Absence of thoracotomy by intrathoracic manual suture and transabdominal removal of surgical specimen during Ivor Lewis robotic esophagectomy.

In the surgical treatment of esophageal cancer, robotic surgery allows performing an intrathoracic handsewn anastomosis in a simpler, faster and more comfortable way for the surgeon than open surgery and traditional minimally invasive surgery. With this, we avoid the use of self-suture instruments, some of which require a small thoracotomy for their introduction. However, the retrieval of the specimen requires the practice of this thoracotomy, of variable size, that can be associated with intense chest pain. We describe a technical modification of the classic robotic Ivor Lewis that allows removal of the surgical piece through a minimal abdominal incision, thus avoiding controlled rib fracture, as well as the possible sequelae of making an incision in the chest wall.

Mechanical triangular esophagogastrostomy: Technical aspects and initial results.

INTRODUCTION: Esophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy (MT), with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of MT anastomosis. METHODS: A retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which MT anastomosis was implemented, between October 2017 and March 2020 in our hospital. RESULTS: 14 patients were included, with a mean age of 63 years. The mean operative time was 436 min (360-581), being diagnosed of anastomotic leak (AL) 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis (AS). The median stay was 20 days, without any death in the series. DISCUSSION: Multiple publications suggest the superiority in terms of AL and AS of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies.

Esofagogastrostomía triangular mecánica: aspectos técnicos y resultados iniciales / Mechanical triangular esophagogastrostomy: Technical aspects and initial results

IntroducciónEl cáncer de esófago representa la octava neoplasia a nivel mundial. El abordaje terapéutico es interdisciplinar y la cirugía es la opción más eficaz. Se han planteado varias técnicas para la realización de la esofagogastrostomía posterior a la esofagectomía, entre ellas, la esofagogastrostomía triangular mecánica, con muy poca experiencia publicada en la literatura occidental. El objetivo de este estudio es describir los aspectos técnicos y los resultados iniciales de la instauración de anastomosis triangular mecánica.MétodosSe realizó una revisión retrospectiva de los pacientes tratados mediante esofaguectomía según la técnica de McKeown, en los cuales se realizó anastomosis triangular mecánica entre octubre de 2017 y marzo de 2020 en nuestro hospital.ResultadosFueron incluidos 14 pacientes, con una media de edad de 63 años. El tiempo operatorio promedio fue de 436 min (360-581); fueron diagnosticados de fuga anastomótica 3 de los 14 pacientes (21,4%) y otros 3 pacientes presentaron estenosis anastomótica. La mediana de estancia fue de 20 días, sin ningún fallecimiento en la serie.ConclusionesMúltiples publicaciones señalan la superioridad en términos de fuga anastomótica y estenosis anastomótica de la anastomosis triangular mecánica. Esto también se observa en nuestra serie, en la cual, a pesar de lo reducido de la muestra, se observó una rápida mejoría en los indicadores posterior a los primeros casos, por lo que este tipo de anastomosis puede ser una opción segura para la confección de la anastomosis esofagogástrica posterior a la esofaguectomía. Son necesarios más estudios para alcanzar conclusiones definitivas (AU)

IntroductionEsophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy, with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of triangular esophagogastrostomy anastomosis.MethodsA retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which triangular esophagogastrostomy anastomosis was implemented, between October 2017 and March 2020 in our hospital.ResultsA total of 14 patients were included, with a mean age of 63 years. The mean operative time was 436minutes (360-581), being diagnosed of anastomotic leak 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis. The median stay was 20 days, without any death in the series.ConclusionsMultiple publications suggest the superiority in terms of anastomotic leak and anastomotic stenosis of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies (AU)

Esofaguectomía «tubeless»: menos es más / “Tubeless” esophagectomy: Less is more

La cirugía del cáncer de esófago es un procedimiento complejo con tasas de morbimortalidad elevadas, por lo que para obtener resultados adecuados se precisa de centros experimentados, un completo soporte multidisciplinar y vías clínicas adecuadas. Se describe la experiencia inicial y la técnica de la esofaguectomía «tubeless» en la que tras realizar una resección esofágica y linfadenectomía mediastínica extendida, al final del procedimiento no son colocados drenajes ni sondas de ningún tipo, con el fin de disminuir la agresividad del mismo, mejorar el bienestar postoperatorio y acelerar la recuperación funcional del paciente. (AU)

The esophageal cancer surgery is a complex procedure with elevated rates of both morbidity and mortality, which is why, in order to achieve adequate results, it should be performed in high volume centers, where complete multidisciplinary support is available and recent clinical guidelines are applied. We describe the initial experience and the technique of “tubeless” esophagectomy where esophageal resection and mediastinal lymphadenectomy are performed and no drains nor tubes of any kind are placed, with the aim to decrease the level of surgical aggression, enhance the postoperative comfort and accelerate the patient́s recovery. (AU)

"Tubeless" esophagectomy: Less is more.

