Enrique Norero M

Ventilación mecánica en pacientes con patologías agudas del Sistema Nervioso Central: sobrevida y pronóstico funcional

Background: The need of mechanical ventilation among patients with acute neurological diseases is considered a poor prognostic sign. Aim: To determine the mortality and functional recovery of neurological patients requiring mechanical ventilation. Patients and methods: Prospective study of 77 patients (42 men, age 54±19 years, with 11±4 points of Glasgow coma scale (GCS), 61% with cerebrovascular disease), that were admitted to the intensive care unit with neurological disease and that required mechanical ventilation. Functional recovery was assessed at 18 months with Glasgow outcome scale (GOS) and Barthel index. Results: Thirty percent of patients died during follow up. Among surviving patients, 47% had a good recovery or moderate disability, and 74% had a Barthel index equal to or over 70. Arterial hypertension, age over 70 and mechanical ventilation longer than 6 days were associated with bad functional prognosis. Conclusions: Neurological patients requiring mechanical ventilation had a lower mortality than previously reported, and half of the survivors have an independent life. This study supports intensive care management in this group of patients (Rev Med Chile 2004; 132: 11-8). (Key Words: Intensive care; Neurologic manifestations; Ventilators, mechanical)

Lipoma gástrico gigante sintomático tratado con gastrectomía subtotal laparoscópica: caso clínico

Gastric lipoma is a rare benign gastric tumor. We report a 62-year-old man, who presented with abdominal pain, vomiting and weight loss. An upper gastrointestinal endoscopy showed a gastric antral, submucosal tumor. Abdominal ultrasound and computed tomography revealed a large antral lesion with content of high echogenicity and fat density, measuring 11 x 6 cm. The patient was treated with a laparoscopic distal subtotal gastrectomy, and a Roux-en-Y reconstruction. The patient had no postoperative morbidity, was started on a liquid diet on the third postoperative day and was discharged on the third postoperative day. The pathological study revealed a gastric lipoma with clear margins. This laparoscopic procedure represents a good alternative in the treatment of this benign gastric tumor.

Resultados perioperatorios y sobrevida alejada de la pancreatoduodenectomía con resección vascular

Introduccion: La pancreatoduodenectomia (PDD) con reseccion vascular (RV) cuando existe invasion de la vena porta o mesenterica superior (VP-VMS) es controversial. Objetivo: Evaluar los resultados del perioperatorio y la sobrevida alejada de los pacientes sometidos a esta tecnica. Material y Metodo: Estudio retrospectivo que incluyo a los pacientes con un tumor periampular en quienes se realizo una PDD con RV entre 1990 y 2008. Se compararon los resultados del perioperatorio y de sobrevida alejada con el grupo sometido a una PDD sin RV durante el mismo periodo. Se comparo tambien la sobrevida con los pacientes no resecados. Resultados: Se realizaron 188 PDD, en 8 (4%) de estos pacientes se realizo PDD con RV (Edad: 58 ± 14 anos, Hombres: 4). La morbilidad postoperatoria para la PDD con y sin RV fue de 75% y 59% (p = ns). La mortalidad postoperatoria para los grupos con y sin RV fue de 0% y 8% (p = ns). En 6 de los 8 pacientes el diagnostico fue cancer de pancreas y en 4 se confirmo histopatologicamente la invasion de VP-VMS. La sobrevida del grupo con y sin RV no tuvo diferencia significativa (medianas 25 y 16 meses; p = ns). La sobrevida de los pacientes sometidos a una PDD con RV fue superior a los pacientes no resecados (medianas 25 y 3 meses; p = 0,0001). Conclusiones: La PDD con RV obtiene resultados perioperatorios y de sobrevida alejada comparables a una PDD sin RV. La sobrevida alcanzada con esta tecnica es ampliamente superior a la de los pacientes no resecados.

