Álvaro Zúñiga

Un índice neutrófilo/linfocito elevado se asocia a peor pronóstico en cáncer de colon etapa II resecado

The neutrophil/lymphocyte ratio is an effective marker of inflammation and can have prognostic value in surgical patients. Aim: To evaluate the effect of an increased neutrophil/lymphocyte ratio (NLR) on perioperative complications ana overall ana disease-free survival in patients undergoing elective resection for stage II colon cancer. Material and Methods: Data was obtained from clinical charts, preoperative blood results and hospital records of all patients undergoing an elective curative resection for colon cancer, between 2000 and 2007. Preoperative NLR was calculated. Follow-up was obtained from a prospectively maintained colorectal cancer database, clinical records and questionnaires. Uni and multivariable analysis were performed to identify associations, and survival analysis was performed using Kaplan-Meier curves. Results: One hundred twenty two patients with a mean age of 69years (52% males), were evaluated. Median follow-up was 73 months, and overall survival for 1 and 5 years was 95% and 68%, respectively. On a multivariable analysis after adjusting for age, sex, tumor depth invasion, use of adjuvant therapies and American Society of Anesthesiology preoperative risk score, an NLR > 5 was associated with an increased perioperative complication rate (odds ratio: 3,06, p = 0,033). Kaplan-Meier survival analysis showed a worse overall and disease-free survival for patients with NLR greater than five. Conclusions: A preoperative NLR of five or more is associated with greater perioperative morbidity and worse oncological outcomes in patients undergoing resection for elective stage II colon cancerBACKGROUND The neutrophil/lymphocyte ratio is an effective marker of inflammation ana can have prognostic value in surgical patients. AIM To evaluate the effect of an increased neutrophil/lymphocyte ratio (NLR) on perioperative complications ana overall ana disease-free survival in patients undergoing elective resection for stage II colon cancer. MATERIAL AND METHODS Data was obtained from clinical charts, preoperative blood results and hospital records of all patients undergoing an elective curative resection for colon cancer, between 2000 and 2007. Preoperative NLR was calculated. Follow-up was obtained from a prospectively maintained colorectal cancer database, clinical records and questionnaires. Uni and multivariable analysis were performed to identify associations, and survival analysis was performed using Kaplan-Meier curves. RESULTS One hundred twenty two patients with a mean age of 69 years (52% males), were evaluated. Median follow-up was 73 months, and overall survival for 1 and 5 years was 95% and 68%, respectively. On a multivariable analysis after adjusting for age, sex, tumor depth invasion, use of adjuvant therapies and American Society of Anesthesiology preoperative risk score, an NLR > 5 was associated with an increased perioperative complication rate (odds ratio: 3.06, p = 0.033). Kaplan-Meier survival analysis showed a worse overall and disease-free survival for patients with NLR greater than five. CONCLUSIONS A preoperative NLR of five or more is associated with greater perioperative morbidity and worse oncological outcomes in patients undergoing resection for elective stage II colon cancer.

The Volume of Lactated Ringer's Solution Required to Maintain Preload and Cardiac Index During Open and Laparoscopic Surgery

BACKGROUND: Recent studies have emphasized the importance of perioperative fluid restriction. However, fluid restriction regimens may increase the likelihood of insufficient perioperative fluid administration or may result in excess intravascular crystalloid replacement. We postulate that the use of transesophageal echocardiography may reduce the amount of crystalloid administered during open and laparoscopic colorectal surgery. METHODS: Fifteen ASA I and II patients scheduled for open colorectal surgery, and 15 patients scheduled for laparoscopic surgery were studied. Lactated Ringers solution was infused during the procedures. Left ventricular end diastolic volume index (LVEDVI) and cardiac index were assessed throughout surgery and used to guide the rate of lactated Ringers solution administration. Statistical analysis was performed with Students t-test for unpaired samples. RESULTS: The rate of crystalloid administration required to maintain baseline LVEDVI and cardiac index was 5.9 ± 2 mL · kg−1 · h−1 for open surgery and 3.4 ± 0.8 mL · kg−1 · h−1 for laparoscopic surgery (P < 0.01). This slower rate for laparoscopic surgery was offset by the longer surgical duration. CONCLUSION: The rate of crystalloid solution to maintain baseline LVEDVI and cardiac index was greater in open surgery than laparoscopic surgery, and lower than commonly recommended for colorectal surgery.

Are topical oestrogens useful in faecal incontinence? Double‐blind randomized trial

Background  Histopathological studies have shown the presence of oestrogenic receptors in the anal sphincter, which presumes a role in muscular trophism for circulating oestrogens. This could explain the increase in faecal incontinence (FI) in postmenopausal women.

