¿Sirven los hallazgos prequirúrgicos para interpretar las lesiones ováricas neoplásicas y no neoplásicas e influir en las decisiones quirúrgicas en niñas y adolescentes? / Can preoperative findings help to interpret neoplastic and non-neoplastic lesions of ovary and affect surgical decisions in children and adolescents?

Antecedentes. Las masas ováricas son frecuentes en la población pediátrica. Suele realizarse cirugía conservadora de los ovarios porque la mayoría son quistes benignos o funcionales. Objetivo. Investigar quéhallazgos prequirúrgicos sirven para diferenciar la patología de las lesiones ováricas, influir en las decisiones quirúrgicas y predecir la posibilidad de conservar los ovarios. Método. Se incluyeron pacientes operadas con diagnóstico de masa ovárica. Revisión retrospectiva de edad, síntomas, examen físico, marcadores tumorales, características radiológicas y resultados anatomopatológicos. Resultados. Durante el estudio, se operaron 98 pacientes y se incluyeron 86. Media de edad: 9,7 ± 5,62 años. Las patologías no neoplásicas representaron el 68,6 %, las neoplásicas, el 31,4 %, la tasa de malignidad, el 4,6 %. Las neoplasias incluyeron componente sólido, ausencia de torsión ovárica y diámetro >9 cm (p < 0,001;p < 0,001; p = 0,001).Se halló torsión anexial en el 34,9 %. El diámetro medio no difirió significativamente entre los grupos con o sin torsión; la incidencia de torsión fue mayor en las masas <6 cm (p = 0,019). Se realizó cirugía conservadora de los ovarios en 48 pacientes (55,8 %) y ooforectomía, en 38 (44,2 %). El tratamiento dependió de la naturaleza (p < 0,001) y del tamaño (p < 0,001) de la lesión pero no de la edad y la torsión. Conclusión. Una masa puramente quística <9 cm, con torsión y marcadores negativos indica masa no neoplásica. La presencia de un componente sólido y la ausencia de torsión están asociadas con riesgo de cáncer.

Background: Ovarian masses are common in all pediatric age groups. Ovarian-sparing surgery is favored since most cases are benign or functional cysts. Detection of a few malignant cases prevents morbidity and mortality. Objective: to investigate which of the preoperative findings can help to distinguish the pathology of the ovarian lesions, affect the surgical decision and predict the possibility of ovarian preservation. Method: Patients operated with diagnosis of ovarian mass were enrolled in the study between 2000-2015. Age, symptoms, physical examination findings, tumor markers, radiologic features, operative notes, and pathology results were reviewed retrospectively. Results: During the study period, 98 patients were operated and 86 were included. Mean age was 9.7±5.62 years. Non-neoplastic pathologies constitute 68.6 % of cases; 31.4 % was neoplastic. Malignancy rate was 4.6 %. Solid component, absence of ovarian torsion and diameter >9 cm were more commonly seen in neoplastic cases (p<0.001, p<0.001, p=0.001). Adnexal torsion was found in 30 (34.9 %) patients. Mean diameter did not differ significantly between groups with or without torsion; incidence of torsion was greater in patients with masses <6 cm (p=0.019). Ovarian-sparing surgery was performed in 48 (55.8 %) and oopherectomy in 38 (44.2 %) patients. Surgical approach was affected by nature (p<0.001) and size (p<0.001) of the lesion; it was independent of age and presence of torsion. Conclusion: A purely cystic mass <9 cm, with torsion and negative markers, orients towards a non-neoplastic mass. The presence of solid component and absence of torsion are associated with increased risk of malignancy.

Can preoperative findings help to interpret neoplastic and non-neoplastic lesions of ovary and affect surgical decisions in children and adolescents? / ¿Sirven los hallazgos prequirúrgicos para interpretar las lesiones ováricas neoplásicas y no neoplásicas e influir en las decisiones quirúrgicas en niñas y adolescentes?