Endoscopic submucosal dissection for early gastric cancer

endoscopic submucosal dissection for early gastric cancer introduction: Endoscopic submucosal dissection (ESD) is nowadays the standard treatment for a subgroup of early gastric cancer with low risk of lymph node metastasis. This procedure has the advantage of achieving a higher percentage of negative margins and of allowing resections of larger tumors compared with the endoscopic mucosal resection (EMR) method, being less invasive compared with surgery. aim: To analyze the postoperative outcomes, histology and overall survival of patients undergoing ESD in our center. methods: Descriptive study. Data were collected from clinical records of patients undergoing ESD from January 2008 to June 2012. results: 15 patients (8 males and 7 females, median age 70 years (45-88)) were included. The tumor was located at upper, middle and lower third in 2, 5 and 8 patients, respectively. Median tumor size was 13.5 mm (6-21). Most tumors were classified as type IIc. Among postoperative complications, there was 1 gastric bleeding and 3 gastric perforations. Hospital stay was 3 days (1-23). There was no mortality. There was one case of submucosal invasion. negative margins were achieved in 86.7%. There was one deep and one lateral positive margin, managed by surgery and re-ESD, respectively. At 16 months (7-61) of median follow-up, overall survival was 100%. Tumor recurrence was observed in one patient at 51 months, was treated by surgery. conclusion: ESD is a feasible technique in the minimally invasive management of early gastric cancer, allowing a high percentage of negative margins.

ÚLCERA MARGINAL PERFORADA POST BYPASS GÁSTRICO LAPAROSCÓPICO

Perforated marginal ulcer after laparoscopic gastric bypass introduction: Perforated marginal ulcer is a serious event that usually requires reoperation and is associated with morbidity and mortality. Characterization and management of these patients is still debated. Objective: To describe a series of patients subjected to a laparoscopic gastric bypass (LGBP) that evolved with a perforated marginal ulcer. material and m ethods: Records of patients undergoing a LGBP the last 10 years and evolved with a perforated marginal ulcer were retrospectively reviewed. Clinical features, treatment and perioperative morbidity and mortality were analyzed. results: During this period 2,095 patients were subjected to a LGBP, 12 of them presented a perforated marginal ulcer, corresponding to 10 women and 2 men. Mean age was 39 (21-60) and mean body mass index at the time of initial surgery was 34 (29.3 to 38.6). Ten patients were smoker at the moment of perforation. The occurrence of this happened at a mean of 27 months (range 3-54, median 23.5) after surgery. Eleven cases had a surgical resolution, with a laparoscopic approach in 9 of them and laparotomy on 2. In all cases, a perforated ulcer in the jejunal side of the gastro- jejunal anastomosis was found. There was no mortality or morbidity associated with surgery. conclusions: In our experience the occurrence of perforated marginal ulcer after a LGBP develops in a small percentage of patients. The laparoscopic approach is of choice, presenting a low morbidity and mortality. Smoking was present in most patients.

Prevención de la recurrencia peritoneal en el tratamiento quirúrgico del cáncer gástrico

Prevention of peritoneal recurrence of gastric cancer The peritoneal cavity is the main site of gastric cancer recurrence after curative surgery. When this re currence occurs, patients may experience bowel obstruction, dehydration and multiple hospital admissions. The therapeutic options that may decrease the rate of peritoneal recurrence and increase five years survival are intraoperative hyperthermic chemotherapy, extensive intraoperative peritoneal lavage and routine bursectomy. We herein review the oncological results of curative surgery for gastric cancer, its failure patterns and the risk factors for peritoneal recurrence. We also review the studies aiming to prevent peritoneal carcinomatosis.