The esophageal cancer surgery is a complex procedure with elevated rates of both morbidity and mortality, which is why, in order to achieve adequate results, it should be performed in high volume centers, where complete multidisciplinary support is available and recent clinical guidelines are applied. We describe the initial experience and the technique of "tubeless" esophagectomy where esophageal resection and mediastinal lymphadenectomy are performed and no drains nor tubes of any kind are placed, with the aim to decrease the level of surgical aggression, enhance the postoperative comfort and accelerate the patient́s recovery.

Resultados de una encuesta nacional sobre el manejo terapéutico del cáncer de esófago / Results of a National Survey about Therapeutic Management in Esophageal Cancer

En la actualidad existen numerosos puntos de controversia en el manejo perioperatorio y quirúrgico de los pacientes con cáncer de esófago. El objetivo de este trabajo es describir las posibles diferencias en el tratamiento coadyuvante y quirúrgico de estos pacientes entre los hospitales de nuestro país mediante un estudio descriptivo de las encuestas respondidas entre febrero y abril de 2020. Se evaluaron las características de cada centro, el número de procedimientos, el manejo del adenocarcinoma de tercio distal y del carcinoma escamoso de tercio medio, el tipo de anastomosis, el empleo de sonda nasogástrica y drenajes y el seguimiento de una vía clínica. La mediana de esofaguectomías anuales por centro es de 10, realizando solamente el 7,1% más de 20. En el adenocarcinoma distal el 62,5% emplea quimiorradioterapia preoperatoria, un abordaje abdominal y transtorácico (57,1%) y una linfadenectomía infracarinal (51,8%) o extendida (41,1%). En el carcinoma escamoso de tercio medio el 89,3% emplea quimiorradioterapia preoperatoria, una cirugía en 3 campos (73,2%) y una linfadenectomía mediastínica ampliada (52%). La anastomosis intratorácica se realiza de forma mecánica en el 77,8% y la cervical preferentemente de forma manual (71,4%). Los drenajes pleurales y abdominales son colocados habitualmente por el 77,6 y el 48,2%, respectivamente, mientras que la sonda nasogástrica es empleada normalmente por el 57,1%. El 57,1% siguen una vía clínica y el 28,6% un protocolo de recuperación intensificada específico. Por tanto, en el manejo del cáncer de esófago, existen claras diferencias entre los hospitales de nuestro país con relación al tratamiento coadyuvante, abordaje quirúrgico, tipo de linfadenectomía y anastomosis practicadas. (AU)

There are numerous controversial aspects in the perioperative and surgical management of patients with esophageal cancer. The aim of this study is to evaluate the differences between the hospitals of our country in the adjuvant and surgical treatment of these patients. We conducted a descriptive study of 56 surveys answered from February to April 2020, evaluating hospital characteristics, number of procedures, management of distal adenocarcinoma and squamous cell carcinoma of the middle third of the esophagus, type of anastomosis, use of nasogastric tube and drains, and clinical follow-up. The median number of annual esophagectomies per hospital was 10, and only 7.1% performed more than 20. In distal adenocarcinoma, 62.5% use preoperative chemoradiotherapy, an abdominal and transthoracic approach (57.1%), and an infracarinal lymphadenectomy (51.8%) or extended to right paratracheal lymph nodes (41.1%). In squamous cell carcinoma of the middle third of the esophagus, 89.3% use preoperative chemoradiotherapy, surgery in three fields (73.2%) and extended mediastinal lymphadenectomy (52%). Intrathoracic anastomosis is performed mechanically in 77.8% and cervical anastomosis preferably manually (71.4%). Pleural and abdominal drains are usually placed by 77.6% and 48.2%, respectively, while the nasogastric tube is normally used by 57.1%. A clinical pathway is followed by 57.1%, and 28.6% use a specific enhanced recovery after surgery protocol. Thus, in the management of esophageal cancer, there are some clear differences between hospitals in our country regarding adjuvant treatment, surgical approach, type of lymphadenectomy and anastomosis performed. (AU)

Mechanical triangular esophagogastrostomy: Technical aspects and initial results. / Esofagogastrostomía triangular mecánica: aspectos técnicos y resultados iniciales.

