Miguel A Cumsille G

Antígeno carcinoembrionario preoperatorio como factor pronóstico independiente en cáncer de colon y recto

Background: CEA is widely used in the follow up of patients with colorectal carcinoma. Aim: To study the value of preoperative CEA as an independent prognostic factor in colorectal carcinoma. Patients and methods: Analysis of 373 operated patients (204 females, age range 21-92 years) with colorectal carcinoma and a mean follow up of 53 months. The cutoff value for CEA was 5 ng/ml. Ninety four percent of patients had an excisable tumor, 79% had involvement of perirectal/pericolonic adipose tissue and 46% had lymph node involvement. Staging was done using Dukes-Turnbull and TNM classifications. Results: CEA was normal in 61% of cases, over 5 ng/ml in 39% and over 15 ng/ml in 22%. There was a strong correlation between mean preoperative CEA and tumor stage, depth and lymph node involvement. During the follow up, 140 patients died, 57 with normal and 83 with elevated CEA. Cancer mortality in patients subjected to a curative excision of the tumor (Dukes A-C2/TNM IIII) was 9% for colonic tumors and 36% for rectal tumors (p <0.001). There were no survival differences in patients with Dukes B/TNM II tumors according to preoperative CEA. Among Dukes C/TNM III tumors, survival difference was only significant for rectal tumors. A Cox model disclosed tumor stage, location and preoperative CEA as independent prognostic factors for survival. Conclusions: CEA is an independent prognostic factor for survival in colorectal carcinoma and high levels suggest an advanced disease (Rev Med Chile 2004; 132: 691-700). (Key Words: Carcinoembryonic antigen; Colorectal neoplasms; Neoplasm staging; Tumor markers, biological)

Factores pronósticos en el cáncer colorrectal: Análisis multivariado de 224 pacientes

Background: Staging of colorectal carcinoma has prognostic value and allows to take decisions about adjuvant therapy and follow up. Prognostic factors are not universally accepted and there are different staging classifications. Aim: To assess the prognostic value of clinical and pathological variables in 224 patients subjected to a curative resection of a colorectal carcinoma. Patients and methods: A retrospective analysis of 99 men and 125 women, aged 23 to 91 years old subjected to a curative resection of a colorectal carcinoma and followed up for a mean of 72 months. Results: Global survival at 60 months was 72%. Univariate analysis showed that tumor localization, vascular permeation, wall infiltration and number of involved lymph nodes had an influence on survival. A Cox regression model disclosed tumor localization (colon versus rectum), a carcinoembrionic antigen over 30 ng/ml, vascular permeation, presence of 1 to 4 involved lymph nodes, or 5 or more lymph nodes and the presence of an apical lymph node as variables with significant prognostic value. Conclusions: Our series confirms the prognostic importance of lymph node involvement. This parameter is incorporated in Jass, GITSG (both modifications of Dukes classification) and TNM staging scores. (Rev Med Chile 2001; 129: 237-46).

Prevalencia de la ateromatosis carotídea en pacientes con enfermedad cerebro vascular oclusiva

Background: Hispanics have a greater incidence of stroke and prevalence of intracranial atherosclerosis than whites. Aim: To study the prevalence of extracranial atherosclerosis among patients admitted to a hospital with an ischemic stroke. Material and methods: A prospective study in stroke patients admitted to a Neurology ward in a University Hospital. All were subjected to a CT scan, carotid duplex-Doppler ultrasonographic examination with Doppler measurement of blood flow velocity, permeability and plaques. Cardiac emboli were searched with transthoracic and transesophagic echocardiography. Results: One hundred ten patients (39 women), aged 67.5±11.4 years old were studied. Stroke was atherothrombotic in 46 (41.8%), embolic in 30 (27.3%), lacunar in 27 (24.6%) and of other type in 7 (6.4%). Ninety two patients (84.4%) had high blood pressure, 38% had high cholesterol levels, 35% had a cardiac disease and 26% were smokers. Thirty five subjects (31.8%) had a normal carotid ultrasonography, 46 (41.8%) had mural plaques, 16 (14.5%) had multiple plaques without occlusion, 13 (11.8%) had a partial occlusion and 7 (6,4%) had a total occlusion. Logistic regression analysis disclosed no significant relationship between stroke types and carotid atherosclerosis. Age was the only significant predictor for carotid atherosclerosis. Conclusions: The prevalence of severe carotid atherosclerosis in this group of stroke patients was less than expected (Rev Med Chile 2001; 129: 161-5).

