[Minimally invasive esophagectomy]. / Esofagectomía mínimamente invasiva.

INTRODUCTION: Currently, the bases for the treatment of esophageal cancer are surgical resection and chemotherapy. Among the various surgical techniques used, minimally invasive esophagectomy (MIE) aims to reduce surgical aggression and cardiopulmonary complications while maintaining basic oncological principles. We present the results of our initial experience with this technique in the treatment of esophageal cancer. MATERIAL AND METHOD: Fourteen patients with a diagnosis of esophageal cancer were selected to undergo MIE in three stages: right thoracoscopy, laparoscopy, and left cervicotomy with cervical esophagogastric anastomosis. Histological diagnosis was epidermoid carcinoma (n = 11) and high grade dysplasia (n = 3), one of which was highly suspicious of malignant transformation. After extension studies, preoperative clinical stages were as follows: stage 0 (n = 3), stage IIA (n = 10), and stage III (n = 1). Seven patients were treated with chemotherapy and neoadjuvant radiotherapy and the remainder underwent surgery without prior treatment. RESULTS: The mean operating time was 299 minutes (range: 195-425). The conversion rate was 14% (n = 2). Mortality was 0% and morbidity was 50%, consisting of three major complications and four minor complications. No anastomotic dehiscence or wound infections were observed. Complete (R0) resections were achieved in 92.8% (n = 13). Transfusion needs were 1.1 U/patient. The mean number of nodes removed was 10.2/patient (range: 5-17). The mean length of hospital stay was 21 days (range: 9-64). Postoperative follow-up ranged from 1 to 17 months. All patients were alive and disease-free except for one patient with liver metastases. CONCLUSIONS: Although MIE is a demanding technique, we believe that it is technically feasible in the treatment of esophageal cancer with acceptable postoperative morbidity and mortality. Consequently, it should be considered as an alternative to open surgery in selected patients.

Esofagectomía mínimamente invasiva / Minimally invasive esophagectomy

Introducción. La resección quirúrgica, la radioterapia y la quimioterapia son en la actualidad las bases para el tratamiento del cáncer de esófago. Entre las diferentes técnicas quirúrgicas, la esofagectomía mínimamente invasiva (EMI) pretende reducir la agresión quirúrgica y las complicaciones cardiopulmonares manteniendo los principios oncológicos básicos. Presentamos los resultados de nuestra primera experiencia con esta técnica en el tratamiento del cáncer de esófago. Material y método. Se seleccionó a 14 pacientes con diagnóstico de cáncer de esófago para intervenirlos con la técnica EMI en 3 tiempos: toracoscopia derecha, laparoscopia y cervicotomía izquierda con anastomosis esofagogástrica a nivel cervical. Los diagnósticos histológicos fueron de carcinoma epidermoide (n = 11) y displasia de alto grado (n = 3), uno de ellos con alta sospecha de transformación maligna. Tras el estudio de extensión, los estadios clínicos preoperatorios fueron los siguientes: estadio 0 (n = 3), estadio IIA (n = 10) y estadio III (n = 1); 7 pacientes fueron tratados con quimioterapia y radioterapia neoadyuvante y el resto, con cirugía sin tratamiento previo. Resultados. La duración media de la intervención ha sido de 299 min (intervalo, 195-425 min). El índice de reconversiones ha sido del 14% (n = 2). La mortalidad fue 0 en esta serie y la morbilidad, del 50%, 3 complicaciones mayores y 4 menores, sin que se apreciara ninguna dehiscencia anastomótica ni infección de herida. La tasa de resecciones completas R0 fue del 92,8% (n = 13). Las necesidades transfusionales han sido de 1,1 U/paciente. La media de ganglios extirpados ha sido de 10,2/paciente (intervalo, 5-17). La estancia media ha sido de 21 (9-64) días. El seguimiento postoperatorio oscila entre 1 y 17 meses, y todos los pacientes están vivos y libres de enfermedad, a excepción de una paciente con metástasis hepáticas. Conclusiones. A pesar de ser una técnica exigente, consideramos que la EMI en el tratamiento del cáncer esofágico es técnicamente posible y tiene una aceptable morbimortalidad postoperatoria, por lo que habría que considerarla como una alternativa a la cirugía abierta en casos seleccionados (AU)

Introduction. Currently, the bases for the treatment of esophageal cancer are surgical resection and chemotherapy. Among the various surgical techniques used, minimally invasive esophagectomy (MIE) aims to reduce surgical aggression and cardiopulmonary complications while maintaining basic oncological principles. We present the results of our initial experience with this technique in the treatment of esophageal cancer. Material and method. Fourteen patients with a diagnosis of esophageal cancer were selected to undergo MIE in three stages: right thoracoscopy, laparoscopy, and left cervicotomy with cervical esophagogastric anastomosis. Histological diagnosis was epidermoid carcinoma (n = 11) and high grade dysplasia (n = 3), one of which was highly suspicious of malignant transformation. After extension studies, preoperative clinical stages were as follows: stage 0 (n = 3), stage IIA (n = 10), and stage III (n = 1). Seven patients were treated with chemotherapy and neoadjuvant radiotherapy and the remainder underwent surgery without prior treatment. Results: The mean operating time was 299 minutes (range: 195-425). The conversion rate was 14% (n = 2). Mortality was 0% and morbidity was 50%, consisting of three major complications and four minor complications. No anastomotic dehiscence or wound infections were observed. Complete (R0) resections were achieved in 92.8% (n = 13). Transfusion needs were 1.1 U/patient. The mean number of nodes removed was 10.2/patient (range: 5-17). The mean length of hospital stay was 21 days (range: 9-64). Postoperative follow-up ranged from 1 to 17 months. All patients were alive and disease-free except for one patient with liver metastases. Conclusions. Although MIE is a demanding technique, we believe that it is technically feasible in the treatment of esophageal cancer with acceptable postoperative morbidity and mortality. Consequently, it should be considered as an alternative to open surgery in selected patients (AU)

Glucagonoma and pseudoglucagonoma syndrome.

CONTEXT: Glucagonoma syndrome may present either associated with a pancreatic neoplasm which secretes glucagon or as a pseudo-glucagonoma associated with other diseases. It is extremely infrequent but well-known with a current prevalence estimated at 1/20,000,000. DESIGN: A retrospective review of glucagonoma and pseudoglucagonoma cases observed between January 1998 and December 2003 in three hospitals. PATIENTS: Five cases: 3 with a demonstrable glucagon-secreting tumor and 2 cases without an associated neoplasm. MAIN OUTCOME MEASURES: Age, sex, initial diagnosis, associated symptoms, and pathology were analyzed as were procedures employed in diagnosis, imaging studies, laboratory data, surgery and follow-up. RESULTS: Hyperglycemia and elevated plasma glucagon levels were found in all cases. In 3 cases, hypo-aminoacidemia and a descrease in fatty acids were found. No changes of zinc levels were observed. Abdominal ultrasound studies were of no value except in evaluating pancreatitis. A CT-scan was conclusive when a pancreatic neoplasm existed and 3 patients were operated on a curative basis. DISCUSSION: Necrolytic migratory erythema was the key diagnosis in all cases. Surgery was intended to be curative. The follow-up was of 8, 37 and 57 months in the cases of true glucagonoma syndrome. CONCLUSIONS: A real prevalence of glucagonoma syndrome could be greater than currently estimated. In our series, it was 13.5/20,000,000. Pseudoglucagonoma syndrome remains a rarity.