalmente pela idade do paciente, nível pré-operatório de proteína C reativa, necessidade de ressecção intestinal, variáveis clínicas pós-operatórias e presença de EAPO.

Laparoscopic redo fundoplication alone, redo nissen fundoplication, or toupet fundoplication combined with roux-en-y distal gastrectomy for treatment of failed nissen fundoplication / Refazer fundoplicatura laparoscópica, refazer fundoplicatura a nissen ou toupet combinada com gastrectomia distal em y-roux para tratamento de recidiva após fundoplicatura a nissen

ABSTRACT BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

RESUMO RACIONAL: A fundoplicatura de Nissen laparoscópica falha em controlar o refluxo gastroesofágico em quase 15% dos pacientes e a maioria deles deve ser reoperada devido aos sintomas. Diferentes técnicas cirúrgicas têm sido sugeridas. OBJETIVOS: Apresentar os resultados pós-operatórios de pacientes submetidos a 3 procedimentos diferentes: Reoperação e fundoplicatura de Nissen laparoscópica apenas (Grupo A), reoperação e fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal (Grupo B) ou reoperação e conversão para Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux (Grupo C). MÉTODOS: estudo prospectivo incluindo 77 pacientes submetidos inicialmente a fundoplicatura de Nissen laparoscópica que apresentaram recidiva do refluxo gastroesofágico após a operação. Eles foram avaliados antes e após a reoperação com questionário clínico e estudos funcionais específicos. Reestabelecida a anatomia da junção esôfago-gástrica, procedeu-se às referidas cirurgias. Nenhum paciente perdeu seguimento. RESULTADOS: Os sintomas persistentes foram observados com maior frequência nos pacientes dos Grupos A ou B, associados à estenose da fundoplicatura, fundoplicatura intratorácico ou fundoplicatura torcida. No Grupo C, os sintomas recorrentes associados a essa alteração anatômica foram observados com pouca frequência. Esfincter esofágico inferior incompetente foi confirmado em 57,7% dos pacientes pertencentes ao Grupo A em comparação com 17,2% após fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal, e 26% após a Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux. Nesse grupo, apesar do alto percentual de pacientes com esfincter esofágico inferior incompetente, 8,7% apresentaram refluxo ácido anormal após a cirurgia. CONCLUSÕES: As técnicas de Nissen ou Toupet combinados com a gastrectomia distal em Y de Roux são seguras e eficazes para o manejo da falha da fundoplicatura a Nissen. A técnica de Toupet é preferível para pacientes que sofrem principalmente com disfagia e dor.

LYMPHOPARIETAL INDEX IN ESOPHAGEAL CANCER IS STRONGER THAN TNM STAGING IN LONG-TERM SURVIVAL PROGNOSIS IN A LATIN-AMERICAN COUNTRY.

BACKGROUND: The identification of prognostic factors of esophageal cancer has allowed to predict the evolution of patients. AIM: Assess different prognostic factors of long-term survival of esophageal cancer and evaluate a new prognostic factor of long-term survival called lymphoparietal index (N+/T). METHOD: Prospective study of the Universidad de Chile Clinical Hospital, between January 2004 and December 2013. Included all esophageal cancer surgeries with curative intent and cervical anastomosis. Exclusion criteria included: stage 4 cancers, R1 resections, palliative procedures and emergency surgeries. RESULTS: Fifty-eight patients were included, 62.1% were men, the average age was 63.3 years. A total of 48.3% were squamous, 88% were advanced cancers, the average lymph node harvest was 17.1. Post-operative surgical morbidity was 75%, with a 17.2% of reoperations and 3.4% of mortality. The average overall survival was 41.3 months, the 3-year survival was 31%. Multivariate analysis of the prognostic factors showed that significant variables were anterior mediastinal ascent (p=0.01, OR: 6.7 [1.43-31.6]), anastomotic fistula (p=0.03, OR: 0.21 [0.05-0.87]), N classification (p=0.02, OR: 3.8 [1.16-12.73]), TNM stage (p=0.04, OR: 2.8 [1.01-9.26]), and lymphoparietal index (p=0.04, RR: 3.9 [1.01-15.17]. The ROC curves of lymphoparietal index, N classification and TNM stage have areas under the curve of 0.71, 0.63 and 0.64 respectively, with significant statistical difference (p=0.01). CONCLUSION: The independent prognostic factors of long-term survival in esophageal cancer are anterior mediastinal ascent, anastomotic fistula, N classification, TNM stage and lymphoparietal index. In esophageal cancer the new lymphoparietal index is stronger than TNM stage in long-term survival prognosis.

El diafragma, el hiato y la unión gastroesofágica / The diaphragm, the hiatus and the gastroesophageal junction

RESUMEN La unión del tubo esofágico con el estómago en lo que denominamos el cardias, su tránsito y relacio nes con el hiato diafragmático, las estructuras fibromembranosas que la fijan y envuelven, la existencia de un esfínter gastroesofágico anatómico y su real morfología, así como la interacción de todos estos elementos, han sido materia de controversia por décadas y aún hoy. Este artículo actualiza la descrip ción de tales estructuras.