INTRODUCTION: Esophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy, with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of triangular esophagogastrostomy anastomosis. METHODS: A retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which triangular esophagogastrostomy anastomosis was implemented, between October 2017 and March 2020 in our hospital. RESULTS: A total of 14 patients were included, with a mean age of 63 years. The mean operative time was 436minutes (360-581), being diagnosed of anastomotic leak 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis. The median stay was 20 days, without any death in the series. CONCLUSIONS: Multiple publications suggest the superiority in terms of anastomotic leak and anastomotic stenosis of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies.

Results of a National Survey about Therapeutic Management in Esophageal Cancer. / Resultados de una encuesta nacional sobre el manejo terapéutico del cáncer de esófago.

There are numerous controversial aspects in the perioperative and surgical management of patients with esophageal cancer. The aim of this study is to evaluate the differences between the hospitals of our country in the adjuvant and surgical treatment of these patients. We conducted a descriptive study of 56 surveys answered from February to April 2020, evaluating hospital characteristics, number of procedures, management of distal adenocarcinoma and squamous cell carcinoma of the middle third of the esophagus, type of anastomosis, use of nasogastric tube and drains, and clinical follow-up. The median number of annual esophagectomies per hospital was 10, and only 7.1% performed more than 20. In distal adenocarcinoma, 62.5% use preoperative chemoradiotherapy, an abdominal and transthoracic approach (57.1%), and an infracarinal lymphadenectomy (51.8%) or extended to right paratracheal lymph nodes (41.1%). In squamous cell carcinoma of the middle third of the esophagus, 89.3% use preoperative chemoradiotherapy, surgery in three fields (73.2%) and extended mediastinal lymphadenectomy (52%). Intrathoracic anastomosis is performed mechanically in 77.8% and cervical anastomosis preferably manually (71.4%). Pleural and abdominal drains are usually placed by 77.6% and 48.2%, respectively, while the nasogastric tube is normally used by 57.1%. A clinical pathway is followed by 57.1%, and 28.6% use a specific enhanced recovery after surgery protocol. Thus, in the management of esophageal cancer, there are some clear differences between hospitals in our country regarding adjuvant treatment, surgical approach, type of lymphadenectomy and anastomosis performed.

Cervical esophaguectomy plus tracheal resection and free jeyuno graft as treatment of esophageal granular cell tumor. / Esofaguectomía cervical más resección traqueal e injerto de yeyuno libre como tratamiento de un tumor de células granulares esofágico.

Granular cell tumor is a very rare entity (0.03%) with controversial management, due to its low incidence and its usually benign behavior (98%). Its location in the digestive tract is unusual (3-11%), being the esophagus the most frequently affected organ, with about 400 published cases. However, the incidence in the cervical esophagus is anecdotal (20 published cases). We present a patient with an esophageal granular cell tumor that invaded trachea, thyroid and soft tissues, performing a block resection of the cervical esophagus, two tracheal rings, thyroid and prethyroid musculature. For digestive reconstruction, a free jejunum graft with microvascular anastomosis was made and tracheal reconstruction was performed using term-terminal anastomosis. The importance of the case is twofold: to contribute more casuistry, and to describe a highly complex surgical technique never indicated in this type of tumors, due to its rarely aggressive character.

Nasogastric tube utilization after esophagectomy: an unnecessary gesture? / Uso de sonda nasogástrica en pacientes sometidos a esofaguectomía: ¿Un gesto innecesario?

