Fernando Maluenda G

Evolución de comorbilidades metabólicas asociadas a obesidad después de cirugía bariátrica

Two hundred thirty two morbid obese patientssubjected to gastric bypass, were evaluated in the preoperative period and every three monthsafter surgery, during a minimum of 12 months. Clinical evolution, blood glucose, seruminsulin, insulin resistance measured with the homeostasis model assessment (HOMA) andserum lipid levels were analyzed.

Obesidad: factor de riesgo para esteatohepatitis y fibrosis hepática

Background: Nonalcoholic fatty liver (NAFL) has been recognized as a cause of chronic liver disease. Its main risk factor is obesity. Aim: To describe the clinical and liver pathological findings in a group of patients who underwent surgery as obesity treatment. Patients and Methods: Sixty eight patients with severe or morbid obesity were subjected to surgery as obesity treatment. Each patient was evaluated with a complete clinical and laboratory medical assessment. A wedge of liver was excised during surgery. Liver biopsies were analyzed without knowledge of clinical and laboratory findings. The presence of steatosis, inflammation (portal or lobular), fibrosis and cirrhosis were recorded in the pathological analysis. Age and body mass index (BMI) were correlated with pathological data. Significance was set at a p value of less than 0.05. Results: Ninety one percent of patients had steatosis, 45% inflammation and 47% fibrosis. One patient had cirrhosis (1,4%). There was a statistically significant association between BMI and moderate or severe steatosis (p <0.03). There was also an association between BMI and portal (p=0.017) and lobular inflammation (p=0.034). A BMI over 40 kg/m2 (morbid obesity) was significantly associated with the presence of fibrosis (p=0.032). Moreover, the presence of moderate or severe steatosis was a risk factor for the development of hepatic fibrosis (p=0.026). Conclusions: Obesity is a major and independent risk factor for steatohepatitis and fibrosis. The degree of steatosis in the liver biopsy, is a risk factor for the development of fibrosis (Rev Med Chile 2002; 130: 731-6)

Nutrición enteral precoz en pacientes con gastrectomía total por cáncer

BACKGROUND: Total parenteral nutrition has a high cost and frequency of complications. Enteral feeding is a feasible alternative that can be started early in the postoperative period. AIM: To assess digestive tolerance to early enteral feeding in cancer patients undergoing total gastrectomy and to compare early enteral feeding (EEF) with total parenteral nutrition plus enteral feeding (TPN + EF), initiated after overcoming postoperative ileus. PATIENTS AND METHODS: Subjects with a resectable gastric cancer were considered eligible for the study. During surgery a nasoenteral tube was placed and patients were prospectively randomized to EEF or TPN + EF. Digestive tolerance, effectiveness, complications and costs between both modalities of nutritional support were compared. RESULTS: Twenty eight patients (15 male, aged 63 +/- 14 years old) were studied. Fourteen patients were randomized to EEF and 14 to TPN + EF. Diarrhea occurred in 14 and 29% of EEF and TPN + EF patients respectively, (p: NS). Patients with TPN + EF received an average of 28 Cal/kg/day and 1.1 g/kg/day proteins. Patients with EEF received an average of 29 Cal/kg/day and 0.8 g/kg/day proteins. At the eighth postoperative day, serum albumin was 3.9 +/- 0.7 and 3.2 +/- 0.5 g/dl in EEF and TPN + EF patients respectively (p < 0.05), serum prealbumin was 16.9 +/- 5 and 12.3 +/- 4.3 mg/dl in EEF and TPN + EF patients respectively (p < 0.05) and nitrogen balance was +2.4 +/- 1.5 and -1.6 +/- 0.6 g/24 h in EEF and TPN + EF patients respectively (p < 0.05). Postoperative hyperglycemia was observed with a lower frequency and nutritional support costs and length of hospital stay were significantly lower in the EEF group. CONCLUSIONS: After total gastrectomy EEF is well tolerated, safe and effective, even during the early postoperative ileus. This therapeutic modality could be the first choice for nutritional support in these patients.

