Lesiones de vía biliar poscolecistectomía: conducta terapéutica actual / Post Cholecystectomy Bile Duct Injuries: Current Therapeutic Option

Resumen La colecistolitiasis es una condición común en Chile. La complicación más frecuente de esta condición es la colecistitis aguda. Aproximadamente 60.000 colecistectomías son realizadas anualmente en nuestro país, convirtiéndola en una de las patologías digestivas más frecuentes. El tratamiento de la colelitiasis ha evolucionado las últimas dos décadas. Con el desarrollo de la laparoscopía a final de 1980, la colecistectomía abierta fue definitivamente sustituida en los 90 por la vía laparoscópica. Desafortunadamente, la generalización de este procedimiento produjo un aumento en la incidencia de lesiones de vía biliar, aumentando desde una 0,1-0,2% hasta un 0,5-0,7%. Si bien, con el progresivo entrenamiento de los cirujanos en la cirugía mínimamente invasiva esta cifra ha disminuido nuevamente, la LVB aún constituye una de las complicaciones más graves en cirugía, generando gran impacto en la calidad de vida del paciente, e incluso costos en salud que pueden llegar a ser devastadores. El manejo de una lesión de vía biliar es, para muchos cirujanos, un desafío quirúrgico, que para su resolución requiere de las habilidades y experiencia de un cirujano hepatobiliar y derivación a centros de salud especializados. Sin duda, la acción más importante es extremar de manera rutinaria las medidas de prevención. Sin embargo, una vez que la lesión se ha producido, el futuro del paciente depende, directamente, del buen criterio del cirujano, tanto para realizar un diagnóstico temprano, como del enfrentamiento terapéutico que realice. El objetivo de este trabajo es dar a conocer diferentes conductas preventivas y terapéuticas cuando esta complicación se presenta.

Calculous biliary disease is a common condition in Chile. Over 60.000 cholecystectomies are performed annually, making gallstone disease one of the most common digestive health problems. The treatment of calculous biliary disease has evolved over the last 2 decades. With the development of laparoscopic technology in the late 1980s, new techniques for cholecystectomy were introduced. By the early 1990s, laparoscopic cholecystectomy had replaced open cholecystectomy in the operative management of gallbladder stone disease. Unfortunately, the widespread application of laparoscopic cholecystectomy has led to a concurrent rise in the incidence of major bile duct injuries. Reports have estimated the incidence has risen from 0.1-0.2 to 0.5-0.7%. Although, exponential training of surgeons in minimally invasive surgery has led to decrease this numbers again, bile duct injuries still constitute one of the most serious complications in surgery, generating a great impact on the patient's quality of life, and even health costs that can be devastating. The management of patients following major bile duct injurie is a surgical challenge, often requiring the skills of experienced hepatobiliary surgeons at tertiary referral centers. In this setting, the most important action is to routinely maximize prevention measures. However, once injury has occurred, patient's future depends directly on the correct judgment of the surgeon, both to make an early diagnosis and to choose the best therapeutic confrontation. The objective of this article is to present the different preventive and therapeutic options available when this complication occurs.

Description of the Terrestrial Larva of Parosca latipalpis (Macquart) (Diptera: Tabanidae) from Southern Chile.

The terrestrial larva of the austral horsefly, Parosca latipalpis (Macquart), identified by molecular techniques, is described. The larva of P. latipalpis resembles Scaptia auriflua (Donovan), Copidapha vicina (Taylor), Myioscaptia muscula (English), and Osca lata (Guérin-Meneville) in many morphological characters, as well as in their terrestrial habitats. Some characters that are shared between these species are unique among Tabanidae and provide evidence of their monophyletic origin, suggesting a typical Gondwanaland group. Larvae of P. latipalpis were found 2-3 cm below of the soil surface and associated with larvae of Coleoptera, Lepidoptera, and Diptera in southern Chile.

