Resección de metástasis hepáticas en cáncer de colon: nuevas perspectivas / Resection of liver metástasis in colon cancer: new perspectives

Liver metastasis of colon cancer is a very common clinical entity. Resective surgery can be used to improve the overall survival and disease-free. The problem is that major resections are associated with hepatic failure caused by an inadequate residual volume. Chemotherapy with diagrams as FOLFOX, FOLFIRI associated with antibodies such as bevacizumab, cetuximab or panitumumable added an important role in the conversion of unresectable to resectable tumors. Another widely used technique is portal vein ligation in a first surgical procedure, that generates left hepatic growth, to perform the resection in a second surgical procedure. The liver hypertrophy is achieved in a period of 2 months. The latest new technical procedure is the association of the ligation portal to the liver partition of the hepatic parenchyma without resection, which allows a segmental hypertrophy of the liver remnant between 7 to 10 days. This technique is called ALPPS. Radiofrecuency also has a role in the treatment of liver metastases. However,it is secondary.

La metástasis hepáticas del cáncer de colon es una entidad clínica muy frecuente. La cirugía resectiva permite mejorar la sobrevida global y libre de enfermedad. El problema es que grandes resecciones se asocian a insuficiencia hepática por un inadecuado volumen residual. La quimioterapia con esquemas como FOLFOX, FOLFIRI asociada a anticuerpos como bevacizumab, cetuximab o panitumumable agregan un rol importante en la conversión de tumores irresecables a resecables. Otra técnica utilizada es la ligadura portal en un primer tiempo, que genera crecimiento hepático izquierdo, para realizar la resección en un segundo tiempo quirúrgico. La hipertrofia hepática se logra en un período de 2 meses. La última novedad técnica es la asociación de la ligadura portal a la transección del parénquima hepático sin resección, lo que permite una hipertrofia segmentaria del hígado remanente entre 7 a 10 días. Esta técnica se denomina ALPPS. La radiofrecuencia también tiene un rol en el tratamiento de las metástasis hepáticas, aunque este es secundario.

Ictericia post-operatoria / Post-operative jaundice

The occurrence of postoperative jaundice should encourage the surgeon to review the wide spectrum of possible causes of jaundice and perform detailed history, physical examination and laboratory tests to define the causes, and take the measures to treat the patient properly. We also emphasize the need to prevent the presence of residual stones in the bile duct and bile duct iatrogenic injuries. This paper describe the possible causes of postoperative jaundice and current recommendations for adequate treatment.

La aparición de ictericia en el postoperatorio debe alertar al cirujano y llevarlo a revisar el gran espectro de causas posibles del cuadro. Se debe realizar una anamnesis y examen físico detallado y complementarlo con exámenes de laboratorio e imágenes según el caso. Además, se insiste en la necesidad de prevenir la presencia de cálculos residuales en colédoco y lesiones iatrogénicas de vía biliar. Se revisan las causas posibles de ictericia postoperatoria y las recomendaciones actuales de manejo.

[Diffuse pulmonary ossification associated with idiopathic pulmonary fibrosis]. / Osificación pulmonar difusa asociada a fibrosis pulmonar idiopática.

Diffuse pulmonary ossification is a rare entity that presents with the formation of mature bone in the pulmonary parenchyma and is associated with diffuse and chronic lung disease, heart disease, or other system disorders. Diffuse pulmonary ossification is usually a postmortem finding by the pathologist. In the case we report, the diagnosis was established by open lung biopsy. The patient was a 79-year-old man with dyspnea, dry cough, and weight loss. He had been a smoker. A chest x-ray revealed reticulonodular bilateral pulmonary infiltrates. Computed tomography revealed interstitial disease predominantly in the septum with multiple cavitations that tended to form honeycomb patterns. Pleural thickening, retraction of the parenchyma, and bilateral fibrosis were also visible. A clinical diagnosis of interstitial fibrosis was established and the patient s course was unfavorable. An open lung biopsy was performed. The lung tissue specimens revealed zones with collapsed alveoli and others with emphysema, some of which produced secretion and erythrocytic extravasation. Interstitial vascular congestion was apparent; bronchioles presented mononuclear and some polymorphonuclear inflammatory infiltrates. Noteworthy was the presence of predominantly interstitial, multicentric foci of osseous trabeculae --some of which included adipose bone marrow. Diffuse pulmonary ossification is usually an incidental finding in autopsies of patients with a history of diffuse chronic pulmonary disease, but it is an unusual diagnosis in living patients. Diffuse pulmonary ossification is of no prognostic significance in pulmonary fibrosis. It is a marker of the chronicity and/or severity of the fibrosis.