Esplenectomía laparoscópica en enfermedades hematológicas

Background: Idiopathic thrombocytopenic purpura (ITP) is the most common indication for elective splenectomy. The laparoscopic approach has been used over the past ten years. Aim: To report our experience with laparoscopic splenectomy. Patients and methods: Retrospective review of 27 patients subjected to splenectomy due to hematological diseases. Among them, 17 patients (78% female, age range 17-70 years old) were subjected to a laparoscopic splenectomy. Eligibility criteria were the presence of benign disease, an informed consent by the patient, a spleen size of less than 20 cm by ultrasound and absence of previous surgery in the upper left quadrant. The rest of the patients were subjected to an open splenectomy. Results: Seventy one percent of patients subjected to laparoscopic splenectomy had an ITP. Mean operating time was 184 minutes. The mean spleen size was 11 cm and the mean weight was 186 g (70-450). No patient died or had complications. No patient required a conversion to an open surgery. Transfusions were not required. The median hospital stay was 3 days. Conclusions: Elective laparoscopic splenectomy is a safe and low risk surgical procedure (Rev Med Chile 2004; 132: 189-94). (Key Words: Laparoscopy; Purpura, thrombocytopenic; Splenectomy; Thrombocytopenia)

Alteraciones de la tolerancia a la glucosa y frecuencia de síndrome metabólico en pacientes con enfermedad por hígado graso no alcohólico

Dr. Jaime Poniachik. Centro de Gastroenterologia, Hospital ClinicoUniversidad de Chile. Santos Dumont 999, Santiago-Chile. Fax: (56-2) 978 8353.E-mail: jponiach@redclinicauchile.clDra. Veronica Araya. Seccion Endocrinologia. Hospital Clinico U. de Chile. SantosDumont 999. Santiago de Chile. Fax: (56-2) 777 6891. E-mail: varaya@redclinicauchile.cl

Características clínicas y de laboratorio de pacientes con reflujo gastroesofágico crónico patológico

Background: Sixty percent of adults has typical symptoms of gastroesophageal reflux in Chile. Aim: To report the clinical and laboratory features of patients with gastroesophageal reflux. Patients and methods: Five hundred thirty four patients (255 male) with gastroesophageal reflux were included in a prospective protocol that included clinical analysis, manometry and endoscopy in all patients, barium swallow in 427, scintigraphy in 195, acid reflux test in 359, 24 h pH in 175, and differential potential of gastroesophageal mucosa in 73 patients. Results: There was no correlation between the severity of symptoms and the endoscopical severity. Patients with Barret esophagus were 12 years older, were male in a greater proportion and had a higher proportion of manometrically incompetent sphincters than patients with esophageal reflux but without esophagitis or with erosive esophagitis. Severity of acid reflux, measured with 24 h pH monitoring was proportional to the endoscopical damage of the mucosa. There was a close relationship between the mucosal change limit determined with differential potentials and with endoscopy. No short esophagi were found. Conclusions: Patients with symptoms of gastroesophageal reflux must be assessed using several objective measures to determine the severity of their pathological alterations.

Resecabilidad y mortalidad operatoria de la gastrectomía subtotal y total en pacientes con cáncer gástrico avanzado, entre 1969 y 2004

Background: The only curative treatment for gastric cancer is its surgical excision associated to a lymph node dissection. Aim: To study the evolution of resectability and operative mortality of total and subtotal gastrectomy for gastric cancer, in a period of 35 years. Material and methods: Review of medical records of 3000 patients with gastric cancer, operated between 1969 and 2004. Resectability and mortality of total and subtotal gastrectomy was compared in four successive periods (1969 to 1979, 1980 to 1989, 1990 to 1999 and 2000 to 2004). Results: In the four periods there was a steady and significant increase in resectability rate from 49 to 85%. Mortality of total and subtotal gastrectomy decreased significantly from 17 to 2% and from 25 to 1%, respectively. Conclusions: Resectability and mortality rates of total and subtotal gastrectomy have improved with time. Probably a better pre and postoperative care and the experience of the surgical team have an influence in this favorable change (Rev Med Chile 2006; 134: 426-32). (Key words: Gastrectomy; Stomach neoplasms; Surgical procedures, operative)