Intervenciones realizadas por residentes de cirugía general / Surgical procedures performed by general surgery residents

Introduction: The national Society of Surgery has defined the minimum number of surgical procedures that must be performed by general surgeons in trainee, however, there is no national data reporting this accomplishment. The aim of this study is to report on detail the surgical interventions performed by General Surgery Residents at the Pontificia Universidad Catolica de Chile (PUC) as lead surgeons. Methods: Retrospective analysis of surgical procedures performed by 26 Residents of the General Surgery Program (GSP) at PUC who graduated between the years 2012 and 2014. A total of 10.102 registered surgeries were reviewed and summarized. Results: The mean number of interventions performed by surgery residents was 481 (20% of them on the first year). The most frequently performed procedures were (mean per resident) laparoscopic cholecystectomy (115;24%), open appendectomy (89;19%), classic hernioplasty (43;9%), laparoscopic appendectomy (34;7%) and open cholecystectomy (25;5%). Regarding complex/sub-specialty interventions, partial/ total colectomy (12;2%), thyroidectomy-parathyroidectomy (9;2%), vascular access (8;2%), thoracotomy-VATS-sternotomy (5;1%) and breast surgery (4;1%) were the most commonly performed. Fifty three percent of all procedures were done in an emergency setting. The proportion of emergency procedures increased through the GSP training (elective vs emergency: 62 vs 38% at first year and 34 vs 66% at third year, respectively; p < 0.002). Interventions were mainly performed in the capital city of Chile, Santiago (74%) and the remaining were done in other provinces. Regarding only abdominal interventions (mean per resident: 366), 42% was performed by laparoscopy. Conclusions: Residents of the PUC-GSP execute a considerable large amount of interventions as resident surgeons throughout their 3-years-training program, exceeding the minimum recommendations established by the national Society of Surgery.

Introducción: Se han definido objetivos mínimos para la formación de Cirujanos Generales, pero no existen publicaciones que den cuenta del cumplimiento de los mismos. El objetivo de este trabajo es comunicar un análisis descriptivo de las intervenciones quirúrgicas realizadas por los residentes del Programa de Cirugía General (PCG) de la Pontificia Universidad Católica de Chile (PUC) en rol de primer cirujano. Material y Método: Se solicitó el registro de operaciones realizadas en rol de 1er cirujano a los 26 egresados entre 2012-2014 del PCG. Se realizó un análisis descriptivo de las 10.102 operaciones registradas. Resultados: El promedio de intervenciones realizadas por residente fue de 481 (20 por ciento en 1er año). Las más frecuentes fueron: colecistectomía laparoscópica (115;24 por ciento), apendicectomía clásica (89;19 por ciento), hernioplastía (43;9 por ciento), apendicectomía laparoscópica (34;7 por ciento) y colecistectomía clásica (25;5 por ciento). Las operaciones de especialidades derivadas que más se realizaron: colectomía (12;2 por ciento); tiroidectomía-paratiroidectomía (9;2 por ciento), accesos vasculares (8;2 por ciento), toracotomía-VATS-esternotomía (5;1 por ciento) y cirugía mamaria (4;1 por ciento). Un 53 por ciento de las intervenciones fueron de urgencia, observándose una inversión de la proporción entre procedimientos electivos vs de urgencia a lo largo de la formación (62 vs 38 por ciento en 1ro y 34 vs 66 por ciento en 3ro; p < 0,002). De las intervenciones abdominales (366), 58 por ciento fue por laparotomía y 42 por ciento por laparoscopia. Un 74 por ciento y 26 por ciento de todas las intervenciones se realizaron en centros de Santiago y regiones, respectivamente. Conclusiones: Los residentes de la PUC completan un volumen importante de intervenciones en rol de primer cirujano durante los 3 años de su PCG, superando las exigencias mínimas establecidas.

Lesiones gástricas en pacientes infectados con Helicobacter pylori: expresión de RAGE (receptor de productos de glicosilización avanzada) y otros inmunomarcadores / Expression of RAGE in Helicobacter pylori infested gastric biopsies

Background: Inflammation is a common phenomenon present in gastric mucosa of patients infected with H. pylori. Activation of the RAGE/multiligand axis is thought to be a relevant factor in cancer-mediated inflammation. RAGE is a membrane receptor, belonging to the immunoglobulin family, and the over-expression of RAGE has been associated with increased invasiveness and metastasis generation in different types of cancer, including gastric cancer. Furthermore recent experiences show that the use of its soluble form (sRAGE) or silencing of the gene coding for this receptor could provide therapeutic benefits in cancer. Aim: To evaluate the immunohistochemical expression of RAGE, MUC-1, β-Catenin free and phosphorylated, Cyclin-D1 and GSK3 in gastric biopsy specimens infected with H. pylori. Material and Methods: Immunohistochemical analysis was carried out in gastric biopsies from 138 patients: 55 with inflammatory injury (no atrophic gastritis), 42 with pre-cancerous conditions (atrophy or intestinal metaplasia) and 41 with dysplastic lesions or in situ adenocarcinoma. Results: There was a high rate of positive RAGE expression in the three groups of biopsies. Biopsies with dysplasia or in situ carcinoma had a significantly higher percentage of RAGE expression than the other groups of biopsies. Conclusions: The increased RAGE expression reported in both dysplasia and incipient cancer support the role of the multiligand/RAGE axis in gastric carcinogenesis.

