[Manejo quirúrgico del divertículo de Zenker]. / Surgical treatment of Zenker's diverticulum.

INTRODUCCIÓN: Los divertículos de Zenker son los divertículos más frecuentes del esófago. El tratamiento quirúrgico más utilizado es la diverticulectomía con miotomía del cricofaríngeo abierta. En años recientes se ha propuesto el tratamiento endoscópico. OBJETIVO: Presentar la experiencia en el manejo de esta patología en un hospital de referencia. MÉTODO: Fueron revisados los expedientes de los pacientes intervenidos quirúrgicamente por divertículo de Zenker en un periodo de 7 años. Los datos obtenidos incluyeron demográficos, cuadro clínico, abordaje diagnóstico, hallazgos transoperatorios y evolución posoperatoria. RESULTADOS: Fueron intervenidos 10 pacientes durante este periodo, con una edad promedio de 64 años (± 8); siete de ellos eran hombres. Los principales síntomas fueron regurgitación y disfagia, presentes en ocho y siete pacientes, respectivamente. Los estudios diagnósticos incluyeron endoscopia (nueve pacientes), esofagograma (seis pacientes) y manometría esofágica (tres pacientes). El tratamiento utilizado en todos los casos fue diverticulectomía con miotomía del cricofaríngeo. Las complicaciones incluyeron perforación esofágica transoperatoria (un paciente) y fístula esofágica (un paciente). Hubo resolución de los síntomas en nueve pacientes; el paciente restante ameritó nueva miotomía seis meses después, con una adecuada evolución. No hubo ninguna muerte. CONCLUSIONES: La diverticulectomía con miotomía del cricofaríngeo es un tratamiento quirúrgico seguro para los pacientes con divertículo de Zenker. BACKGROUND: Zenker's diverticulum represents the most common diverticulum of the esophagus. The standard surgical treatment consists of open cricopharyngeal myotomy with diverticulectomy. In recent years endoscopic treatment has been proposed. OBJECTIVE: We present the surgical experience of this disease in a referral hospital. METHOD: We reviewed the clinical records of all patients submitted to open surgical treatment for Zenker's diverticulum in a 7-year period. The retrieved information included demographic data, clinical manifestations, diagnostic approach, surgery findings and postoperative evolution. RESULTS: During this period 10 patients were submitted to open surgical treatment; the mean age was 64 (± 8) years and seven of them were male. The main complaint was regurgitation and dysphagia that was present in eight and seven patients respectively. Diagnostic studies included endoscopy (nine patients), esophagogram (six patients) and esophageal manometry (three patients). All underwent open cricopharyngeal myotomy with diverticulectomy. Complications included intraoperative esophageal perforation (one patient) and postoperative esophageal fistula (one patient). Resolution of the symptomatology occurred in 9 patients, the other patient required a new myotomy six months later with good results. There was no mortality. CONCLUSIONS: Cricopharyngeal myotomy with diverticulectomy is a safe option for patients with Zenker's diverticulum.

Robotic-assisted Roux-en-Y hepaticojejunostomy after bile duct injury.

BACKGROUND: The Da Vinci Robotic Surgical System has positioned itself as a tool that improves the ergonomics of the surgeon, facilitating dissection in confined spaces and enhancing the surgeon's skills. The technical aspects for successful bile duct repair are well-vascularized ducts, tension-free anastomosis, and complete drainage of hepatic segments, and all are achievable with robotic-assisted approach. METHODS: This was a retrospective study of our prospectively collected database of patients with iatrogenic bile duct injury who underwent robotic-assisted Roux-en-Y hepaticojejunostomy. Pre-, intra-, and short-term postoperative data were analyzed. RESULTS: A total of 30 consecutive patients were included. The median age was 46.5 years and 76.7% were female. Neo-confluences with section of hepatic segment IV were performed in 7 patients (those classified as Strasberg E4). In the remaining 23, a Hepp-Couinaud anastomosis was built. There were no intraoperative complications, the median estimated blood loss was 100 mL, and the median operative time was 245 min. No conversion was needed. The median length of stay was 6 days and the median length of follow-up was 8 months. The overall morbidity rate was 23.3%. Two patients presented hepaticojejunostomy leak. No mortality was registered. CONCLUSION: Robotic surgery is feasible and can be safely performed, with acceptable short-term results, in bile duct injury repair providing the advantages of minimally invasive surgery. Further studies with larger number of cases and longer follow-up are needed to establish the role of robotic assisted approaches in the reconstruction of BDI.