INTRODUCTION: Nasogastric decompressive tube utilization has been accepted as one of the basic perioperative care measures after esophageal resection surgery. However, with the development of multimodal rehabilitation programs and without clear evidence to support their use, the systematic indication of this measure may be controversial. MATERIAL AND METHODS: Retrospective, descriptive and comparative study of patients who had undergone Ivor-Lewis esophagectomy in our center -from January 2015 to December 2018- with placement (Group S), or without placement (Group N) of a decompressive tube in gastroplasty during postoperative period. Epidemiological variables and differences between groups in post-surgical morbidity and mortality, hospital stay, onset of oral tolerance and the need for nasogastric tube placement were evaluated. RESULTS: A total of 43 patients were included in this study, with a median age of 61 years, being 86% male. 46.5% were hypertensive, 25.5% had lung disease and 16.3% had diabetes mellitus. The median length of hospital stay was 9 days in group S versus 11.5 days in group N, with no differences in the onset of oral tolerance. Anastomotic dehiscence rate was 5% and 0% respectively. The overall mortality was 2.3% in the first 90 days, without differences between the groups. Placement of nasogastric tube during postoperative period was required only in 1 patient (4.3%) of the group N. CONCLUSIONS: Non-use of nasogastric tube during postoperative period of an Ivor-Lewis esophagectomy is a safe measure, as it is not associated with a higher rate of complications or hospital stay. This fact may be able to improve patients' comfort and postoperative recovery.

Results of the different surgical options for the treatment of cancer of the esophagogastric junction: Review of the evidence. / Resultados de las diferentes opciones quirúrgicas para el tratamiento del cáncer de la unión esofagogástrica. Revisión de la evidencia.

There is significant controversy in the management of cardiac cancer. It seems unanimous that Siewert type I tumors be operated on as cancer of the esophagus and Siewert type III as gastric cancer. However, for "true" cancer of the gastric cardia or Siewert II, the authors do not agree. There is the obvious need for free proximal and distal margins, as well as correct lymphadenectomy. For some, esophagectomy is necessary to perform correct radical oncological surgery, but other authors defend that an abdominal approach is sufficient to perform total gastrectomy and distal esophagectomy. Recent and older papers published do not clarify this issue, and their results are contradictory. Chemotherapy prior to surgery can reduce the size of the tumor and the presence of lymphadenopathies.

Postoperative complications and survival rate of esophageal cancer: Two-period analysis. / Complicaciones postoperatorias y supervivencia del cáncer de esófago: análisis de dos periodos distintos.

INTRODUCTION: Nowadays, treatment of esophageal cancer requires a multidisciplinary approach, in which esophagectomy remains the mainstay. The aim of this report is to assess whether multimodal treatment and minimally invasive surgery have led to a lower morbidity rate and an improvement in survival rates. METHODS: Retrospective evaluation of 318 patients diagnosed with esophageal cancer including 81 esophagectomies. The periods of 2000-2007 and 2008-2015 were compared, analyzing the prognostic factors that may have an impact in morbidity and survival rate. RESULTS: Major postoperative complications according to the Clavien-Dindo classification accounted for 35%, showing a decrease between the 1.st and 2.nd period: 41% morbidity vs. 30%, 27% mortality vs. 9% (p < .001) and 13.5% fistulas vs. 7%. The implementation of thoracoscopic esophagectomy contributed to the outcome improvement, as shown by 19% morbidity and 5% mortality rates, with triangularized mechanical anastomosis showing 9% fistula and 5% stenosis. The overall 5-year survival rate was 19%, with a significant increase from 11% in the 1.st period to 28% in the 2.nd (p < .001). CONCLUSIONS: Multidisciplinary assessment of patients with esophageal cancer, as well as better selection and indication of treatment and the introduction of new minimally invasive techniques (thoracoscopy and triangularized mechanical anastomosis), have improved the morbidity and mortality rates of esophagectomies, resulting in increased survival rates of these patients.

Faringo-íleo-colo anastomosis con suplemento vascular microquirúrgico en reconstrucción del tracto digestivo superior / Pharyngo-ileo-colo-anastomosis with micro-vascular blood supply augmentation for surgical reconstruction of the upper digestive tract

Resumen Introducción Los pacientes sometidos a desconexión total con cierre al nivel del seno piriforme debido a necrosis completa del esófago y estómago después de la ingestión cáustica representan un desafío quirúrgico para restablecer la ingestión oral y la calidad de vida. Objetivo El objetivo de este trabajo es presentar la experiencia con un caso clínico con necrosis total de esófago y estómago posingestión de cáuticos por lo que fue inicialmente sometido a esofagectomía y gastrectomía total. Método La reconstrucción del tracto digestivo superior se efectuó mediante una faringo-íleo-colo anastomosis, con suplemento de irrigación sanguínea arterial y drenaje venoso mediante técnica de anastomosis microquirúrgica. Resultados No se observaron complicaciones postoperatorias mayores y en el resultado a largo plazo se logra alimentación oral normal con una recuperación nutricional adecuada y buena calidad de vida. Conclusión Esta es un procedimiento a plantear en pacientes con estenosis faríngea sin posibilidad de reemplazo esofágico con procedimientos menos complejos.