Disección sub-mucosa endoscópica en cáncer gástrico incipiente / Endoscopic sub-mucosal dissection for early gastric cancer

Introduction: Gastric cancer is the leading cause of mortality in Chile and the survival rates are in direct relation with the stage of the disease. Early gastric cancer is defined as that confined to the mucosa or submucosa, regardless of the presence or absence of regional lymph node metastases and it is characterized for its great prognosis, with a survival rate of more than 90 percent at ten years of follow up. Endoscopic submucosal dissection is a technique described and developed in Japan that allows the endoscopic complete en-bloc resection of lesions of more than 2 cm with tumor cell-negative margins. Method: Databases (Pubmed, EBSCO, Cochrane) were reviewed under the terms "gastric cancer", "early gastric cancer", "endoscopic submucosal dissection". Results: The results of published series demonstrate survival rates comparable to standard surgery with less morbidity and without mortality. The present revision describes the endoscopic submucosal dissection technique in early gastric cancer, its indications, the results, the analysis of the resected pieces, the complications and the follow up of the patients. Conclusion: Endoscopic submucosal dissection is a feasible technique, with excellent oncologic results and low morbidity in selected patients.

Introducción: El cáncer gástrico es la primera causa de muerte por cáncer en Chile y la sobrevida se encuentra en directa relación con la etapa de la enfermedad. El cáncer gástrico incipiente se define como aquel cáncer limitado a la mucosa o sub-mucosa independiente del compromiso ganglionar y se caracteriza por su excelente pronóstico, con sobrevida mayor a 90 por ciento a 10 años de seguimiento. La disección sub-mucosa endoscópica es una técnica descrita y desarrollada en Japón que permite la resección en bloque y con márgenes negativos de tumores incipientes mayores a 2 cm por vía endoscópica. Método: Se realizó una búsqueda en las bases de datos (Pubmed, EBSCO, Cochrane) bajo las palabras clave: "gastric cáncer", "early gastric cáncer", "endoscopic submucosal dissection". Resultados: Los resultados de grandes series demuestran una sobrevida comparable a la cirugía clásica, con menor morbilidad y sin mortalidad asociada. La presente revisión describe la técnica de disección sub-mucosa endoscópica en cáncer gástrico incipiente, sus indicaciones, los resultados, el análisis de las piezas resecadas, las complicaciones y el modo de seguimiento de los pacientes. Conclusión: La disección sub-mucosa endoscópica es una alternativa válida, con buenos resultados a largo plazo en pacientes debidamente seleccionados.

[Expression of RAGE in Helicobacter pylori infested gastric biopsies]. / Lesiones gástricas en pacientes infectados con Helicobacter pylori: expresión de RAGE (receptor de productos de glicosilización avanzada) y otros inmunomarcadores.

BACKGROUND: Inflammation is a common phenomenon present in gastric mucosa of patients infected with H. pylori. Activation of the RAGE/multiligand axis is thought to be a relevant factor in cancer-mediated inflammation. RAGE is a membrane receptor, belonging to the immunoglobulin family, and the over-expression of RAGE has been associated with increased invasiveness and metastasis generation in different types of cancer, including gastric cancer. Furthermore recent experiences show that the use of its soluble form (sRAGE) or silencing of the gene coding for this receptor could provide therapeutic benefits in cancer. AIM: To evaluate the immunohistochemical expression of RAGE, MUC-1, ß-Catenin free and phosphorylated, Cyclin-D1 and GSK3 in gastric biopsy specimens infected with H. pylori. MATERIAL AND METHODS: Immunohistochemical analysis was carried out in gastric biopsies from 138 patients: 55 with inflammatory injury (no atrophic gastritis), 42 with pre-cancerous conditions (atrophy or intestinal metaplasia) and 41 with dysplastic lesions or in situ adenocarcinoma. RESULTS: There was a high rate of positive RAGE expression in the three groups of biopsies. Biopsies with dysplasia or in situ carcinoma had a significantly higher percentage of RAGE expression than the other groups of biopsies. CONCLUSIONS: The increased RAGE expression reported in both dysplasia and incipient cancer support the role of the multiligand/RAGE axis in gastric carcinogenesis.

The existence of a relationship between increased serum alanine aminotransferase levels detected in premarketing clinical trials and postmarketing published hepatotoxicity case reports.

