Fernando Pimentel M

Pólipos vesiculares: correlación entre hallazgos ecográficos e histopatológicos

BACKGROUND Gallbladder polyps are becoming a common finding. The management of these polyps is complicated considering that they can bear malignant lesions. AIM To analyze the ultrasonographic and histopathologic findings of patients operated due to gallbladder polyps. PATIENTS AND METHODS The records of patients with ultrasonographic diagnosis of gallbladder polyp and that underwent cholecystectomy in a thirteen years period were reviewed, collecting their demographic, ultrasonographic and histopathological data. RESULTS One hundred and twenty three patients were operated. The mean age was 44+/-13 years, and 69% were women. The mean size of polyps in ultrasonography was 7.3+/-5 mm. Histopathology confirmed the presence of polyps in 79% of patients, with a mean size and number of lesions of 5.1+/-3.8 mm and 2.1+/-2, respectively. Nine percent of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p =0.003). Four cases of adenoma (3.2%) were diagnosed; one of them had in situ carcinoma. All were single and larger than 10 mm. We found a significant correlation between ultrasonographic and histopathological polyp size determination (r =0.47; p =0.002). Polyp size was also a predictor of the presence of adenoma (p =0.043; confidence intervals: 1.006-1.424). CONCLUSIONS There is a good correlation between the size of the gallbladder polyp in ultrasonography and the size in the histopathology report. Gallbladder adenoma is uncommon and it correlates with the size of the polyp. In this series, size was the only predictor of the presence of adenoma.

Necrosectomía laparoscópica en pancreatitis aguda

Laparoscopic necrosectomy in severe pancreatitis. Retrospective analysis of 11 patients Background: Laparoscopic surgery can be used in the treatment of severe acute pancreatitis. Aim: To report the experience with laparoscopic necrosectomy and abscess drainage in severe acute pancreatitis. Material and Methods: Retrospective analysis of medical records of 11 patients aged 13 to 78 years (10 males), with severe pancreatitis, subjected to laparoscopic necrosectomy or abscess drainage between 2006 and 2009. Results: Operative time ranged from 110 to 205 min. In all cases, a satisfactory necrosectomy and collection drainage were performed. No complications were recorded and no patient required to be converted to open surgery. Five patients were reoperated. In three of these, the laparoscopic approach was used again. Conclusions: Laparoscopic necrosectomy is safe and useful for patients with severe pancreatitis.

DESARROLLO DE UNA NUEVA TÉCNICA ENDOSCÓPICA PARA EL TRATAMIENTO DE LA ACALASIA: POEM (PER-ORAL ENDOSCOPIC MYOTOMY)

Development of a new endoscopic technique for treatment of achalasia: POEM (Per-Oral Endoscopic Myotomy) Achalasia is the most common primary motor esophageal disturbance. The most recommended surgical treatment is laparoscopic surgical myotomy. In the last years a new endoscopic technique, called Per Oral Endoscopic Myotomy, was developed for the treatment of the disease. Approximately 1.000 patients have been treated using this technique with good results and a low rate of complications. The five critical steps of the technique are elevation of esophageal mucosa, mucosal incision, creation of a submucosal tunnel, myotomy of internal circular muscular fibers of the esophageal wall, extending it to the stomach and closure of the mucosal wound. This article reports the technique and the implementation of an ex vivo swine training model to learn the technique.

Definiciones y conceptos en hepatolitiasis

Resumen es: La hepatolitiasis o litiasis intrahepatica, se define como la presencia de calculos en los conductos bi - liares proximales al confluente biliar. La etio...

Dispositivo endoscópico duodeno yeyunal restrictivo en pacientes obesos mórbidos, experiencia inicial en humanos

Initial human experience with a restrictive, duodenal-jejunal by-pass liner for the treatment of morbid obesity Background: The EndoBarrier TM Gastrointestinal Liner creates an endoscopic duodenal-jejunal bypass leading to weight loss in morbidly obese patients. Aim: To evaluate the safety and effi cacy of the EndoBarri- er TM with a 4 mm restrictor in morbidly obese patients. Material and Methods: Ten obese patients aged 18 to 54 years (eight women) with a body mass index (BMI) ranging from 35.8 to 45 kg/m 2 were enrolled. Patients were followed for 12 weeks after the placement of the device, when it was removed. Outcomes measured were percent excess weight loss (%EWL), minor and major adverse events. Results: The mean implant time was 33 ± 4 minutes with a mean fl uoroscopy time of 14.8 ± 3 minutes. There were no major adverse events. Periodic episodes of nausea and vomiting lead to the endoscopic dilation of the restrictor hole with a 6 mm balloon between 2nd and 8th weeks in seven patients (70%). One subject required a second dilation with a 10 mm balloon. The device was endoscopically removed at the 12 th week in all patients. The mean removal time was 47 ± 53.8 minutes (range 10-155 minutes). At week 12, BMI decreased from 40 ± 3.9 to 34.5 ± 3.1 kg/m 2 , and %EWL was 39.8% (range, 21.7% - 65.3%). The mean total weight loss was 16.7 ± 4.4 kg. Conclusions: The EndoBarrier TM Gastrointestinal Liner with the addition of a duodenal restrictor is a safe