Factores asociados a la dehiscencia clínica de una anastomosis intestinal grapada: análisis multivariado de 610 pacientes consecutivos

Proposito: La dehiscencia de una anastomosis intestinal (DA) es una complicacion grave, lo que ha motivado la busqueda de factores de riesgo asociados con ella. El proposito de este estudio es analizar los factores predictivos de DA en una serie consecutiva de pacientes con una anastomosis grapada. Material y Metodo: Estudio longitudinal prospectivo de 610 pacientes (54% mujeres) con un promedio de edad de 58,9 anos (extremos 14-88). Las principales indicaciones quirurgicas fueron el cancer colorrectal (55%), la enfermedad diverticular (16%) y el megacolon (11%). Se utilizo un modelo de regresion logistica para estudiar la posible asociacion entre la DA y 17 variables. Resultados: La DA ocurrio en 23 pacientes (3,8%). Hubo un 3% (9/300) de DA en el grupo de las anastomosis colo-rectales altas y 12% (9/73) en el grupo de anastomosis bajas (p=0.001). De los 23 pacientes con DA, 14 requieren una reintervencion y 9 fueron manejadas en forma conservadora. La mortalidad global fue 1% (6/610), la mitad debido a complicaciones septicas de la DA. Al comparar los pacientes sin y con DA, la tasa de reoperaciones fue 6,4% y 61% (p<0.0001), la tasa de infeccion de herida operatoria fue 6,6% y 61% (p<0.0001), el tiempo de hospitalizacion promedio fue 11 y 29,9 dias (p<0.0001) y la mortalidad operatoria fue 0,5% y 13% (p<0.0001), respectivamente. En el analisis univariado el genero, la altura de la anastomosis, el diametro de la grapadora circular, el tiempo operatorio, el drenaje a la pelvis y el antecedente de radioterapia fueron significativas. En el analisis multivariado solo el genero (masculino), la altura de la anastomosis al margen anal y el antecedente de radioterapia pelvica se mantienen como variables independientes asociadas al riesgo de DA. Conclusion: Las anastomosis bajas, la radioterapia preoperatoria y el genero masculino son factores de riesgo independientes de DA clinica en el analisis multivariado. En los pacientes con multiples factores de riesgo de DA debe considerarse la confeccion de una ostomia proximal de proteccion

Reoperaciones precoces en cirugía colorrectal: análisis uni y multivariado de factores de riesgo

Proposito: Analizar el impacto clinico y los factores de riesgo de una reintervencion precoz (antes de los 30 dias) en pacientes sometidos a una reseccion con anastomosis por patologia colorrectal. Pacientes y Metodo: Estudio prospectivo de 610 pacientes (54% mujeres) con un promedio de edad de 58,9 anos, el 74% de ellos intervenidos por cancer y enfermedad diverticular. El impacto clinico se midio por la tasa de infeccion del sitio operatorio (ISO), el tiempo de hospitalizacion promedio (THP) y la mortalidad operatoria (MO). A traves de un modelo de regresion logistica, usando el procedimiento stepwise para la seleccion de variables, se estudio la asociacion entre la reintervencion y 17 variables independientes. Resultados: La tasa global de reoperaciones fue 6,4%, debido a la dehiscencia de anastomosis en 14 pacientes (36%) y la perforacion intestinal (no relacionada con la anastomosis) en 7 (18%). La MO global de la serie fue 1% (6/610). La MO asociada con la reoperacion fue 10% (4/39) versus 0,3% (2/571) en el grupo no reintervenido (p=0.0001). El THP y la tasa de ISO fueron significativamente mayores en los pacientes reoperados (p=0.0001). En el analisis univariado el genero, la patologia benigna, el tipo de anastomosis, el tipo de grapadora, la altura de la anastomosis, el tiempo operatorio y la albumina serica preoperatoria aparecen asociados con la ocurrencia de una re-laparotomia precoz. En el analisis multivariado solo el genero y la albumina < 3,5g/dl se mantienen como factores de riesgo independientes, mientras que el uso de drenaje pelviano aparece como un factor protector. Conclusiones: El genero (masculino) y el estado nutricional aparecen como factores de riesgo de una reoperacion precoz luego de cirugia colorrectal. El impacto de una reintervencion precoz se expresa en una aumento en 8 veces de la tasa de ISO, triplica el THP y la MO es treinta veces mayor

Resultados del tratamiento quirúrgico del cáncer de colon: Análisis de 439 pacientes

Resumen es: Mortality for colon cancer duplicated in the last 15 years in Chile. Aim: To analyze im- mediate and late results of surgical treatment of colon cancer. ...