BACKGROUND: Ovarian masses are common in all pediatric age groups. Ovarian-sparing surgery is favored since most cases are benign or functional cysts. Detection of a few malignant cases prevents morbidity and mortality. Objective: to investigate which of the preoperative findings can help to distinguish the pathology of the ovarian lesions, affect the surgical decision and predict the possibility of ovarian preservation. METHOD: Patients operated with diagnosis of ovarian mass were enrolled in the study between 2000-2015. Age, symptoms, physical examination findings, tumor markers, radiologic features, operative notes, and pathology results were reviewed retrospectively. RESULTS: During the study period, 98 patients were operated and 86 were included. Mean age was 9.7±5.62 years. Non-neoplastic pathologies constitute 68.6 % of cases; 31.4 % was neoplastic. Malignancy rate was 4.6 %. Solid component, absence of ovarian torsion and diameter > 9 cm were more commonly seen in neoplastic cases (p < 0.001, p < 0.001, p=0.001). Adnexal torsion was found in 30 (34.9 %) patients. Mean diameter did not differ significantly between groups with or without torsion; incidence of torsion was greater in patients with masses < 6 cm (p=0.019). Ovariansparing surgery was performed in 48 (55.8 %) and oopherectomy in 38 (44.2 %) patients. Surgical approach was affected by nature (p < 0.001) and size (p < 0.001) of the lesion; it was independent of age and presence of torsion. CONCLUSION: A purely cystic mass < 9 cm, with torsion and negative markers, orients towards a non-neoplastic mass. The presence of solid component and absence of torsion are associated with increased risk of malignancy.

Antecedentes. Las masas ováricas son frecuentes en la población pediátrica. Suele realizarse cirugía conservadora de los ovarios porque la mayoría son quistes benignos o funcionales. Objetivo. Investigar qué hallazgos prequirúrgicos sirven para diferenciar la patología de las lesiones ováricas, influir en las decisiones quirúrgicas y predecir la posibilidad de conservar los ovarios. Método. Se incluyeron pacientes operadas con diagnóstico de masa ovárica. Revisión retrospectiva de edad, síntomas, examen físico, marcadores tumorales, características radiológicas y resultados anatomopatológicos. Resultados. Durante el estudio, se operaron 98 pacientes y se incluyeron 86. Media de edad: 9,7 ± 5,62 años. Las patologías no neoplásicas representaron el 68,6 %, las neoplásicas, el 31,4 %, la tasa de malignidad, el 4,6 %. Las neoplasias incluyeron componente sólido, ausencia de torsión ovárica y diámetro > 9 cm (p< 0,001;p< 0,001; p = 0,001).Se halló torsión anexial en el 34,9 %. El diámetro medio no difirió significativamente entre los grupos con o sin torsión; la incidencia de torsión fue mayor en las masas < 6 cm (p = 0,019). Se realizó cirugía conservadora de los ovarios en 48 pacientes (55,8 %) y ooforectomía, en 38 (44,2 %). El tratamiento dependió de la naturaleza (p< 0,001) y del tamaño (p< 0,001) de la lesión pero no de la edad y la torsión. Conclusión. Una masa puramente quística < 9 cm, con torsión y marcadores negativos indica masa no neoplásica. La presencia de un componente sólido y la ausencia de torsión están asociadas con riesgo de cáncer.

Radioterapia neoadyuvante e intraoperatoria en sarcoma de muslo y región poplítea para salvamento de extremidad. Reporte de caso y revisión de la literatura / Preoperative and intraoperative radiotherapy for limb sparing surgical resection in a popliteal fossa sarcoma. Case report and review of the literature

Resumen Los sarcomas de tejidos blandos de las extremidades necesitan para su manejo la realización de resecciones oncológicas amplias con el fin de lograr márgenes negativos. En ocasiones los casos con compromiso de estructuras neurovasculares y/u óseas requieren la amputación de la extremidad como única alternativa quirúrgica. Presentamos el caso de un paciente con diagnóstico de liposarcoma que comprometía la fosa poplítea y el paquete neurovascular. Recibió radioterapia neoadyuvante, resección compartimental y radioterapia intraoperatoria, que posibilitaron la conservación de la extremidad. La cirugía logró márgenes microscópicos libres, con una adecuada funcionalidad y sin recaída a los 42 meses de seguimiento.