New treatment for faecal incontinence using zinc–aluminium ointment: a double‐blind randomized trial

Aim  In a randomized double‐blind study the therapeutic effect of a novel zinc–aluminium ointment was compared with placebo in patients with faecal incontinence.

Abordaje laparoscópico para la reconstrucción de tránsito intestinal post-Hartmann: experiencia de un centro sobre 30 pacientes

INTRODUCTION Intestinal passage reconstruction after Hartmanns (PRH) operation is associated with a high morbidity and mortality of about 1%. Despite the increasing use of laparoscopy as an alternative in PRH, there is a lack of patient series at international level. PATIENTS AND METHODS The prospective series of patients subjected to (PRH) by laparoscopy was analysed using the demographic parameters, ASA classification, reason for primary surgery, time between initial surgery and reconstruction, operation time, conversion to open surgery, bowel rest recovery time, complications, hospital stay and follow up. RESULTS A total of 30 patients with a mean age of 61.5 ± 13 years were operated on using laparoscopy. The ASA classification was 1.8 ± 0.3 the BMI was 26.1 ± 2 Kg/m(2). A total of 63% were admitted due to complicated Hinchley III or IV acute diverticulitis. The interval between initial surgery and the passage reconstruction was 7.1 ± 2 months. Conversion to open surgery was necessary in three cases. The mean intestinal passage recovery was 2.1 ± 1 days and the hospital stay was 5.6 ± 1 days. The long-term complications were one mechanic ileum due to bridles and one case of anastomotic stenosis. CONCLUSIONS The post-Hartmann laparoscopic passage reconstruction is associated with a short intestinal motility recovery time, as well as a less prolonged hospital stay compared to an open surgery series. Randomised studies are needed to determine whether laparoscopic reconstruction is superior to the conventional technique.

Resultados del tratamiento quirúrgico de las metástasis hepáticas por cáncer colorrectal

Background: Surgical resection is the only treatment associated with long-term cure in patients with liver metastasis from colorectal cancer, achieving a 30% to 40% five years survival. Aim: To evaluate the results of liver resection for metastatic colorectal cancer in our centre. Patients and methods: Retrospective study. Epidemiological, perioperative and follow up data of patients undergoing liver resection for metastatic colorectal cancer between January 1990 and July 2007 were assessed. We compared the results between two periods; period 1 (1990-1997) and period 2 (1998-2007). Results: Sixty six patients aged 61±12 years (46 males) underwent 75 resections. An anatomical excision was performed in 54 (72%) cases, a right hepatectomy in 18, an extended right hepatectomy in 11, a left hepatectomy in 1, and a segmentectomy in 24. In 24 (32%) patients the liver resection was simultaneous with the colorectal cancer resection. Operative time was 221±86 min. Hospital stay was 11±5 days. Postoperative morbidity was 35% and surgical mortality was 0%. Resection margin was free of tumor in 53 (80%) patients. Five years overall and hepatic disease-free survival was 38% and 23%, respectively. In period 2, more anatomical resections than in period 1 were performed (77% and 55%, respectively, p =0.04), without an increase in complications (35% and 34%, respectively; p =ns), but with a better five years survival (45% and 21%, respectively, p =0.04). Conclusions: Five years survival for excision of liver metastatic colorectal cancer in our center is similar to that reported abroad. During the second period there has been a trend toward more extensive resections which was associated with a better survival, without an increase in complications or mortality (Rev Med Chile 2009; 137: 487-96). (Key words: Colorectal neoplasms; Neoplasm metastasis; Survival)

Diagnóstico y manejo de colitis ulcerosa grave: Una mirada actualizada

Ulcerative Colitis (UC) is a chronic inflammatory disease involving the colon, with alternating periods of remission and activity. Exacerbations can be severe and associated with complications and mortality. Diagnosis of severe UC is based on clinical, biochemical and endoscopic variables. Patients with severe UC must be hospitalized. First line therapy is the use of intravenous corticoids which achieve clinical remission in most patients. However, 25% of patients will be refractory to corticoids, situation that should be evaluated at the third day of therapy. In patients without response, cytomegalovirus infection must be quickly ruled out to escalate to second line therapy with biological drugs or cyclosporine. Total colectomy must not be delayed if there is no response to second line therapy, if there is a contraindication for second line therapies or there are complications such as: megacolon, perforation or massive bleeding. An active management with quick escalation on therapy allows to decrease the prolonged exposure to corticoids, reduce colectomy rates and its perioperative complications.