ABSTRACT The point where the esophagus connects to the stomach, known as the cardia, its transition and re lationship with the diaphragmatic hiatus, its fibromembranous attachments, the existence of an ana tomic gastroesophageal sphincter and its real morphology, and the interaction between all these ele ments, have been subject of debate for decades that still persist. The aim of this article is to describe the updated information of such structures.

Cirugía laparoscópica con imagen 3D: indicaciones, resultados y evaluación subjetiva y objetiva de cirujanos participantes / Laparoscopic surgery with 3D image: indications, results and subjective and objective evaluation of participating surgeons

Resumen Introducción El uso del sistema de visión 3D en cirugía laparoscópica puede significar una mejor performance de los procedimientos quirúrgicos de mayor complejidad. Objetivo Reportar las indicaciones, los resultados y la valoración de un grupo de cirujanos de diferentes especialidades en el uso de visión 3D. Materiales y Método: Se analizan las indicaciones quirúrgicas y los resultados subjetivos y objetivos del uso del sistema óptico 3D (n = 155 pacientes) en cirugía laparoscópica compleja. Para evaluación subjetiva se aplicó a una encuesta de percepción cualitativa a los cirujanos participantes tipo Likert. Para la evaluación objetiva, se registran los tiempos quirúrgicos empleados en los diferentes procedimientos efectuados y las complicaciones postoperatorias y se comparan con los pacientes operados con sistema 2D (n = 783 pacientes) en el mismo periodo. Resultados el 70,6% concuerda tener mejor imagen con la técnica 3D, el 64,7% de los cirujanos refieren que se puede reducir el tiempo operatorio, el 58,8% considera que se puede reducir el error quirúrgico, el 92% y 100% respectivamente afirman que el confort del cirujano es mejor con el uso de óptica 3D y que esta técnica es recomendable para los procedimientos complejos. El tiempo operatorio se redujo en algunos procedimientos, especialmente urológicos. No se encontró diferencias sustanciales al comparar los resultados con el uso de sistema 3D versus 2D en cuanto a complicaciones postoperatorias. En la 3D no se encontró mortalidad postoperatoria, probablemente por el menor número de pacientes de ese grupo. Conclusión La laparoscopia 3D posee una buena valoración por los cirujanos que la emplearon, principalmente en calidad de imagen, reducción del tiempo operatorio y confort del cirujano en comparación con la laparoscopía 2D convencional. No se encontró diferencias sustanciales al comparar los resultados con el uso de sistema 3D versus 2D en cuanto a tiempo operatorio ni complicaciones postoperatorias.

Introduction The use of the 3D vision system in laparoscopic surgery can mean better performance in more complex surgical procedures. Aim Report the indications, results and assessment of a group of surgeons of different specialties in the use of 3D vision. Materials and Method Surgical indications and subjective and objective results of the use of 3D optical system in patients (n = 155) submitted to complex laparoscopic surgery are analyzed. Subjective evaluation based on a survey of qualitative perception (Likert) was applied to the participating surgeons. For objective evaluation, the operatory times and postoperative complications were recorded and compared with the results observed with the use of the 2D system (783 patients) in the same period. Results 70.6% agree to have a better image with the 3D technique, 64.7% of surgeons report that the operative time can be reduced, 58.8% consider that it can be reduced the surgical error, 92% and 100% respectively considered that the comfort of the surgeon is better with the use of 3D optics and that this technique is recommended for complex procedures. No substantial differences were found when comparing the results with the use of 3D versus 2D system by the same surgical teams in terms of operative times and postoperative complications. In 3D, postoperative mortality was probably not found due to the lower number of patients in this group. Conclusion 3D laparoscopy has a good evaluation by the surgeons who used it, mainly in image quality, reduction of operative time and comfort of the surgeon compared to conventional 2D laparoscopy. No substantial differences were found when comparing the results with the use of 3D versus 2D system in terms of operative times or postoperative complications.

Lymphoparietal index in esophageal cancer is stronger than tnm staging in long-term survival prognosis in a latin-american country / índice linfoparietal no câncer esofágico é mais forte do que tnm no prognóstico de sobrevivência em longo prazo em um país latinoamericano

