F. París

Motor Activity of Esophageal Substitute (Stomach, Jejunal, and Colon Segments)

Manometric studies were performed to evaluate motor activity of several types of esophageal substitutes: total stomach (5 patients), isoperistaltic gastric tube (5 patients), jejunal Roux-en-Y loops (4 patients), and isoperistaltic left colon (15 patients). Motor behavior of substitutes was assessed following dry swallows and following several stimuli: intraluminar injection of 30 ml of water or 0.1N hydrochloric acid and swallowing pills. Following dry swallows, there was no response with either stomach or isoperistaltic gastric tube, jejunum showed a variable response, and a response was infrequent in patients with colon transplants. After dry swallows, transmission of the pressure wave through the anastomosis was not observed in any patient. Total stomach and isoperistaltic gastric tube did not respond to any stimulus. Jejunum responded with progressive waves after water and solid stimuli, and had a hyperkinetic response after acid injection. Colon had a constant (80 to 90%) and homogeneous response with progressive waves after all stimuli. After wet swallows, there was transmission through the anastomosis in 2 patients with colon transplants. Our data indicate that stomach and isoperistaltic gastric tubes do not contribute actively to the onward transmission of food in the digestive tract. Jejunum may contribute actively in digestive transit, but its responses are variable. Having steady and homogeneous responses, colon segments take an active part in transit.

Survival and risk model for stage IB non-small cell lung cancer

BACKGROUND The aim of this work is to estimate the prognostic value of a set of clinical-pathological factors in patients resected for non-small cell lung cancer (NSCLC) and classified as stage IB, in order to create a prognostic model for establishing risk groups, and to validate that model. METHODS Among 637 patients resected and classified as stage IB, we analyzed sex, age, symptoms, location, type of resection, cell type, histology, and tumor size. The Kaplan-Meier method was used to estimate the survival. The results were compared using the log-rank test. All the significant variables from this univariable method were then included in a multivariable method of estimation of the proportional risk for survival data developed by Cox, using the variables selected, a regression model was developed for accurately predicting survival. To validate the predictive capability of the regression model, we randomly divided our patients into training and test subsets, containing 322 and 315 cases, respectively. RESULTS The overall 5-year survival rate of the series was 60%. The cell type, the squamous or non-squamous and the tumor size showed a significant influence on survival in the univariable analysis, while, according to the Cox model, only the tumor size and the squamous or non-squamous type entered into regression. Hazard rates were calculated for each patient. The mean risk was 0.87 +/- 0.25 (range 30-1.94). The series was divided into three risk groups (low, intermediate, and high risk) according to the fitted hazard rates, using cut-off points (one standard deviation from the mean). The 5-year survival rates were 85, 59, and 44%, respectively. To validate the model, we repeated the analysis for training and test subsets. Only the tumor size had a significant influence on survival in the univariable analysis. Using the Cox model, also the tumor size entered into regression. The mean risk was 0.79 +/- 0.29 (range 0.09-2.12). Cut-off points were 0.50 and 1.08 for the low, intermediate, and high-risk groups. The 5-year survival rates were 83, 58, and 40%, respectively. We validated the regression model obtained in the training subset by demonstrating its capacity in identifying risk groups in the test subset. The 5-year survival rates were 83, 61, and 49.5% for the low, intermediate, and high-risk groups, respectively (P = 0.0104). CONCLUSIONS Stage IB does not succeed in configuring a group of patients with a homogeneous prognosis, as there is a wide variability in a 5-year survival. The estimation of prognosis derived from a multivariable analysis can obviate the limitations of the actual staging system for NSCLC.

Modelo de riesgo de mortalidad en el carcinoma broncogénico no anaplásico de células pequeñas en estadio I

Objetivo Elaborar y validar un modelo del riesgo de mortalidad en pacientes resecados de un carcinoma broncogenico no anaplasico de celulas pequenas (CBNACP) en estadio I. Pacientes Y Metodo Un total de 798 pacientes diagnosticados de CBNACP fueron resecados y clasificados en el estadio I. Se estudiaron una serie de variables clinicopatologicas y su influencia en la supervivencia, calculada con el metodo de Kaplan-Meier. El modelo de Cox se utilizo para el analisis multivariante. Resultados En el analisis univariante, la edad (p = 0,0461), la sintomatologia (p = 0,0383), la histologia (p = 0,0489), el tamano (p = 0,0002) y la invasion tumoral (p = 0,0010) condicionaron la supervivencia. En el analisis multivariante el tamano (p = 0,0000) y la edad (p = 0,0269) entraron en regresion. Se estimo, aplicando la ecuacion de regresion obtenida en el modelo multivariante, el riesgo de cada paciente, comprobando que la media fue de 1,47 ± 0,31 (rango, 0,68-2,92). La serie se dividio en tres grupos de riesgo (bajo, intermedio y alto), estableciendo los puntos de corte en 1,16 y 1,78 (desviacion estandar de la media). La supervivencia a los 5 anos fue del 85, el 62 y el 46%, respectivamente (p = 0,0000). Para validar la capacidad predictiva del modelo, la serie se dividio al azar en dos grupos: uno de estudio, configurado por 403 pacientes, y otro de validacion, compuesto por 395. En el analisis univariante, en el grupo de estudio, la edad (p = 0,0295), la sintomatologia (p = 0,0396), el tamano (p = 0,0010) y la invasion tumoral (p = 0,0010) condicionaron la supervivencia. Utilizando el modelo de Cox, el tamano (p = 0,0000) y la edad (p = 0,0358) entraron en regresion. La media del riesgo fue de 1,94 ± 0,36 (rango, 0,98-3,32). La serie fue dividida en tres grupos de riesgo, estableciendo los puntos de corte en 1,58 y 2,30. La supervivencia a los 5 anos fue del 90, el 62 y el 46% para los grupos de riesgo bajo, intermedio y alto, respectivamente (p = 0,0000). Aplicando este modelo al grupo de validacion, su capacidad para identificar grupos de riesgo quedo demostrada. La supervivencia a los 5 anos fue del 78, el 61 y el 48%, respectivamente (p = 0,0000). Conclusion Los modelos de riesgo pueden identificar a subgrupos de pacientes potencialmente subsidiarios de tratamientos coadyuvantes a la cirugia, asi como facilitar la comparacion de distintas series.