Colédoco-duodeno anastomosis laparoscópica / Laparoscopic Choledochoduodenostomy

Introducción: Las opciones actuales para realizar procedimientos permanentes de derivación biliodigestiva, secundarios a coledocolitiasis compleja, van desde la cirugía abierta hasta el empleo de procedimientos híbridos laparoendoscópicos. El objetivo del estudio fue realizar un análisis de los resultados obtenidos en pacientes con coledocolitiasis compleja tratados con colédoco-duodeno anastomosis laparoscópica. Métodos: Se realizó un estudio observacional longitudinal en el período comprendido de marzo de 2011 a junio de 2016. Se incluyeron pacientes con coledocolitiasis compleja no resuelta por CPRE o resueltas por CPRE pero con dilatación masiva de vía biliar y evidencia de colestasis persistente, los cuales fueron seleccionados para procedimiento quirúrgico con colédoco-duodeno anastomosis. Resultados: Se incluyeron un total de 19 pacientes. La mayoría mujeres (78,9%), con edad media avanzada (72,4 ± 12 años) y con múltiples comorbilidades. Todos con al menos un episodio (mín-máx: 1-7) de coledocolitiasis o colangitis previos. El diámetro del colédoco fue de 24,9 ± 7mm. El tiempo quirúrgico fue de 218,5 ± 74 min, sangrado de 150 (30-600) mL, inicio de dieta en 3,2 ± 1 días y estancia hospitalaria postoperatoria de 4,9 ± 2 días. Se encontró una mediana de 18 (12-32) meses de seguimiento. Posterior al procedimiento se observó normalización de las pruebas de funcionamiento hepático. Un paciente presentó síndrome del sumidero y un paciente falleció por neumonía nosocomial. Conclusiones: La colédoco-duodeno anastomosis laparoscópica asistida con coledocoscopia representa una técnica segura y eficaz para el tratamiento de pacientes con coledocolitiasis compleja con indicación de derivación biliodigestiva, ofreciendo los beneficios de la cirugía de mínima invasión (AU)

Introduction: Today's options for biliary bypass procedures, for difficult choledocholithiasis, range from open surgery to laparo-endoscopic hybrid procedures. The aim of this study was to analyze the outcomes of patients with difficult choledocholithiasis treated with laparoscopic choledochoduodenostomy. Methods: We performed a prospective observational study from March 2011 to June 2016. We included patients with difficult common bile duct stones (recurrent or unresolved by ERCP) in which a biliary bypass procedure was required. We performed a laparoscopic bile duct exploration with choledochoduodenostomy and intraoperative cholangioscopy. Results: A total of 19 patients were included. We found female predominance (78.9%), advanced mean age (72.4 ± 12 years) and multiple comorbidities. Most patients with previous episodes of choledocholitiasis or cholangitis, mode 1 (min-max: 1-7). Mean common bile duct diameter 24.9 ± 7mm. Mean operative time 218.5 ± 74min, estimated blood loss 150 (30-600) mL, resume of oral intake 3.2±1 days, postoperative length of stay 4.9 ± 2 days. We found a median of 18 (12-32) months of follow-up. All patients with normalization of liver enzymes during follow-up. One patient presented with sump syndrome and one patient died due to nosocomial pneumonia. Conclusions: Laparoscopic choledochoduodenostomy with intraoperative cholangioscopy seems to be safe and effective treatment for patients with difficult common bile duct stones no resolved by endoscopic procedures. This procedure is a good option for patients with advanced age and multiple comorbidities. We offer all the advantages of minimally invasive surgery to these patients (AU)

Laparoscopic Choledochoduodenostomy. / Colédoco-duodeno anastomosis laparoscópica.

INTRODUCTION: Today's options for biliary bypass procedures, for difficult choledocholithiasis, range from open surgery to laparo-endoscopic hybrid procedures. The aim of this study was to analyze the outcomes of patients with difficult choledocholithiasis treated with laparoscopic choledochoduodenostomy. METHODS: We performed a prospective observational study from March 2011 to June 2016. We included patients with difficult common bile duct stones (recurrent or unresolved by ERCP) in which a biliary bypass procedure was required. We performed a laparoscopic bile duct exploration with choledochoduodenostomy and intraoperative cholangioscopy. RESULTS: A total of 19 patients were included. We found female predominance (78.9%), advanced mean age (72.4±12 years) and multiple comorbidities. Most patients with previous episodes of choledocholitiasis or cholangitis, mode 1 (min-max: 1-7). Mean common bile duct diameter 24.9±7mm. Mean operative time 218.5±74min, estimated blood loss 150 (30-600)mL, resume of oral intake 3.2±1 days, postoperative length of stay 4.9±2 days. We found a median of 18 (12-32) months of follow-up. All patients with normalization of liver enzymes during follow-up. One patient presented with sump syndrome and one patient died due to nosocomial pneumonia. CONCLUSIONS: Laparoscopic choledochoduodenostomy with intraoperative cholangioscopy seems to be safe and effective treatment for patients with difficult common bile duct stones no resolved by endoscopic procedures. This procedure is a good option for patients with advanced age and multiple comorbidities. We offer all the advantages of minimally invasive surgery to these patients.