Introduction Patients submitted to total esophagectomy and gastrectomy with complete closure of pharinx due to necrosis after caustic ingestion are a challenging surgical setting for reconstruction of upper digestive transit. Objective The objective of this paper is to present a clinical case and surgical technique for reconstruction of the upper digestive tract after total esophagectomy and gastrectomy. Method Reconstruction of digestive transit was reestablished by means of a pharyngo-ileo-colonic interposition with microsurgical arterial and venous anastomosis for augmentation of blood supply. Results There were not major postoperative complications and at long term follow-up, normal oral nutrition and quality of life improvement was observed. Conclusion This is a surgical procedure for treatment of patients with pharyngeal strictures without any possibility to indicate other less complex procedures.

Histopathological and Immunohistochemical Analysis of the Use of Collagen Dressing as a Reinforcement of Esophagic Anastomosis in a Rat Experimental Model. / Análisis histopatológico e inmunohistoquímico del uso del apósito de colágeno como refuerzo de anastomosis esofágica en un modelo experimental en rata.

INTRODUCTION: One of the most severe complications after esophaguectomy is anastomotic dehiscence. The use of collagen sponges could be an effective way to resolve this complication. Our objective was to perform an experimental model of esophageal anastomosis in rats to study these mechanisms. METHODS: A total of 50 Sprague-Dawley rats were used divided into 2 groups, Tachosil® group (n=25) and control group (n=25). After the section of the abdominal esophagus a single-layer esophago-gastric anastomosis was performed reinforced with 1cm of Tachosil® wrapping the anastomosis in group 1. A functional study was performed using manometry as well as histopathological and immunohistochemical studies for angiogenic, fibrogenic and growth factors. RESULTS: The mortality in our series was 8% in the collagen dressing group, compared to 36% in the control group. When esophageal manometry was performed, the dehiscence pressure was higher in the reinforced anastomosis, On microscopical analysis, in the collagen dressing group a profuse inflammatory reaction with abundant neutrophils and macrophages surrounded by a connective matrix with fibroblasts and blood vessels was observed, The expression of VEGF, FGF1 and FGF2 was noticeably higher in the collagen dressing group. CONCLUSIONS: These results show that the application of collagen dressing facilitates tissue reparation phenomena, and therefore could be very useful as a reinforcement of esophago-gastric anastomosis to prevent dehiscence.

Reconstitución de tránsito esofágico con interposición de colon derecho / Esophageal reconstruction using right colon interposition

Background: Esophageal replacement therapy is indicated for benign and malignant esophageal lesions and can be performed using stomach, jejunum or colon. Aim: To report the experience using right colon interposition for esophageal replacement. Material and Methods: Review of medical records of 41 patients aged 17 to 73 years (29 males), subjected to right colon interposition in the last 20 years. Indications, complications, mortality and long term results were recorded. Results: Forty nine percent of patients had a malignant esophageal lesion. Esophagectomy was performed using a transhiatal route or thoracotomy in 44 and 30 percent of patients, respectively. Retroesternal ascension was the most common route used in 88 percent of patients. The most common surgical complication was cervical fistula in 29 percent of patients, followed by fistula of the anastomosis between colon and jejunum in 7 percent of patients. Pneumonia was the most common medical complication. Postoperative mortality was 7 percent. Conclusions: The mortality in this series of patients is similar to that reported elsewhere.

Introducción: La cirugía de reemplazo esofágico actualmente se indica para tratamiento de enfermedades benignas y malignas del esófago. Existen diversas técnicas de reconstitución de tránsito esofágico que utilizan estómago, yeyuno o colon. Objetivo: Presentar la experiencia acumulada en el Hospital Clínico de la Universidad de Chile utilizando la técnica de transposición de colon derecho para la reconstitución de tránsito esofágico. Materiales y Métodos: Estudio descriptivo restrospectivo que incluyó a los pacientes sometidos a reconstitución de tránsito esofágico mediante interposición de colon derecho, durante los últimos 20 años, basado en la revisión sistemática de historias clínicas, analizando causas, morbilidad precoz y tardía, mortalidad operatoria, compararándolos con los resultados de la literatura. Resultados: Se incluyen 41 pacientes operados, con edad promedio de 63,6 años (17-73), 29 de ellos de sexo masculino (70,7 por ciento). El 48,7 por ciento correspondieron a neoplasias malignas, el resto a patología benigna. En 43,9 por ciento la esofaguectomía se realizó por vía transhiatal y 29,7 por ciento por toracotomía. El ascenso retrosternal fue la vía más empleada (87,8 por ciento). La complicación más frecuente correspondió a la fístula cervical en 29,3 por ciento seguida de la fistula en colo-yeyuno anastomosis en el 7,3 por ciento de los casos. La neumonía fue la complicación médica más frecuente (14,7 por ciento). La mortalidad postoperatoria fue 7,3 por ciento. Conclusión: El uso de interposición de colon derecho tiene indicaciones precisas. La mortalidad operatoria reportada se ajusta a lo encontrado en la literatura internacional.