Abstract The patients with soft tissue sarcomas of the extremities are best treated with wide local excisions, with resection of the primary tumor and normal tissue around the lesion, in order to achieve negative margins; usually when the nerves, the vessels or the bone are surrounded by the tumor, amputation is needed. We report the case of a patient with Liposarcoma in the popliteal fossa, with the tumor involving the nerve and popliteal vessels. The patient underwent to limb-sparing treatment, including preoperative radiotherapy, wide local excision and intraoperative radiotherapy, allowing to keep the extremity, with negative margins, acceptable function of the limb and without recurrence after 42 months of follow up.

Alternativas quirúrgicas conservadoras del útero ante la hemorragia postparto / Conservative surgical alternatives of the uterus on postpartum hemorrhage

La hemorragia posparto es una de las complicaciones obstétricas más temidas y una de las tres primeras causas de mortalidad materna en el mundo, que afecta aproximadamente el 2 % de todas las mujeres parturientas. En su manejo es crucial una actuación inmediata y secuencial, que inicia con el tratamiento farmacológico tradicional y que en muchas ocasiones no logra ser efectivo para detener el sangrado, por lo que se hace necesaria la intervención quirúrgica. El tratamiento conservador del útero ha demostrado ser una alternativa terapéutica útil para disminuir la hemorragia y conservar la fertilidad en aquellas pacientes con paridad no satisfecha. La presente revisión tiene como objetivo recopilar las principales alternativas quirúrgicas conservadoras del útero ante la hemorragia posparto. Ello permitirá a los profesionales vinculados a la atención de la paciente obstétrica grave, profundizar en el conocimiento sobre las técnicas más utilizadas en la actualidad.

Postpartum haemorrhage is one of the most feared obstetric complications and one of the top three causes of world maternal mortality, affecting approximately 2% of all women in labor. In its management, an immediate and sequential approach is crucial, which starts with traditional pharmacological treatment and which in many cases fails to be effective in stopping bleeding, makes surgical intervention necessary. Conservative treatment of the uterus has been shown to be a useful therapeutic alternative for reducing bleeding and preserving fertility in those patients with unsatisfied parity. The present review aims at compiling the main conservative surgical alternatives of the uterus on postpartum haemorrhage. This will allow professionals related to the attention of the severely ill obstetric patient, to deepen on the most currently used techniques.

Complicaciones del uso del pesario con soporte y sin soporte en el prolapso genital completo / Complications from the use of pessary with support and without support in the complete genital prolapse

INTRODUCCIÓN: La prevalencia del prolapso genital se ha incrementado; a menudo cursa de forma asintomática, se suele presentar con síntomas de un "bulto" vaginal. Las opciones de tratamiento incluyen ejercicios del suelo pélvico, manejo expectante, el uso de dispositivos mecánicos y corrección quirúrgica. OBJETIVO: Evaluar las complicaciones inmediatas y tardías del uso del pesario sin soporte y con soporte, en el manejo conservador del prolapso genital completo. MATERIALES Y MÉTODOS: Estudio descriptivo, observacional, transversal y comparativo. Se revisaron 108 historias clínicas de las pacientes atendidas por prolapso genital completo y se evaluaron a las que se les manejó de forma conservadora con pesarios con soporte (Grupo A: 9) y sin soporte (Grupo B: 18). Los dos grupos se compararon tomando en cuenta el aumento de secreción vaginal, aparición de erosión y úlceras vaginales, impactación, fístulas, atipias citológicas, incarceración, hidronefrosis, infección vaginal y complicaciones intestinales. RESULTADOS: Se analizaron 27 pacientes en total, 9 manejadas con pesarios con soporte y 18 con pesarios sin soporte. Hubo diferencia significativa en cuanto al aumento de secreción vaginal con menor secreción en uso del pesarios sin soporte (p=0,045). Se encontró diferencia en la aparición de erosión y úlceras vaginales (p < 0,05). CONCLUSIONES: Hay diferencia significativa en cuanto al aumento de la secreción vaginal y la aparición de erosión y úlceras vaginales en el uso de pesarios sin soporte en comparación con el uso de pesarios con soporte