Tumor sólido pseudopapilar del páncreas: caso clínico

Solid-pseudipapillary pancreatic tumor is an uncommon pancreatic neoplasm of unknown origin that occurs especially in young women. It is a low grade malignancy that rarely metastatizes and generally the prognosis is excellent. Patients are generally asymptomatic with normal liver and pancreatic function and tumor markers generally are negative. It is characterized by a mixed structure with both solid and cystic areas with calcification especially in the cystic areas, that can be seen at CT scan. In some cases MRI and biopsy may be useful to obtain a diagnoses before surgery. The macroscopic pseudopapillary structure with solid and cystic areas with fibrovascular core it is considered. diagnostic. The treatment consisted in an adequate surgical resection and generally it is curative. We present the case of a young 28 years old woman with an asymptomatic pancreatic mass, with solid and cystic areas and calcification at pre-operatory CT. She has no limphoadenopaty and metastases at staging CT scan. She was performed a distal pancreatectomy with splenectomy with the istologic diagnosis of solid-pseudopapillary tumor with the positivity of NSE and CD56 and no nodal metastases. 7 months after surgery she performed a normal life and the follow up examinations are negative for tumor recurrence.

Aspectos quirúrgicos del cáncer de vesícula biliar

There is controversy in some aspects of the surgical treatment of non-mucosal gallbladder carcinoma. An accurate staging based on T (wall) involvement is crucial, otherwise understanding may yield falsely pessimistic results. The decision about the type of resection to be performed should be based on patient status (age, performance, comorbidities, etc) and tumor characteristics (histological type, vascular, neural or lymphatic spread, cell differentiation, tumor involvement of surgical margins in cystic duct, etc). For muscular (T1b) involvement, there is a great controversy about performing a simple cholecystectomy or en-block radical resection. For T2 there is consensus that an en-block radical surgery including liver resection (IVb - V) and lymphonodal clearance should be performed, since this approach has a great impact in survival. The role of surgical excision for tumors with serosal or liver involvement is controversial, due to the poor survival of these patients. However we have observed a 13% actuarial survival at 5 years, in this subset of patients (Rev Med Chile 2005; 133: 723-8). (Key Words: Cholelithiasis; Gallbladder neoplasms, Neoplasm staging)

Causas de mortalidad por colecistectomía tradicional y laparoscópica 1991-2010

Introduccion: La colecistectomia laparoscopica se ha convertido en el gold standard de la cirugia biliar y se emplea masivamente en todo Chile. Objetivos: Determinar la mortalidad operatoria en 4 periodos de 5 anos de la colecistectomia laparoscopica comparada con la colecistectomia tradicional. Material y Metodo: Se incluyo a todos los pacientes sometidos a colecistectomia, ya sea laparotomica o laparoscopica, entre enero de 1991 y diciembre de 2010 (20 anos). Se analizo las causas de mortalidad, el grupo etario en que ocurrio y el tipo de abordaje quirurgico. Resultados: Se operaron un total de 26.441 pacientes, con un promedio de 1.322 operados por ano. La mortalidad global de la colecistectomia laparotomica fue de 0,39% y de la laparoscopica de 0,07%, con un promedio general de 0,16%. Las principales causas de mortalidad fueron patologias medica severas. Solo 2 pacientes de los 43 fallecidos (5%) tuvieron una complicacion directamente derivada de la cirugia como causa de la mortalidad. Conclusiones: La colecistectomia laparoscopica es una operacion de muy baja mortalidad (7 de 10.000 operados). Esta complicacion se presenta principalmente en pacientes con grave patologia biliar, de edad avanzada y con multiples complicaciones medicas.