Resultados de la quimioterapia adyuvante en cancer de colon

Antecedentes: La quimioterapia (QT) adyuvante mejora la sobrevida global y libre de enfermedad de los pacientes con cancer de colon resecados con intencion curativa. El objetivo de este estudio es analizar el perfil de los pacientes que reciben QT adyuvante y evaluar el impacto en la sobrevida. Pacientes y Metodo: Se incluyen todos los pacientes intervenidos por un adenocarcinoma de colon estadio II y III. Se comparan las caracteristicas clinico-patologicas, la recidiva y la sobrevida del grupo que recibio QT (grupo QT) con el grupo tratado con cirugia exclusiva (grupo no-QT) por estadio. Resultados: Se trata de 270 pacientes, 168 en estadio II y 102 en estadio III. En forma global 92 pacientes recibieron QT postoperatoria adyuvante (28 en estadio II y 64 en estadio III). En ambos estadios los pacientes del grupo QT son mas jovenes (p = 0,0002 y p = 0,0006) y tienen un mejor estado nutritivo preoperatorio (p = 0,03 y p = 0,009). En el seguimiento con una media de 67 meses recidivan y fallecen por cancer 2/28 pacientes del grupo QT y 5/140 del grupo control en estadio II, sin diferencias en la recidiva y la sobrevida al comparar ambos grupos (p = 0,91). En el grupo de pacientes en estadio III recidivan 9/64 (14%) pacientes QT versus 13/38 (34%) del grupo no-QT (p = 0,017) y fallecen 6 (9,4%) y 10 (26,3%) pacientes, respectivamente (p = 0,07). En el analisis multivariado se aprecia que el numero de ganglios metastasicos > de 3 (RD = 4,85; IC 95% 1,48 -15,90; p = 0,009) y la quimioterapia adyuvante (RD = 5,37; IC 95% = 1,50 -19,22; p = 0,01) mantienen una significacion estadistica como variable independientes con un claro impacto en la sobrevida. Conclusion: La QT adyuvante mejora la sobrevida a 5 anos de 67,5% a 80% en el estadio III. La QT adyuvante en pacientes en estadio II con factores pronosticos adversos no muestra un beneficio en la sobrevida.

Obesidad e hirsutismo como factores predisponentes de la enfermedad pilonidal sacrococcígea

Antecedentes: La enfermedad pilonidal sacrococcigea (EPSC) se ha asociado con la obesidad y el hirsutismo. El objetivo de este estudio es investigar la relevancia de estas dos caracteristicas como factores de riesgo de una EPSC. Material y Metodo: Estudio prospectivo que incluye todos los pacientes intervenidos por una EPSC en forma consecutiva en forma electiva. Se uso el indice de masa corporal (IMC) para medir el grado de obesidad y se comparo el IMC, la morbilidad y la recidiva con un grupo control de pacientes operados por patologia benigna distinta de la obesidad. El hirsutismo se define como la presencia de pelo abundante y grueso en la region lumbar y espalda. Resultados: Se trata de 74 pacientes (51% varones) con una edad promedio de 22,6 anos para las mujeres y 27,8 para los hombres (p=0,02). El IMC promedio fue 28,6 para los varones versus 26,4 para las mujeres (p=0,03). Los pacientes con sobrepeso y obesidad tuvieron un promedio de edad superior que los pacientes con IMC normal (p<0,0001). El 54% de los pacientes fue catalogado como hirsutos, sin diferencias en el promedio de edad ni del IMC. El grado de hirsutismo fue significativamente mayor en los varones que en la mujeres (p=0,014). Al comparar con el grupo control (n=62), no hubo diferencias en cuanto al promedio del IMC (p=0,31) ni el grado de hirsutismo (p=0,56) entre ambos grupos. Tampoco hubo diferencias significativas en cuanto a la morbilidad postoperatoria y la recidiva de la enfermedad en pacientes con obesidad y/o hirsutismo. Conclusion: La obesidad y el hirsutismo no son factores de riesgo de desarrollar una EPSC, no aumentan la morbilidad postoperatoria ni la recidiva

Características clínico-moleculares del cáncer gástrico cardial asociado al virus Epstein Barr

BACKGROUND Mortality caused by cardial gastric cancer in Chile, is increasing. Previously we demonstrated an association between Epstein Barr virus and this specific location of gastric cancer. AIM To perform a clinical and molecular characterization of cardial gastric cancer associated to Epstein Barr virus. MATERIAL AND METHODS Epstein Barr virus was identified in 93 cardial gastric tumors, by in situ hybridization. Clinical and pathological features, survival and expression of p53 and c-erbB2 were compared between tumors with or without the presence of the virus. RESULTS Twenty two (23.6%) tumors expressed Epstein Barr virus. No difference in sex or age of patients with tumors positive or negative for the virus was observed. Epstein Barr positive tumors had a tendency to have a higher frequency of Bormann III endoscopic appearance and a lower frequency of p53 accumulation (p=0.06). Five years survival was 67% and 42% of tumors positive and negative for the presence of the virus, respectively (p=0.57). CONCLUSIONS Our results, although not significant, show a tendency towards unique characteristics of cardial gastric tumors associated to Epstein Barr.