[Disseminated peritoneal hydatidosis manifested as intestinal ischaemia]. / Hidatidosis peritoneal diseminada manifestada como isquemia intestinal.

BACKGROUND: The hydatid disease, or echinococcosis, is endemic in Mediterranean countries, as well as in Australia, Asia, Africa, South America, and Canada. Among its complications is intraperitoneal rupture, a rare form of presentation, with highly variable symptoms. The treatment of choice is surgery plus adjuvant medical treatment in most patients. OBJECTIVE: A case is presented of a patient with disseminated peritoneal hydatidosis manifested as intestinal ischaemia. CLINICAL CASE: A 50-year-old male was admitted to the emergency room with a history of chronic abdominal pain that worsened in the last 24hours. He showed signs of sepsis in the physical examination and was subjected to surgery, in which intestinal ischaemia was found due to a disseminated peritoneal cystic disease, which had led to mesentery retraction. An intestinal resection with an end-ileostomy was performed. The results of the biopsy of the cystic lesions was disseminated peritoneal echinococcosis. Medical treatment was started with albendazole and praziquantel. CONCLUSION: This case shows a rare presentation of disseminated peritoneal hydatidosis, which led to intestinal ischaemia.

Eventración diafragmática en el adulto. Reporte de un caso / Diaphragmatic eventration in adults. Case report

Resumen Introducción: El diafragma es un órgano fibromuscular cuya función fisiológica es otorgar la fuerza mecánica para la ventilación. Otra de las funciones del diafragma es dividir la cavidad torácica de la cavidad abdominal2. El diafragma se ve afectado rara vez por enfermedades. Entre las patologías primarias se encuentra la eventración diafragmática. Reporte de caso: Paciente del sexo femenino de 21 años de edad sin antecedentes de importancia quien presenta caída de su propia altura y trauma contuso en tórax. Se realiza radiografía como parte del estudio y se observa elevación del hemidiafragma izquierdo. El estudio se complementa con tomografía axial computada y se diagnostica eventración diafragmática. Ante los hallazgos, se plantea el procedimiento quirúrgico como terapia definitiva; sin embargo, la paciente no lo acepta, por lo que se ha mantenido en seguimiento por la consulta externa. Discusión: La eventración diafragmática es causada por debilidad de la parte muscular diafragmática. Se cree que es causada por la ausencia congénita o funcional de la musculatura diafragmática. El cuadro clínico generalmente es asintomático; en caso de existir sintomatología, ésta se relaciona a problemas respiratorios. El diagnóstico se corrobora con estudios radiológicos, de los cuales los más utilizados son la radiografía de tórax y la tomografía axial computada. El tratamiento puede ser conservador o quirúrgico. El pronóstico dependerá del grado de hipoplasia pulmonar y la de coexistencia de alguna otra alteración. Conclusión: La eventración diafragmática es rara vez diagnosticada en pacientes adultos asintomáticos. El manejo dependerá de la decisión del cirujano y del paciente.

Abstract Background: The diaphragm is a fibromuscular organ whose primary function is related to ventilation. It also serves as a barrier between pleural and abdominal cavities. This organ is rarely affected by pathologic entities, but eventration is among the primary diseases of this structure. Case Report: We present the case of a 21 year old female with no relevant personal history. She arrived to the emergency room with thoracic blunt trauma. Chest radiography is indicated, showing elevation of the left hemidiaphragm. This study was complemented with a computed tomography making a presumptive diagnosis of diaphragmatic eventration. As part of the treatment, we proposed surgical therapy but the patient refused and now she is under surveillance in her clinic. Discussion: Diaphragmatic eventration is caused by the weakness of the muscular part of the organ. It is thought that is caused by functional or congenital absence of the diaphragmatic musculature. The clinical presentation is variable but, in most of the cases, the patients are asymptomatic. The diagnosis is made by radiologic studies such as chest plains and computed tomography. Treatment could be conservative or surgical. The prognosis will depend on the degree of pulmonary hypoplasia and the coexistence of other malformations. Conclusion: Diaphragmatic eventration is rarely diagnosed in adults and the treatment will depend on the surgeon´s and the patient´s joined decision.