INTRODUCTION: The prevalence of genital prolapse has increased; often it is asymptomatic, usually presents with symptoms of a vaginal "bulge". Treatment options include pelvic floor exercises, expectant management, the use of mechanical devices and surgical correction. OBJECTIVES: Evaluate the immediate and late complications of the use of pessary without support and with support in the conservative management of the entire genital prolapse. MATERIALS AND METHODS: Descriptive, observational, transversal and comparative study. 108 medical records of patients treated by complete genital prolapse were reviewed and evaluated which were managed conservatively with pessaries supported (Group A: 9) and unsupported (Group B: 18). The two groups are compared taking into account the increased vaginal discharge, vaginal appearance of erosion and ulcers, impaction, fistulas, cytologic atypia, incarceration, hydronephrosis, vaginal infection and intestinal complications. RESULTS: 27 patients were analyzed in total, 9 handled pessaries supported and 18 unsupported pessaries. There was significant difference in terms of vaginal discharge increasment with less secretion in unsupported use of pessaries (p = 0.045). A difference was found in the occurrence of erosion and vaginal ulcers (p < 0.05 ). CONCLUSIONS: There is a significant difference in terms of vaginal discharge increasment and occurrence of erosion and ulcers vaginal pessaries using unsupported compared with using supported pessaries

Fracturas por compresión vertical de columna lumbar / Vertical compression fracture of the lumbar spine

Fundamento: las fracturas de columna por el mecanismo de compresión axial sin lesión neurológica, constituyen un paradigma en relación a su tratamiento conservador o quirúrgico. Existen controversias en la literatura sobre el tipo de tratamiento de esta lesión. Objetivo: realizar una revisión sobre los criterios de selección de ambos tipos de tratamiento. Métodos: se realizó una revisión bibliográfica de un total de 330 artículos publicados en Pubmed, Hinari y Medline mediante el localizador de información Endnote, de ellos se utilizaron 52 citas seleccionadas para realizar la revisión, 46 de ellas de los últimos cinco años donde se incluyeron dos libros. Desarrollo: se analizaron diferentes factores para decisión del tipo del tratamiento, entre los que se encontraron: la escala de severidad de las fracturas del segmento lumbosacro propuesta por Vaccaro AR, los grados de cifosis, la usurpación del canal medular. Por otra parte se realizó una comparación de diferentes autores en relación al tipo de tratamiento empleado en sus investigaciones y las indicaciones quirúrgicas para sus pacientes. Conclusiones: basado en la revisión realizada y los estudios consultados, los pacientes con fractura de columna sin lesión neurológica pueden ser tratados de forma conservadora independientemente del grado de inestabilidad mecánica que presenten.

Background: fractures of the spine by axial compression mechanism without neurological lesion are a paradigm in connection with its conservative or surgical treatment. There is controversy in the literature about the type of treatment of this lesion. Objective: to make a review about the selection criteria of both types of treatment. Methods: a bibliographic review of 330 articles published in Pubmed, Hinari and Medline by means of the reference management software Endnote was made. Fifty-two citations were selected for the review, 46 of them from the last five years; two books were included. Development: different factors for deciding the type of treatment were analysed. Some of the factors were the following: severity scale of the fractures of the lumbosacral segment proposed by Vaccaro AR, kyphosis degree, and medullary channel. On the other hand, a comparison of different authors was made according to the treatment applied in their researches and the surgical indications for their patients. Conclusions: according to the review made and the studies consulted, the patients with fractures of the spine without neurological lesion can be treated conservatively in spite of the degree of mechanical instability they present.