Práctica contemporánea de la angioplastia coronaria en Chile: Informe final del Registro Nacional de Angioplastia Coronaria (RENAC) 2001-2002

Background:Coronary angioplasty was introduced in Chile in 1982, but only after the introduction of stents it became commonplace. However, the results of this procedure at the national level remain largely unknown. Aim: To assess the results and characteristics of coronary angioplasty and develop a national registry in Chile (RENAC). Patients and Methods: All centers performing angioplasty were invited to contribute prospectively with the clinical, angiographic, procedural characteristics and results of all consecutive coronary angioplasty procedures attempted between June 2001 and October 2002. Results: In 10 centers, 1768 lesions were treated in 1484 procedures (22.98% in women). Mean age was 60.8±11.3 years old. Diabetes was found in 21.8%, hypertension in 60.2%, dyslipidemia in 52.0%, active smoking in 40.0%, renal failure in 6.2%. Myocardial infarction was recent in 28.4% and acute in 19.7%. Forty eight percent of patients had unstable angina and 15.5% had stable angina. Fifty three percent of patients had single vessel disease and 71%, normal left ventricular eyection fraction. One vessel was treated in 90.6% of patients and 81.7% of lesions were treated with stents, 17.9% only with baloon and in 0.4% with atherectomy. Angiographic success was obtained in 95.2%. Clinical success was obtained in 92.2%, and 95.1% in patients without acute myocardial infarction. Overall inhospital death was 2.2%. In patients without myocardial infarction, the figure was 1.1%. Conclusions: Coronary angioplasty in Chile is performed mostly for the treatment of acute coronary syndromes. Stents are the most frequently used devices. The high success, low mortality and complications observed are comparable to North American registries (Rev Med Chile 2004; 132: 913-22)Background: Coronary angioplasty was introduced in Chile in 1982, but only after the introduction of stents it became commonplace. However, the results of this procedure at the national level remain largely unknown. Aim: To assess the results and characteristics of coronary angioplasty and develop a national registry in Chile (RENAC). Patients and Methods: All centers performing angioplasty were invited to contribute prospectively with the clinical, angiographic, procedural characteristics and results of all consecutive coronary angioplasty procedures attempted between June 2001 and October 2002. Results: In 10 centers, 1768 lesions were treated in 1484 procedures (22.98% in women). Mean age was 60.8±11.3 years old. Diabetes was found in 21.8%, hypertension in 60.2%, dyslipidemia in 52.0%, active smoking in 40.0%, renal failure in 6.2%. Myocardial infarction was recent in 28.4% and acute in 19.7%. Forty eight percent of patients had unstable angina and 15.5% had stable angina. Fifty three percent of patients had single vessel disease and 71%, normal left ventricular eyection fraction. One vessel was treated in 90.6% of patients and 81.7% of lesions were treated with stents, 17.9% only with baloon and in 0.4% with atherectomy. Angiographic success was obtained in 95.2%. Clinical success was obtained in 92.2%, and 95.1% in patients without acute myocardial infarction. Overall inhospital death was 2.2%. In patients without myocardial infarction, the figure was 1.1%. Conclusions: Coronary angioplasty in Chile is performed mostly for the treatment of acute coronary syndromes. Stents are the most frequently used devices. The high success, low mortality and complications observed are comparable to North American registries (Rev Med Chile 2004; 132: 913-22). (Key Words: Coronary disease; Angioplasty, transluminal, percutaneous Coronary; Stents)BACKGROUND Coronary angioplasty was introduced in Chile in 1982, but only after the introduction of stents it became commonplace. However the results of this procedure at the national level remain largely unknown. AIM To assess the results and characteristics of coronary angioplasty and develop a national registry in Chile (RENAC). PATIENTS AND METHODS All centers performing angioplasty were invited to contribute prospectively with the clinical, angiographic, procedural characteristics and results of all consecutive coronary angioplasty procedures attempted between June 2001 and October 2002. RESULTS In 10 centers, 1768 lesions were treated in 1484 procedures (22.98% in women). Mean age was 60.8 +/- 11.3 years old. Diabetes was found in 21.8%, hypertension in 60.2%, dyslipidemia in 52.0%, active smoking in 40.0%, renal failure in 6.2%. Myocardial infarction was recent in 28.4% and acute in 19.7%. Forty eight percent of patients had unstable angina and 15.5% had stable angina. Fifty three percent of patients had single vessel disease and 71%, normal left ventricular eyection fraction. One vessel was treated in 90.6% of patients and 81.7% of lesions were treated with stents, 17.9% only with baloon and in 0.4% with atherectomy. Angiographic success was obtained in 95.2%. Clinical success was obtained in 92.2%, and 95.1% In patients without acute myocardial infarction. Overall inhospital death was 2.2%. In patients without myocardial infarction, the figure was 1.1%. CONCLUSIONS Coronary angioplasty in Chile is performed mostly for the treatment of acute coronary syndromes. Stents are the most frequently used devices. The high success, low mortality and complications observed are comparable to North American registries.