Gastrectomía laparoscópica en cancer gástrico

Introduccion: La cirugia laparoscopica ha sido incorporada como una alternativa de tratamiento curativo en cancer gastrico. El objetivo de este estudio es evaluar los resultados quirurgicos inmediatos de pacientes sometidos a gastrectomia laparoscopica por cancer gastrico incipiente e intermedio en el Hospital Clinico de la Pontificia Universidad Catolica de Chile y en el Hospital Dr. Sotero del Rio. Material y metodo: Se incluyen todos los pacientes sometidos a gastrectomia laparoscopica por cancer gastrico incipiente e intermedio (T1 - T2) en ambas instituciones. Resultados: Desde Mayo de 2005 a Diciembre del 2006, 13 pacientes fueron sometidos a gastrectomia laparoscopica, 9 hombres (70 %). Edad promedio 62+ 12 anos. El tiempo operatorio promedio fue 293 + 51 minutos, la estadia hospitalaria 7,3 + 2,8 dias. No hubo complicaciones quirurgicas. El promedio de ganglios resecados fue de 27 + 18. De acuerdo a la clasificacion TNM-AJCC, 9 pacientes se encontraban en etapa IA y 4 en etapa IB. Discusion: La gastrectomia laparoscopica es una alternativa segura en el tratamiento quirurgico del cancer gastrico incipiente e intermedio

Tratamiento laparoscópico de la acalasia esofágica en niños: Análisis de 4 casos

Introduccion: La acalasia esofagica se presenta en un bajo porcentaje en la poblacion general y en ninos es mas infrecuente aun. Su etiologia no es clara, sin embargo se ha observado una alteracion de los plexos submucosos del esofago. Existen multiples tratamientos, de los cuales, la cirugia ha demostrado ser el mejor. La via laparoscopica disminuye la estadia hospitalaria, las complicaciones y mantiene la efectividad de la via abierta. Objetivos: Presentar los 4 primeros pacientes menores de 15 anos operados en el Hospital Clinico de la Universidad Catolica por acalasia esofagica via laparoscopica. Pacientes y Metodos: Se analizo los registros clinicos de aquellos pacientes menores de 15 anos, sometidos a una miotomia de Heller laparoscopica entre 1995 y 2003. Se analizo el sexo y la edad, las enfermedades asociadas, el tiempo de evolucion de la enfermedad, tratamientos previos y su resultado, el peso, la talla, el indice de masa corporal, la baja de peso debido a la enfermedad, el estudio preoperatorio, los resultados quirurgicos y el seguimiento. Resultados: Tres hombres y una mujer con una edad promedio de 14 anos. Dos habian recibido tratamiento previo con inyeccion de toxina botulinica, con resultados satisfactorios en forma transitoria. No se requirio conversion a cirugia abierta ni hubo morbimortalidad postoperatoria. Todos los pacientes tienen seguimiento actualizado y se encuentran conformes con los resultados. Conclusiones: La Miotomia de Heller laparoscopica mantiene la efectividad de la cirugia abierta con una baja morbimortalidad postoperatoria y buenos resultados funcionales

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.

Reparación de hernia incisional por vía laparoscópica: Resultados iniciales

Introduccion: La hernia incisional (HI) es una de las complicaciones mas frecuentes en cirugia abdominal abierta, siendo una alternativa para su correccion la hernioplastia por via laparoscopica. El objetivo de este trabajo fue evaluar la factibilidad y eficacia de la reparacion laparoscopica de la HI con seguimiento a corto plazo, dando a conocer nuestra experiencia inicial. Material y Metodo: Estudio retrospectivo de pacientes sometidos a hernioplastia incisional laparoscopica entre marzo de 2006 y octubre de 2008 en el Hospital Clinico de la Pontificia Universidad Catolica de Chile. Se evaluo variables demograficas, perioperatorias, morbilidad y recidiva. Resultados: Fueron operados 21 pacientes en este periodo, 16 de genero femenino, con un promedio de edad e indice de masa corporal de 54 ± 13 anos y 32,2 ± 6,5 kg/m2, respectivamente. Uno de ellos se convirtio a cirugia abierta. El diametro mayor del anillo hemiario fue en promedio 8,4 ±3,9 cm (rango 3-17) y la mediana de tiempo operatorio fue de 92 minutos (rango 45-300). La estadia hospitalaria fue 3,0 ±1,6 dias, en promedio. Durante la misma cirugia se realizo en dos pacientes gastrectomia en manga y colecistectomia. Se presentaron complicaciones precoces menores en dos pacientes (10%), una atelectasia pulmonar y un seroma, y complicaciones tardias menores en otros dos pacientes (10%), que correspondio a dolor prolongado en la zona operatoria en ambos. No hubo mortalidad en la serie. El seguimiento fue 100%, con un promedio de 14 meses (rango 4-36), sin recidiva en este periodo. Conclusiones: La hernioplastia incisional laparoscopica es una tecnica factible de realizar en nuestro medio, sin complicaciones mayores en esta serie y buenos resultados a un ano de seguimiento.

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.