uan Carlos Díaz J

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.

Resultados premilinares de la gastroplastia horizontal con anastomosis en Y de Roux como cirugía bariática en pacientes con obesidad severa y mórbida

Background: Morbidly obese subjects have a high incidence of complications. The poor results of dietary treatments, has prompted the search of new therapies for obesity and among these, surgical procedures. Aim: To report the long term results of horizontal gastroplasty with Roux en Y anastomosis in morbidly obese subjects. Patients and methods: Fifty patients with an initial body mass index of 41.3 ± 6 kg/m2 have been subjected to a horizontal gastroplasty with Roux en Y anastomosis. During the study period, surgical techniques were modified, reducing the gastric pouch size, adding a truncal vagotomy, cholecystectomy, and increasing the length of the Roux en Y loop from 70 to 100 cm. Twenty five patients have been followed for two years. Results: There was no operative mortality and one patient had an anastomotic leak that required 35 days of hospitalization. During follow up, in one patient, the stapled suture line loosened. After two years of follow up, weight decreased from 112 ± 19 to 77.2 ± 14 kg. Conclusions: Horizontal gastroplasty with Roux en Y anastomosis achieved an adequate weight loss with a low rate of complications in this group of morbidly obese subjects.

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

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.

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)

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.

Morbilidad y mortalidad operatoria de la gastrectomía subtotal y total por cáncer gástrico 2004 a 2010: Parte I de un estudio prospectivo

Complications and mortality of total and subtotal gastrectomy for gastric cancer Background: Surgery for gastric cancer may have high rates of complications and mortality. Aim: To analyze operative mortality of total and subtotal gastrectomy in the period 2004-2010. Material and Me- thods: Prospective study 345 patients with gastric cancer, mean age 62 years, 64% males, subjected to a total or subtotal R0, R1 or R2 gastrectomy. All patients were assessed in the postoperative period and all com- plications were recorded. Results: Total and subtotal gastrectomies were performed in 224 and 69 patients respectively. Postoperative complications consisted in anastomotic leaks, duodenal stump leaks, hemoperi- toneum, pulmonary infections and intestinal obstruction. Mortality of total gastrectomy R1 or R2 was 2.1% whereas palliative gastrectomy, to improve quality of life, had 15% mortality. Subtotal gastrectomy had 1.4% mortality. Conclusions: There has been a reduction in operative mortality of gastrectomy for gastric cancer, however the rate of complications has not changed.