Los llamados tumores y pseudotumores broncopulmonares benignos

Resumen Se presenta la estadistica del Servicio, consistente en 47 tumores y pseudotumores broncopulmonares. Siguiendo la clasificacion embriogenica de Spencer, se detallan los datos epidemiologicos, clinico-radiologicos, y terapeuticos de los mismos, aportando los resultados quirurgicos, con un solo caso de mortalidad, y escasa morbilidad. Se discuten los aspectos clinicos y terapeuticos comunes, derivados de la localizacion endobronquial, y los caracteres diferenciales de las variedades histologicas. Resaltamos la capacidad evolutiva de los carcinomas adenoides quisticos. En el plano quirurgico se insiste en la necesidad de preservar al maximo el parenquima funcionante. Finalmente se presenta el grupo de los pseudotumores broncopulmonares con su punto de coincidencia y sus diferencias con los tumores broncopulmonares llamados benignos.

Gastroplasty with Partial or Total Plication for Gastroesophageal Reflux: Manometric and pH-metric Postoperative Studies

From January, 1975, to December, 1980, 83 patients with sliding hiatal hernia, gastroesophageal reflux, or both were treated using a modified Collis gastroplasty associated with either partial or total gastric application. When partial plication was used, the five-year clinical results were considered satisfactory in 27 out of 35 patients (77%). When total plication was used, the results were satisfactory in 41 out of 46 patients (89%) after follow-up ranging from 12 to 60 months (average, 36 months), but no symptoms of gastroesophageal reflux reappeared in any patient. In patients undergoing partial plication, the mean preoperative high-pressure zone of 11.20 +/- 8.19 mm Hg increased after operation to 17.31 +/- 10.50 mm Hg, but in the second postoperative studies the value decreased to 13.69 +/- 7.24 mm Hg. When 360 degrees plication was used, the preoperative value of the high-pressure zone--9.36 +/- 4.80 mm Hg--increased after operation to 17.70 +/- 7.53 mm Hg but did not decrease significantly in the second postoperative studies: 16.46 +/- 7.99 mm Hg. When partial plication was used, the positivity of the abdominal compression test was 9 and 28% in the early and late postoperative studies, respectively. Using total plication, the percentage of positivity in the early and late postoperative periods was 0 and 2%, respectively. Concerning the acid reflux test, when partial plication was used, the test was positive in 3 out of 27 patients (11%) in the early postoperative studies and in 7 out of 30 (23%) one year later. For the total plication procedure, the percentage of positive tests was null in the first control and 3% in the second postoperative studies.

Tracheoplasty in a large tracheoesophageal fistula.

Postintubation tracheoesophageal fistulas (TEFs) are severe lesions that can be associated with tracheal stenosis and therapeutic difficulties. A case is reported of a woman with TEF and postintubation tracheal stenosis with 6.5 cm of affected trachea, and total esophageal exclusion. A tracheoplasty method is described patching the loss of the tracheal membranous wall with the posterior esophageal wall. In a final step, a self-expanded tracheal stent and esophagocolic bypass were added.

Lesser Curvature Tubular Gastroplasty with Partial Plication for Gastroesophageal Reflux: Manometric and pH-metric Postoperative Studies

Thirty-four patients with sliding hiatal hernia, gastroesophageal reflux, or both were treated by lesser curvature gastroplasty with partial gastric plication, using a surgical stapler. Before operation, esophageal manometric studies were performed in 33 patients and during the early postoperative period (1 to 3 months), in 34. The esophageal pH test was performed before operation in 22 patients, shortly after discharge in 27, and later in 30 patients. The clinical results were considered satisfactory in 30 patients (88%) after follow-up ranging from 18 to 33 months (average, 23 months). Before the procedure, the abdominal compression test was positive in 25 of 30 patients (83%). In early postoperative studies it was positive in 1 out of 34 patients (3%), but in the second series of postoperative studies it was positive in 9 out of 32 (28%). After instillation of hydrochloric acid into the stomach, the esophageal pH test was considered positive in 17 out of 22 patients in preoperative studies (77%). In early postoperative studies the test was positive in 3 out of 27 patients (11%) and one year later, in 7 out of 30 (23%). The later postoperative studies showed a higher number of positive reflux tests than the early studies, 28 and 23% positive in manometric and pH tests, respectively.

Tratamiento quirurgico del enfisema bulloso del adulto

Resumen Se presentan 20 pacientes operados de bullas de enfisema clasificados en dos grupos segun su extension. Tras senalar la disnea como sintoma predominante y responsable de la indicacion quirurgica en la mayoria de nuestros pacientes, se expone la sistematica de estudio y tratamiento. En el capitulo de resultados hay que destacar la ausencia de mortalidad operatoria en nuestra serie. Si bien la evolucion clinica postoperatoria de los pacientes encuadrados en el Grupo I —enfisema localizado— es muy buena, en el Grupo II —enfisema difuso— los resultados a corto plazo son buenos para ir deteriorandose paulatinamente debido al caracter evolutivo de la enfermedad de base. En la discusion hemos pretendido plantear la dificil problematica de la indicacion quirurgica y aportar una serie de criterios que creemos importantes a la hora de valorar un presunto candidato al tratamiento quirurgico.