ABSTRACT Background: The identification of prognostic factors of esophageal cancer has allowed to predict the evolution of patients. Aim: Assess different prognostic factors of long-term survival of esophageal cancer and evaluate a new prognostic factor of long-term survival called lymphoparietal index (N+/T). Method: Prospective study of the Universidad de Chile Clinical Hospital, between January 2004 and December 2013. Included all esophageal cancer surgeries with curative intent and cervical anastomosis. Exclusion criteria included: stage 4 cancers, R1 resections, palliative procedures and emergency surgeries. Results: Fifty-eight patients were included, 62.1% were men, the average age was 63.3 years. A total of 48.3% were squamous, 88% were advanced cancers, the average lymph node harvest was 17.1. Post-operative surgical morbidity was 75%, with a 17.2% of reoperations and 3.4% of mortality. The average overall survival was 41.3 months, the 3-year survival was 31%. Multivariate analysis of the prognostic factors showed that significant variables were anterior mediastinal ascent (p=0.01, OR: 6.7 [1.43-31.6]), anastomotic fistula (p=0.03, OR: 0.21 [0.05-0.87]), N classification (p=0.02, OR: 3.8 [1.16-12.73]), TNM stage (p=0.04, OR: 2.8 [1.01-9.26]), and lymphoparietal index (p=0.04, RR: 3.9 [1.01-15.17]. The ROC curves of lymphoparietal index, N classification and TNM stage have areas under the curve of 0.71, 0.63 and 0.64 respectively, with significant statistical difference (p=0.01). Conclusion: The independent prognostic factors of long-term survival in esophageal cancer are anterior mediastinal ascent, anastomotic fistula, N classification, TNM stage and lymphoparietal index. In esophageal cancer the new lymphoparietal index is stronger than TNM stage in long-term survival prognosis.

RESUMO Racional: A identificação de fatores prognósticos do câncer de esôfago permitiu prever a evolução dos pacientes. Objetivo: Avaliar diferentes fatores prognósticos da sobrevida em longo prazo do câncer de esôfago e avaliar um novo fator prognóstico da sobrevida em longo prazo chamado índice linfoparietal (N+/T). Método: Estudo prospectivo do Hospital Clínico da Universidade do Chile, entre janeiro de 2004 e dezembro de 2013. Incluiu todas as operações de câncer de esôfago com intenção curativa e anastomose cervical. Os critérios de exclusão incluíram: câncer em estágio 4, ressecções R1, procedimentos paliativos e operações de emergência. Resultados: Cinquenta e oito pacientes foram incluídos, 62,1% eram homens, a idade média foi de 63,3 anos. Um total de 48,3% eram escamosos, 88% eram cânceres avançados, a colheita média de linfonodos foi de 17,1. A morbidade cirúrgica pós-operatória foi de 75%, com 17,2% de reoperações e 3,4% de mortalidade. A sobrevida global média foi de 41,3 meses, a sobrevida em três anos foi de 31%. A análise multivariada dos fatores prognósticos mostrou que variáveis significativas foram elevação pelo mediastinal anterior (p=0,01, OR: 6,7 [1,43-31,6]), fístula anastomótica (p=0,03, OR: 0,21 [0,05-0,87]), classificação N (p=0,02, OR: 3,8 [1,16-12,73]), estágio TNM (p=0,04, OR: 2,8 [1,01-9,26]) e índice linfoparietal (p=0,04, RR: 3,9 [1,01-15,17]. As curvas ROC do índice linfoparietal, classificação N e estádio TNM apresentam áreas abaixo da curva de 0,71, 0,63 e 0,64, respectivamente, com diferença estatística significativa (p=0,01). Conclusão: Os fatores prognósticos independentes de sobrevida em longo prazo no câncer de esôfago são a elevação mediastinal anterior, fístula anastomótica, classificação N, estágio TNM e índice linfoparietal. No câncer de esôfago, o novo índice linfoparietal é mais forte que o estágio TNM no prognóstico de sobrevida em longo prazo.

INTRODUCTION OF THE NEW LYMPHOPARIETAL INDEX FOR GASTRIC CANCER PATIENTS.

BACKGROUND: The identification of prognostic factors of gastric cancer (GC) has allowed to predict the evolution of patients. AIM: Assess the reliability of the lymphoparietal index in the prediction of long-term survival in GC treated with curative intent. METHOD: Prospective study of the Universidad de Chile Clinical Hospital, between May 2004 and May 2012. Included all gastric cancer surgeries with curative intent. Exclusion criteria were: gastrectomies due to benign lesions, stage 4 cancers, R1 resections, palliative procedures, complete esophagogastrectomies and emergency surgeries. RESULTS: A total of 284 patients were included; of the sample 65.4% were male,mean age of 64.5 years,75% were advanced cancers, 72.5% required a total gastrectomy, 30 lymph nodes harvest. Surgical morbidity and mortality were 17.2% and 1.7%. 5-year survival was 56.9%. The N+/T index could predict long-term survival in all de subgrups (p<0.0001), although had a reliable prediction in early GC (p=0.005), advanced GC (p<0.0001), signet ring cell GC (p<0.0001), proximal GC (p<0.0001) and distal GC (p<0.0001). The ROC curves N+/T index, LNR and T classification presented areas below the curve of 0.789, 0.786 and 0,790 respectively, without a significant statistical difference (p=0.96). CONCLUSION: The N+/T index is a reliable quotient in the prognostic evaluation of gastric adenocarcinoma patients who have been resected with curative intent.