atricio Burdiles P

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.

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).

Reflujo gastroesofágico patológico en pacientes con obesidad severa, mórbida e hiper obesidad

Background: Overweight can be a risk factor for pathological gastroesophageal reflux or hiatal hernia. Aim: To study the prevalence of gastroesophageal reflux in patients with severe obesity. Patients and methods: Sixty seven patients, 51 female, aged 17 to 56 years old with a body mass index over 35 kg/m2, were studied. An upper gastrointestinal endoscopy was performed in all, esophageal manometry was done in 32 and 24 h pH monitoring was done in 32 patients. Results: Seventy nine percent of patients complained of heartburn and 66% of regurgitation. In 16 patients, endoscopy was normal. An erosive esophagitis was found in 33 patients, a short columnar epithelium in 12 and a Barret esophagus with intestinal metaplasia in six. Normal endoscopic findings and erosive esophagitis were present with a higher frequency in women. No association between the degree of obesity and esophageal lesions was observed. Lower esophageal sphincter pressure and abdominal length were significantly higher in subjects with a body mass index over 50 compared to those with a body mass index between 35 and 39.9 kg/m2. No differences were observed in 24 h pH monitoring. Conclusions: A high proportion of severely obese patients had symptoms and endoscopical findings of pathological gastroesophageal reflux (Rev Med Chile 2001; 129: 1038-43

Comparación del tratamiento médico y quirúrgico en pacientes con obesidad grado III (obesidad mórbida)

This is a review of publications comparing the results of medical and surgical treatment of morbid obesity. An overall conclusions is that the frequency of cardiovascular complications or cancer is higher among patients receiving medical treatment. Surgical treatment is associated with a better weight loss, reduction in complications and quality of life. Mortality risk decreases significantly after surgical treatment, when compared with patients receiving medical therapy Therefore, management of morbid obesity should be carried out by multidisciplinary teams with experience on gastrointestinal surgery. In this way the complications and mortality of bariatric surgery would be minimized.

Sobrevida de pacientes con cáncer de esófago sometidos a esofagectomía total torácica

Background: Esophageal carcinoma has a dismal prognosis. Several authors have reported a very low survival in Chile. Aim: To report the survival of patients with esophageal carcinoma, subjected to esophageal resection. Material and methods: Analysis of 108 patients subjected to thoracic esophageal resection between 1985 and 1996. Patients were classified according to the location of the tumor and its staging. Results: Eleven patients died in the immediate postoperative period and 90 patients were followed. In 53 the exact cause of death was determined. Global five years survival was 29% and median survival was 18 months. Survival was 100% in stage I tumors. Adjuvant therapy resulted in a better survival of stage III tumors. Survival of stage IV tumors was worst than stage I to III tumors. There was no survival difference between squamous carcinoma or adenocarcinoma. Tumors located in the superior third of the esophagus had a worst prognosis. Causes of death were mediastinic metastases, local recidivism, pleural or pulmonary metastases and less frequently, brain, bronchial or bone metastases. Conclusions: The survival of these, patients with esophageal carcinoma did not differ from the figures reported abroad. (Rev Med Chile 2000; 128: 64-74)

Efecto del bypass en la esofagitis erosiva en pacientes con obesidad mórbida

Background: Obesity is an important risk for pathological gastroesophageal reflux. Aim: To assess the effects of gastric bypass on obese subjects with erosive esophagitis. Patients and methods: Sixty two morbid obese subjects (aged 16 to 70 years, 41 females) with erosive esophagitis at the moment of surgery were studied. These patients were subjected to a gastric bypass with gastric resection. They were followed with upper gastrointestinal endoscopy every one year, looking for the presence of erosions or ulcers in the distal esophagus. Results: The mean follow up period was 21 months. Prior to surgery all patients had heartburn or regurgitation and at two years after surgery, 97% were asymptomatic. Esophagitis was found in 97 and 6.5% before and after surgery, respectively. Two patients had an esophageal ulcer, that healed on follow up endoscopy. There was a 72% reduction of overweight on late follow up. Conclusions: Gastric bypass is effective to control pathological gastroesophageal reflux in patients with morbid obesity

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)