[Initial results of robotic esophagectomy for esophageal cancer]. / Resultados iniciales de la esofaguectomía robótica en el cáncer de esófago.

INTRODUCTION: There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. PATIENTS AND METHODS: Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. RESULTS: Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). CONCLUSIONS: Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.

Número total de operaciones de patología digestiva alta en Chile año 2011 / Number of gastrointestinal surgical interventions performed in Chile during 2011

Background: There is paucity of information about the number of gastrointestinal surgical interventions in Chile. Aim: To report the number of gastrointestinal operations carried out in Chile during 2011. Material and Methods: Review of databases from the Department of Statistics and Health care information of the Ministry of Health. The two most common gastrointestinal surgical interventions and four highly complex interventions were selected. Results: The most common gastrointestinal intervention was cholecystectomy in 52.000 cases, followed by appendectomy in 37.000 cases. A gastrectomy for gastric cancer was performed in 1.032 cases, performing a total gastrectomy in 74 percent and with a 2.9 percent mortality. Esophagectomy was carried out in 42 patients with an overall mortality of 9.5 percent. A pancreatectomy for pancreatic cancer was performed in 102 patients (pancreatoduodenectomy in 68 percent), with an overall mortality of 5.9 percent. Bariatric surgery was performed in 2.834 cases (vertical gastrectomy in 70 percent and gastric bypass in 30 percent). Conclusions: Cholecystectomy was by far the most common surgical procedure performed. Esophagectomy and pancreatectomy were associated with a high mortality rate. Gastrectomy for gastric cancer had a low postoperative mortality.

Introducción: No hay datos oficiales sobre el número total de intervenciones quirúrgicas referentes a patología gastrointestinal alta. Objetivo: Conocer algunos datos estadísticos al respecto. Material y Método: Se obtuvo del Departamento de Estadísticas e Informaciones de Salud del Ministerio de Salud el total de intervenciones realizadas el año 2011 en Chile, seleccionando las 2 operaciones más frecuentes y 4 operaciones de alta complejidad definidas por la patología de base, la complejidad del acto quirúrgico y la mortalidad operatoria. Resultados: Después de la cesárea, la colecistectomía es la operación más frecuente (52.000 pacientes) seguida de la apendicectomía (37.000 pacientes). La gastrectomía por cáncer gástrico se realizó en 1.032 pacientes con una mortalidad operatoria global de 2,9 por ciento. La gastrectomía total se efectuó en 74 por ciento de los casos. La esofaguectomía se realizó en 42 pacientes con mortalidad global de 9,5 por ciento. La pancreatectomía por cáncer de páncreas se efectuó en 102 pacientes con una mortalidad global de 5,9 por ciento, siendo la pancreatoduodenectomía la intervención más frecuente (68 por ciento). La cirugía bariátrica comprende 2 operaciones con un total de 2.834 casos, con una proporción de 70 por ciento para la gastrectomía vertical y un 30 por ciento para el bypass gástrico. Conclusiones: La colecistectomía es la intervención quirúrgica no obstétrica más frecuente. La esofaguectomía y la pancreatectomía, se realizan en un bajo número de pacientes, siendo la mortalidad operatoria de ambos procedimientos alta. La gastrectomía por cáncer gástrico tiene una baja mortalidad operatoria. Se reporta por primera vez una cifra oficial referente al número de cirugías bariátricas.