Valoración territorial del geopatrimonio de la zona costera del sur del Desierto de Atacama, Chile (27°S)

The southern coastal zone of the Atacama Desert, mainly in the Caldera and Copiapo area, is known for its geomorphological and paleontological features that are recognized nationally and internationally by their geoheritage significance. In this context, a zoning of the territory was carried on, which main objective was to generate a scientific base that takes into account the intrinsic value of these natural elements and that will allow an integrated land use management of this zone. The coastal area is characterized by fossiliferous marine terraces, coastal dunes and particularly by the great Dune Sea located in the coastal range of Copiapo, in addition to protected marine and coastal areas, as Isla Grande de Atacama. In this way, territorial units ranked by its geoheritage value, were determined using a multicriteria analysis methodology, that integrates different spatial variables as geomorphology, location of geosites, coastal vegetation and existing protected areas. Higher valued territorial units resulted to be the dune sea, paleontological sites, fossiliferous cliffs and the wetland of the estuary of the Copiapo river. In particular, the dune sea, forms a remarkable scenic landscape of regional and national importance and this geoheritage component of the coastal desert of northern Chile, jointly with the other highly valorized features, should be considered in the proposals for integrated management of the coastal zone.

Mortality trends from colorectal cancer in Chile.

are to be congratulated on the rigorous approach to data collection, analysis and insightful reflection on the potential limitations of the study design while providing important data relevant to a large proportion of colorectal surgical practice. Indeed we also concur with the editor’s commentary indicating that this article raises questions still outstanding in the pursuit of a paradigm shift towards laparoscopic colorectal surgery. The authors demonstrate that patients undergoing laparoscopic surgery have more favourable characteristics including female sex, higher location of rectal tumour and lower Union for International Cancer Control (UICC) stage. Furthermore patients undergoing conversion have greater operative time, intra/postoperative complications and 30-day mortality. Finally the authors conclude that the ‘benefit of laparoscopy seems to be extinguished at the moment of conversion ... [and] is a dramatic phenomenon, when the patients with the most favourable characteristics achieve the poorest results’. We consider this supposition an unfair representation and wish to focus on the analysis of those patients having a laparoscopic operation converted to open surgery which formed 12% of the series. Data on patient and tumour characteristics are not provided for this particular subgroup and it is conceivable that the proportion of converted cases represents the 28.5% and 30.6% of tumours < 6 cm and UICC III respectively. Furthermore the relatively large number of subjects (201) having conversion was not subjected to a multivariate regression analysis. This information would have been of interest in identifying potential predictive factors for conversion. Conversion remains central if the data reporting a negative outcome are to be accepted. We acknowledge that it is hard to dissect out the exact reasons for conversion, but we wish to highlight the potential role of tumour biology in this particular subgroup. We propose that one reason for a poorer short-term (and long-term) outcome in patients undergoing conversion is that the act of conversion may be a marker for poor tumour biology, radicality of surgery and the potential for complications. Indeed the negative impact of postoperative infection and blood transfusion on the cancer-specific outcome continues to receive interest [2–4]. In conclusion clearly the increasing use of laparoscopic surgery in colorectal cancer is inevitable but we feel that for rectal cancer further evidence-based assessment is required. The debate raised by the article would benefit from an additional preoperative analysis of predictive factors for conversion and anthropometric/ three-dimensional reconstruction of pelvic anatomy when considering patients for laparoscopic or open rectal surgery [5,6]. Author contributions

Tumor mixto del colon con metástasis hepáticas

Resumen Los tumores compuestos del colon presentan celulas endocrinas y exocrinas, son infrecuentes y su tratamiento seria similar al de los adenocarcinomas. Presentamos una paciente de 44 anos que consulto por dolor abdominal. La tomografia computarizada mostro un tumor del angulo esplenico del colon y 2 lesiones compatibles con metastasis hepaticas. La biopsia preoperatoria revelo un adenocarcinoma. Se la opero, confirmandose los hallazgos tomograficos. Se practico una hemicolectomia derecha ampliada con reseccion de diafragma, ileosigmoidoanastomosis y extirpacion de ambas metastasis. La evolucion postoperatoria fue satisfactoria. El estudio anatomopatologico revelo un adenocarcinoma tubular moderadamente diferenciado, con areas de carcinoma neuroendocrino poco diferenciado y metastasis en 25 de 28 linfonodos. Las 2 metastasis hepaticas tambien presentaban areas de carcinoma neuroendocrino poco diferenciado. Actualmente la paciente se encuentra asintomatica, en tratamiento con quimioterapia.