Osificación pulmonar difusa asociada a fibrosis pulmonar idiopática / Diffuse pulmonary ossification associated with idiopathic pulmonary fibrosis

La osificación pulmonar difusa es una rara entidad que consiste en la formación de hueso maduro en el parénquima pulmonar, asociada a patología pulmonar difusa y crónica, cardíaca o extracardiopulmonar. Esta entidad constituye habitualmente un hallazgo anatomopatológico post mortem. En este caso se realiza el diagnóstico mediante biopsia pulmonar a cielo abierto. Presentamos el caso de un varón de 79 años, con disnea, tos seca y pérdida de peso. Había sido fumador. En la radiografía de tórax se apreciaba un infiltrado pulmonar bilateral reticulonodulillar. La tomografía computarizada evidenció afectación intersticial con predominio septal y múltiples cavidades con tendencia a la panalización; engrosamiento pleural, retracción del parénquima y fibrosis bilateral. Se estableció el diagnóstico clínico de fibrosis intersticial idiopática, y el paciente evolucionó desfavorablemente. Se realizó una biopsia a cielo abierto. La biopsia pulmonar evidenció zonas de colapso alveolar y otras enfisematosas, algunas con secreción y extravasación eritrocitaria. Había vasocongestión intersticial; los bronquiolos presentaban infiltrado inflamatorio mononuclear y algunos polimorfonucleares. Llamaba la atención la presencia de trabéculas óseas, algunas que incluían la médula ósea, de tipo adiposo, en focos multicéntricos, predominantemente intersticiales. La osificación pulmonar difusa constituye habitualmente un hallazgo incidental en autopsias de pacientes con antecedentes de enfermedad pulmonar crónica difusa, siendo inusual el diagnóstico en un paciente vivo. La osificación pulmonar difusa no posee significación pronóstica en la fibrosis pulmonar. Constituye un signo de cronicidad y gravedad de la enfermedad (AU)

BICAP tumor probe en el tratamiento paliativo de la estenosis esofágicas malignas / BICAP tumor probe in the treatment of malignant sophageal stenosis

Background: BICAP tumor probe is a device that consists in an energy source and olives that deliver bipolar electricity. It can be used for the fulguration of esophageal tumors after endoscopic dilatation. Aim: To report the experience in the treatment of malignant esophageal stenoses using the BICAP tumor probe. Patients and methods: Patients with advanced esophageal tumors in aphagia, that were not candidates for palliative surgery were included in this study. After endoscopic dilatation, the tumor was fulgurated with the BICAP tumor probe. Results: Twenty one patients (nine male, aged 43 to 91 years old) were treated with the device. A mean of 1.3 sessions with BICAP were necessary to obtain tumor permeabilization, which was obtained in all patients. One patient died of pneumonia 15 days after the procedure. All other patients were ingesting liquid or semisolid diets after two months of follow up. Mean survival after the procedure was 3.8 months. Conclusions: Electrical fulguration of esophageal tumors is a valid therapeutic alternative in aphagic patients

[Epworth drowsiness scale value in obstructive sleep apnea syndrome]. / Valor de la escala de somnolencia de Epworth en el diagnóstico del síndrome de apneas obstructivas del sueño.

Hypersomnia is one of the most consulted symptoms among patients evaluated at sleep disorder centers and it is frequently related to obstructive sleep apnea syndrome (OSAS). Our hypothesis is that Epworth sleepiness scale (ESS) is the parameter with the greatest predictive value in the OSAS diagnosis. We compared patients with OSAS diagnosis to a control group. In both groups we compared ESS with body mass index (BMI), neck circumference (NC), waist perimeter (WP). Anthropometric index (BMI, NC and WC), were similar in both groups (p < 0.10). When we analyzed ESS, a score greater than 10 was observed in the OSAS group, with a significant difference between groups (p < 0.001). Epworth sleepiness scale yielded 60% of sensibility, 82% of specificity and a positive predictive value of 85%. The negative predictive value was 52%. Confidence index was 70%. The relationship between OSAS and ESS scale was significant (Pearson Chi-Square value 7.5). Odds Ratio for apneas was 15 and its confidence interval was lower than 1.5 and upper than 141. We conclude that with ESS score exceeding 10 points OSAS should be suspected.

Valor de la escala de somnolencia de Epworth en el diagnóstico del síndrome de apneas obstructivas del sueño. / [Epworth drowsiness scale value in obstructive sleep apnea syndrome]

Hypersomnia is one of the most consulted symptoms among patients evaluated at sleep disorder centers and it is frequently related to obstructive sleep apnea syndrome (OSAS). Our hypothesis is that Epworth sleepiness scale (ESS) is the parameter with the greatest predictive value in the OSAS diagnosis. We compared patients with OSAS diagnosis to a control group. In both groups we compared ESS with body mass index (BMI), neck circumference (NC), waist perimeter (WP). Anthropometric index (BMI, NC and WC), were similar in both groups (p < 0.10). When we analyzed ESS, a score greater than 10 was observed in the OSAS group, with a significant difference between groups (p < 0.001). Epworth sleepiness scale yielded 60

of sensibility, 82

of specificity and a positive predictive value of 85

. The negative predictive value was 52

. Confidence index was 70

. The relationship between OSAS and ESS scale was significant (Pearson Chi-Square value 7.5). Odds Ratio for apneas was 15 and its confidence interval was lower than 1.5 and upper than 141. We conclude that with ESS score exceeding 10 points OSAS should be suspected.