Italo Braghetto M

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.

Síndrome Prader Willi asociado a obesidad mórbida: tratamiento quirúrgico

Prader-Willi Syndrome (PWS) is a multisystemic genetic disease characterized by hypothalamic hypogonadism, mental retardation and compulsive hyperphagia associated with early and severe obesity. Complications of overweight, such as type-2 diabetes Mellitus, dyslipidemia and diffuse atheromatosis are common. We report a 15 years old morbid obese male with PWS, with a body mass index of 57.7 kg/m2, refractory to weight-lowering treatments. He underwent preoperative evaluation and treatment by a multidisciplinary team, and subjected to a 95% gastrectomy, leaving a 50 ml remnant pouch and a long limb (120 cm) Y-Roux gastro-jejuno anastomosis. There were no surgical complications, oral feeding was initiated at the 5th day with an hypocaloric diet. During the first postoperative year, the patient lost 70 kg, achieving a body mass index of 30 kg/m2. Surgical treatment can become a therapeutic choice for obesity in PWS patients (Rev Med Chile 2003; 131: 427-31).

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.

Manejo actual de la acalasia del esófago: revisión crítica y experiencia clínica

The therapeutic options for treatment of Achalasia of the esophagus include medical treatment, endoscopic and surgical procedures. The latter can be either conservative, such as cardiomyotomy or more aggressive, such as cardioplasty or esophageal resection. In this article, we discuss the early and long term results after the different therapeutic options. We also present the results of our recent surgical experience. The definitive results seem to be better after surgical treatment compared to medical management or endoscopic procedures (Rev Med Chile 2002; 130. 1055-66).

Perforación esofágica: Experiencia clínica y actualización del tema

Esophageal perforation is a complicated clinical entity that demands a high level of diagnostic and therapeutic skills. The management alternatives vary from conservative treatment to esophagectomy, including primary suture and esophageal exclusion. This paper is a review of the literature and personal experience with this condition, focusing on etiology, clinical presentation, diagnostic workout, treatment, complications and mortality. Finally, we propose a management algorithm.

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)

Hiperobesidad y obesidad mórbida: estudio comparativo

Hiperobesity v/s morbid obesity: a comparative study Introduction: Bariatric surgery is effective and safe in treating obese patients with BMI > 40, howe- ver, higher preoperative weight could increases morbidity and mortality. Aim: To describe and compare the perioperative and mid term outcomes between hiperobese and morbidly obese patients submitted to gastric bypass. Material and Method: A prospective study of hiperobese patients submitted to gastric bypass over the past 10 years. We analyzed clinical characteristics, perioperative morbimortality and resolution of comor- bidities. The results were compared with a group of morbidly obese patients matched by age and sex. Results: 146 hiperobese were operated and compared with 165 morbidly obese patients. 66.8% were female and the average age of the total group was 39.9 ± 12.4 years, with no signifi cant differences between groups by sex and age. The average BMI was 53 and 44.4 respectively. 21.5% had diabetes mellitus 2, 39.5% hypertension, 31% dislipidemia and 8.4% osteoarthritis, with no signifi cant differences between groups except for a higher prevalence of dyslipidemia in the morbidly obeses (p = 0.001). 10.4% had surgical complications during the postoperative period, with no differences between both groups (p = 0.24). One year later all patients had a signifi cant decrease in weight, however, hiperobeses showed a more pronounced decrease (p = 0.001). The fasting glucose, cholesterol and triglycerides levels also showed a signifi cant decrease without reaching differences between the groups. Conclusions: The gastric bypass is effective in achieving weight loss and resolution of comorbidities in morbidly obese as well as hiperobese patients, with no signifi cant differences in surgical complications and mortality.

ENDOMETRIOSIS DE LA PARED ABDOMINAL

SUMMARY Background: The presence of abdominal wall endometriosis (AWE) used to be confused with other surgical pathologies that may appear in these zones. Objective: To evaluate the AWE clinical characteristics. Method: Retrospective study of all the patients hospitalized with the histopathologycal diagnosis of AWE, between January 1997 and December 2005. Results: There was found AWE only in 14 patients. Their mean age was 33.2 years old. The symptoms were: cyclic pain (71.4%), abdominal wall mass (100%), dyspareunia (21.4%) and dysmenorrhea (42.8%). All patients had at least one gynecologic (2 patients with laparoscopic procedures) or obstetric surgery (85.7% had previous cesarean section). Only one patient had previously been diagnosed with pelvic endometriosis. Their symptoms started after an average of 3.5 years after surgery. The AWE had a mean size of 3.2 cm. The preoperative diagnosis was correct in 64.3%. The incorrect preoperative diagnoses were 3 granuloma, 1 inguinal hernia and 1 lipoma. All patients required surgery. 64.3% of the patients it was necessary a polytetrafluoethylene mesh. Four patients (28.5%) had AWE recurrences. 60% of the wrong initial diagnosis recurred versus 11.1% of the

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)

Progresión de metaplasia intestinal a adenocarcinoma en esófago de Barrett: utilidad de la vigilancia endoscópica

Background: The potential progression from intestinal metaplasia to low grade dysplasia, to high grade dysplasia and to adenocarcinoma represents a well recognized sequence in patients with Barretts esophagus (BE). The time required for this transformation is not well known. Aim: To report the results of a 10 years follow up of patients with BE. Material and methods: Between 1989 and 2000 we followed 402 patients with BE. Results: Sixty six subjects (16.2%) presented low grade dysplasia at the time of diagnosis and 10 patients (2 women/8 men) developed adenocarcinoma during the follow-up period. Four out of these 10 patients were operated because of gastro-esophageal reflux disease, but after 3-5 years, reflux symptoms recurred. The other 6 patients rejected surgery and were on Omeprazole with good symptomatic results. Two patients had a short BE ( 10 cm BE. The mean time elapsed from intestinal metaplasia to low grade dysplasia was 9 months, to high grade dysplasia 56 months and to adenocarcinoma 82 months. From low grade dysplasia to early cancer it was 18 months, from high grade dysplasia to early cancer 14 months and from high grade dysplasia to advanced transmural cancer 14 months. All patients were subjected to esophagectomy. Five patients detected at State I are alive without any evidence of recurrence after 36 to 130 months after surgery. Five patients with advanced transmural carcinoma subjected to radical esophagectomy died because of progression of the malignancy between 3 and 24 months after surgery. Conclusions: Progression to adenocarcinoma may occur even in absence of reflux symptoms while on acid suppression therapy. Detection at early stage intestinal metaplasia in the esophagus offers a high chance of cure after surgical resection (Rev Med Chile 2003; 131: 587-96)