Repair of aortic root in patients with aneurysm or dissection: comparing the outcomes of valve-sparing root replacement with those from the Bentall procedure / Reparação de raiz aórtica em pacientes com aneurisma ou dissecção: comparando os resultados da técnica de substituição valve-sparing com os da operação de Bentall

INTRODUCTION: Management of aortic root aneurysm or dissection has been the subject of much discussion that has led to some modifications. The current trend is a valve-sparing root replacement. We compared the outcome following valve sparing root repair with Bentall procedure. METHODS: We retrospectively evaluated 70 patients who underwent root replacement for aneurysm or dissection and compared the outcomes of valve-sparing root replacement with those of the Bentall procedure from January 2007 to December 2011 at our institution. RESULTS: Twenty-five patients had valve-sparing aortic root replacement (VSR, including reimplantation or remodeling) (23 males and 2 females), and 45 patients had the Bentall procedure (34 males and 11 females). Patients who underwent a VSR were younger with a mean age of 55.4 ± 14.8 years compared to those who underwent the Bentall procedure with a mean age of 60.6 ± 12.7 (P=ns). The preoperative aortic insufficiency (AI) in the VSR group was moderate in 8 (32%) patients, and severe in 6 (24%). Preoperative creatinine was 1 ± 0.35 mg/dl in the VSR group and 1.1 ± 0.87 mg/dl in the Bentall group. In the VSR group, 3 (12%) patients had emergency surgery; by contrast, in the Bentall group, 8 (17%) patients had emergent surgery. Concomitant coronary artery bypass grafting (excluding coronary reimplantation) was performed in 8 (32%) patients in the VSR group and in 12 (26.6%) patients in the Bentall group (P=0.78); additional valve procedures were performed in 2 (8%) patients in the VSR group and in 11 (24.4%) patients in the Bentall group. The perioperative mortality was 8% (n=2) and 13.3% (n=6), for the VSR and Bentall procedures, respectively (P=0.7, ns). The total duration of intensive care unit stay was 116.6 ± 106 hours for VSR patients and 152.5 ± 218.2 hours for Bentall patients (P=0.5). The overall length of stay in the hospital was 10 ± 8.1 days for VSR and 11 ± 9.52 days for Bentall (P=0.89). The one-year survival was 92% for the VSR group and 79.0% for the Bentall group. The seven-year survival for the VSR group was 92% and 79% for the Bentall group (95% CI [1.215 to 0.1275], P=0.1). CONCLUSION: Aortic valve-sparing root replacement can be performed with acceptable morbidity and mortality with a comparable long-term survival to the Bentall procedure.

INTRODUÇÃO: Manejo de aneurisma da aorta ou dissecção da raiz tem sido objeto de muita discussão que levou a algumas modificações. A tendência atual é o uso da técnica de substituição valve-sparing (VSR). Nós comparamos o resultado da reparação da raiz utilizando a técnica de substituição valve-sparing com o procedimento de Bentall. MÉTODOS: Foram avaliados, retrospectivamente, 70 pacientes submetidos à substituição da raiz de aneurisma ou dissecção, comparando os resultados da técnica de substituição valve-sparing com os do procedimento Bentall de janeiro de 2007 a dezembro de 2011 em nossa instituição. RESULTADOS: Vinte e cinco pacientes foram submetidos à substituição da valva aórtica com o uso da técnica valve-sparing (VSR, incluindo o reimplante ou remodelação) (23 homens e duas mulheres), e 45 pacientes pelo procedimento de Bentall (34 homens e 11 mulheres). Pacientes que se submeteram à VSR eram mais jovens, com idade média de 55,4 ± 14,8 anos em comparação àqueles que foram submetidos ao procedimento Bentall, idade média de 60,6 ± 12,7 anos (P = ns). A insuficiência aórtica pré-operatória no grupo VSR foi moderada em oito (32%) pacientes e grave em seis (24%). Creatinina pré-operatória foi 1 ± 0,35 mg/dl, no grupo do VSR, e 1,1 ± 0,87 mg/dl, no grupo de Bentall. No grupo VSR, três (12%) pacientes foram operados em caráter de emergência e, no grupo de Bentall, oito (17%). Revascularização do miocárdio concomitante (excluindo reimplante coronariano) foi realizada em oito (32%) pacientes no grupo VSR e, em 12 (26,6%), no grupo de Bentall (P=0,78); procedimentos valvares adicionais foram realizados em 2 (8%) pacientes no grupo do VSR e em 11 (24,4%) no grupo de Bentall. A mortalidade perioperatória foi de 8% (n = 2) e 13,3% (n = 6), para os procedimentos de VSR e Bentall, respectivamente (P=0,7, ns). O tempo de internação na unidade de terapia intensiva foi de 116,6 ± 106,0 horas para pacientes VSR e 152,5 ± 218,2 horas para pacientes Bentall (P=0,5). O tempo de permanência no hospital foi de 10 ± 8,1 dias para VSR e 11 ± 9,52 dias para Bentall (P=0,89). A sobrevida em um ano foi de 92,0 % para o grupo VSR e 79,0% para o grupo de Bentall. A sobrevivência de sete anos para o grupo VSR foi de 92% e 79% para o grupo de Bentall (IC95% [1,215 a 0,1275], P=0,1). CONCLUSÃO: A técnica valve-sparing substituição da raiz aórtica pode ser realizada com a morbidade e mortalidade aceitáveis, e sobrevivência aceitável a longo prazo comparável com o procedimento de Bentall.