Carcinoma mixto adenocarcinoma y neuroendocrino periampular en un paciente con neurofibromatosis tipo 1: Caso clínico

Neurofi bromatosis is a hereditary autosomal-dominant disease, with high rates of de novo mutations and carries a high risk of neoplasms. It affects both sexes and all races and ethnic groups. It is characterized by multiple cutaneous lesions and tumors, both benign and malignant, especially in the nervous system. We report a 52 years old woman with a type 1 neurofi bromatosis, presenting with fever, jaundice and weight loss. On physical examination, the patient was jaundiced and had “cafe au lait” spots in the skin. A magnetic resonance imaging showed bile duct dilation and a possible ampullar carcinoma. The patient was operated, during the exploration she presented a periampullary tumor and multiple small nodular lesions in the stomach, the tumor was resected with a pancreaticoduodenectomy and the nodular gastric lesions were biopsied. The pathological study revealed a combined adenocarcinoma and neuroendocrine duodenal tumor. The study of the stomach lesions revealed a gastrointestinal stromal tumor. Four months after surgery, the patient is in good conditions

Intususcepción intestinal posterior a bypass gástrico en Y de Roux

Intussusception after Roux-en-Y Gastric Bypass causing bowel obstruction. Report of one case Wereporta�41�yearsoldfemalewhounderwentagastricbypass�10�yearsago.�Shepresentedanexcess� weightlossof�114%.�Sherequiredacholecystectomyandanothersurgicalprocedureduetoaninternalher- nia.�Thepatientcomplainedofrecurrentabdominalpainandanabdominalcomputedtomographyshowedan� intestinalintussusceptionlocatedatthejejuno-jejunoanastomosis.�Shewasoperatedandthediagnosiswas� confirmed. �Anenlargementofthebiliopancreaticloopandabezoarwerealsofound.�A�15�cmintestinalresec- tionoftheenlargedportionofthebiliopancreaticloopandanewjejuno-jejunoanastomosiswereperformed.� Thepatientrecovereduneventfullyandwasdischargedonthefourthpostoperativeday.�Theoccurrenceof� intestinalintussusceptionasacauseofintestinalobstructionaftergastricbypassisrare.�Ithasbeenreported� afteropenandlaparoscopicsurgery.�Thereareseveraltheoriesaboutthecauseofintussusceotion,�likechanges� inintestinalmotility,�ahighexcessweightloss,�butaconclusivecausehasnotbeenidentified. �Generallythe� locationoftheintussusceptionsisatthejejuno-jejunoanastomosisanditappearstobeinaretrogradefashion� inthemajorityofcases.�Thetreatmentiscontroversial,�withseveraloptions;�simplereduction,�reductionand� intestinalfixation,�butapparentlyintestinalresectionhasbetterresults.��

Incidencia, factores de riesgo y tratamiento de las complicaciones biliares del trasplante hepático*

Abstract Biliary tract complications after liver transplantation Introduction: Biliary tract complications (BC) are cause of mortality after liver transplantation (LT). There are different treatment alternatives for this complication. Aim: to determinate incidence, risk factors and treatment of biliary complications after LT. Materials and Methods: A retrospective descriptive cohort of patients undergoing LT between March 1994 and March 2009. Risk factors and incidence for BC were ex-plored. Also the BC impact on overall survival on LT patients was assessed. We used SPSS 15.0 for statistical analysis and considered a significant p value less than 0.05. Results: 107 LT were performed in 102 patients. In 30 (28%) there was some biliary complication. Ten (33.3%) were early complications (< 3 months) and 20 (66.7%) were late (≥ 3 month). Anastomotic stricture was the more frequent BC. The gender male recipient, the cold ischemic time and biliary reconstruction technique without tutor were associated with an increased risk for BC. Endoscopic treatment of biliary stricture was successful in 91% of cases at one year follow up. Three (10%) patients died due to BC or their long-term treatment.

Tumores quísticos del páncreas

Los tumores quisticos del pancreas son un grupo heterogeneo de neoplasias pancreaticas que comprenden las neoplasias quisticas mucinosas (50 %), los cistoadenomas serosos (30 %), las neoplasias mucinosas papilares intraductales (12 %), los tumores quisticos papilares (3 %) y los crecimientos miscelanea (5 %) ( figs. 195-1 y 195-2 ).