Manejo de las fístulas de las anastomosis esófago-intestinales con prótesis autoexpandibles (PAE) en pacientes con cáncer: Reporte de casos / The Use of Self-expanding Metal Stents to Manage Fistulas of Esophageal Intestinal Anastomosis in Patients with Cancer

Objetivo. Mostrar la experiencia en el manejo de pacientes con dehiscencia de las anastomosis esófago-yeyunales o esófago-gástricas con prótesis autoexpandibles esofágicas (PEA). Material y métodos. Durante los años 2012 y 2013 se registraron las complicaciones posgastrectomía total en pacientes con cáncer gástrico con anastomosis efectuadas a nivel abdominal o a nivel torácico. Se incluyeron solo los pacientes con dehiscencias o fugas de las anastomosis. Se elaboró una hoja de registro donde se consignó de cada paciente la edad, sexo, localización de la lesión, estado clínico, si recibió repleción nutricional, quimioterapia y o radioterapia, día de presentación de la fístula o dehiscencia, cuantificación del tamaño, tipo de manejo, mortalidad, prótesis utilizada, número de prótesis, migración y retiro. Resultados. Se registraron 6 pacientes, 5 con dehiscencia a nivel abdominal y uno a nivel torácico. Cinco con adenocarcinoma gástrico y uno por GIST gástrico con metástasis hepáticas. Dos habían recibido repleción nutricional por perdida mayor de 10% de su peso corporal. A todos los pacientes se les realizó anastomosis con sutura mecánica. Cuatro hombres y dos mujeres. A cinco pacientes se les realizó estudio radiológico con medio de contraste hidrosoluble, confirmando la dehiscencia en tres de ellos. Todos los pacientes fueron manejados con reexploración quirúrgica y drenaje. Solo a dos pacientes se les colocó la prótesis durante la nueva cirugía. Dos pacientes requirieron de una segunda prótesis por migración. En total la migración se observó en 50% de los pacientes. La estancia hospitalaria más larga fue de 68 días, con una mortalidad de dos pacientes (33%), uno con una fístula crónica manejada con dos prótesis y el otro el mismo día de su reintervención. Las prótesis fueron retiradas después de la cuarta semana. Conclusiones. La frecuencia de esta complicación varía de 0 a 30%. El reconocimiento temprano y manejo oportuno son esenciales ...

Objective: The objective of this study is to show our experience in the management of patients with dehiscence of jejunal-esophageal or esophageal-gastric anastomoses through the use of esophageal self-expanding stents. Materials and Methods: During 2012 and 2013 all complications following gastrectomies in gastric cancer patients with anastomoses were recorded. Only patients with dehiscence or anastomotic leaks were included in this study. An information form was used to record each patient’s age, sex, location of lesion, medical condition, whether nutritional repletion had been received, whether patient had undergone chemotherapy or radiation therapy, date of presentation of the fistula or dehiscence, measurements of size, type of management used, mortality, stent used, number of stents used, stent migration and stent removal. Results: Six patients, four men and two women, five of whom had abdominal dehiscence and one who had thoracic dehiscence, were included. They had five gastric adenocarcinomas and one gastric GIST with liver metastasis. Two had received nutritional repletion because they had lost 10% of their body weight. All patients were had their anastomoses stapled. Five patients underwent radiological studies with water-soluble contrast which confirmed dehiscence in three of them. All patients were managed with surgical re-exploration and drainage. Only two patients had their stents replaced during surgery which were required because of stent migration. Migration was observed in 50% of these patients. The longest hospital stay was 68 days. Two patients (33%) died, one had a chronic fistula managed with two prostheses and the other died on same day as his second surgical intervention. Stents were removed after the fourth week. Conclusions: The frequency of this complication varies from 0% to 30%. Early recognition and appropriate management are essential when faced with this complication. A few years ago this complication was ...

Endoprótesis recubierta en el manejo de la fístula cervical tras esofaguectomía / Covered stent in the management of cervical anastomotic leaks after esophaguectomy

Small cervical esophageal anastomotic leaks are usually treated conservatively, with considerable delays to oral feeding and a prolonged hospital stay. Self-expanding covered stents endoscopically placed are suggested as an alternative treatment. We report our hospital experience with covered stents, with good functional results but also potential morbidity.

La fístula anastomótica esofágica cervical suele manejarse de forma conservadora, lo que retrasa el inicio de la alimentación oral y prolonga la estancia hospitalaria. El uso de endoprótesis recubiertas colocadas vía endoscópica se utiliza como una alternativa para evitar esta situación. Presentamos dos casos manejados con endoprótesis recubierta, con adecuado funcionamiento pero no exenta de morbilidad.