Laringectomía total ampliada en carcinoma laríngeo avanzado T4a / Total laryngectomy in advanced laryngeal neoplasma T4a

Background: In Chile a significant number of patients is presented with advanced laryngeal cancer at diagnosis with poor prognosis and less than 50% survival at 5 years. Nowadays choosing the organ sparing treatment, but in selected cases total laryngectomy is a valid treatment option. Aim: To present the results obtained with the extended total laryngectomy in patients with advanced laryngeal carcinoma. Patients and Methods: Retrospective analysis of all patients with advanced laryngeal carcinoma T4a underwent total extended laryngectomy at our center between 2007-2010. Results: 18 patients, a woman, a median age 64 years (range, 50-82), they were studied and etapified with Rhino-Laryngo-Fibrescope Olympus© and CT. Seven patients underwent emergency tracheostomy. All patients underwent total extended laryngectomy with primary pharyngeal closure. The median tumor size was 4.3cm. In 17 patients R0 was achieved. Postoperative complication was presented in one patient with a pharyngocutaneous fistula. Thirteen patients were sent to radiotherapy. After a follow-up of 17 months (range, 2-55): one, two and three years of survival was 88.8 percent, 50 percent and 50 percent respectively. Conclusion: In the serie, extended total laryngectomy is a good therapeutic alternative in patients with advanced laryngeal carcinoma, with low surgical morbidity, short hospital stay and favorable survival.

Introducción: En Chile se presenta un importante número de pacientes con cáncer laríngeo avanzado al momento del diagnóstico, con mal pronóstico y una supervivencia menor al 50 por ciento a 5 años. Actualmente, se opta por el tratamiento conservador de órganos, en casos seleccionados la laringectomía total es una alternativa. Objetivo: Presentar los resultados de la laringectomía total ampliada en carcinoma laríngeo avanzado. Pacientes y Método: Análisis retrospectivo de los pacientes con carcinoma laríngeo avanzado T4a sometidos a laringectomía total ampliada en nuestro centro entre 2007-2010. Resultados: La serie estuvo constituida por 18 pacientes, una mujer, mediana de 64 años (rango, 50-82), estudio y etapificación con nasofibroscopia y TC. En siete pacientes se realizó traqueostomía de urgencia. En todos los pacientes se realizó laringectomía total ampliada. El tamaño tumoral fue 4,3 cm como mediana. En 17 pacientes se logró R0. Como complicación un paciente presentó una fístula faringocutánea. Fueron enviados a radioterapia 13 pacientes. Tras un seguimiento de 17 meses (rango, 2-55): la supervivencia a uno, a dos y a tres años fue de 88,8 por ciento, 50 por ciento y 50 por ciento respectivamente. Conclusión: En esta serie, la laringectomía total ampliada es una buena alternativa para los pacientes con carcinoma laríngeo avanzado T4a por su baja morbilidad quirúrgica, corta estadía hospitalaria y supervivencia favorable.