BACKGROUND: Drug-induced liver injury (DILI) profile in most drugs' available information is based on both the incidence of alanine aminotansferase (ALT) elevations in clinical trials and published case reports. AIM: To assess the relationship between ALT elevations in clinical trials and the number of published case reports in the postmarketing setting. METHODS: Hepatotoxic drugs were identified from product labelling and classified in high-medium risk (Black Box Warning or Precautions section) or low risk (a statement in the Adverse Reactions section). Incidence of ALT elevations (> or = 3 x ULN) for drug (I(D)) and placebo (I(C)) treated patients in premarketing clinical trials and DILI published case reports were retrieved from product labelling and MEDLINE. RESULTS: The median I(C) was 10/1000. The high-medium-risk drugs' median I(D) was significantly higher compared with low-risk drugs (17/1000 vs. 10/1000; P = 0.046). Chi-squared test, absolute difference and odds ratio comparing I(D) and I(C) identified 35%, 51% and 77% of high-medium-risk drugs respectively. Less number of case reports were associated with low- than high-medium-risk drugs (1 vs. 7; P = 0.001). A high odds ratio in clinical trials (I(D) vs. I(C)) was the strongest predictor of published DILI case reports. CONCLUSION: A relationship between increased ALT incidence in premarketing clinical trials and postmarketing published case reports exists.

[Resident evaluation of general surgery training programs]. / Evaluación de los Programas de Formación en Cirugía General. Encuesta a los alumnos de postítulo.

BACKGROUND: The profile of the general surgeon has changed, aiming to incorporate new skills and to develop new specialties. AIM: To assess the quality of postgraduate General Surgery training programs given by Chilean universities, the satisfaction of students and their preferences after finishing the training period. MATERIAL AND METHODS: A survey with multiple choice and Likert type questions was designed and applied to 77 surgery residents, corresponding to 59% of all residents of general surgery specialization programs of Chilean universities. RESULTS: Fifty five per cent of residents financed with their own resources the specialization program. Thirty nine percent disagreed partially or totally with the objectives and rotations of programs. The opportunity to perform surgical interventions and the support by teachers was well evaluated. However, 23% revealed teacher maltreatment. Fifty six percent performed research activities, 73% expected to continue training in a derived specialty and 69% was satisfied with the training program. CONCLUSIONS: Residents considered that the quality and dedication of professors and financing of programs are issues that must be improved. The opportunity to perform surgical interventions, obtaining a salary for their work and teacher support is considered of utmost importance.

Evaluación de los Programas de Formación en Cirugía General: encuesta a los alumnos de postítulo / Resident evaluation of general surgery training programs

Background: The profile of the general surgeon has changed, aiming to incorporate new skills and to develop new specialties. Aim: To assess the quality of postgraduate General Surgery training programs given by Chilean universities, the satisfaction of students and their preferences after finishing the training period. Material and methods: A survey with multiple choice and Likert type questions was designed and applied to 77 surgery residents, corresponding to 59 percent of all residents of general surgery specialization programs of Chilean universities. Results: Fifty five per cent of residents financed with their own resources the specialization program. Thirty nine percent disagreed partially or totally with the objectives and rotations of programs. The opportunity to perform surgical interventions and the support by teachers was well evaluated. However, 23 percent revealed teacher maltreatment. Fifty six percent performed research activities, 73 percent expected to continue training in a derived specialty and 69 percent was satisfied with the training program. Conclusions: Residents considered that the quality and dedication of professors and financing of programs are issues that must be improved. The opportunity to perform surgical interventions, obtaining a salary for their work and teacher support is considered of utmost importance.

Load transfer mechanism for different metatarsal geometries: a finite element study.

The load transfer mechanism across the skeleton of the human foot is very important to understand its biomechanical function. In this work, we develop several computational models to compare the biomechanical response of different metatarsal geometries. Finite element 3D simulations of feet reconstructed from computer tomography (CT) scans were used to evaluate the stress/strain distributions during the stance posture. The numerical predictions for pathological and healthy foot geometries present different load transfer mechanisms that can provide a biomechanical explanation of why some metatarsal geometrical configurations cause different foot skeletal stresses. The most significant result in all cases was a reduction between 20% and 30% of the peak load supported by the first metatarsal. Therefore, we conclude that a clearly unloaded first metatarsal, overloading the rest, is a risk factor to induce metatarsalgia.

Abscesos esplénicos: Comunicación de siete casos y revisión de la literatura / Splenic abscesses: Report of seven cases

Background: Splenic abscesses are uncommon, appear in subjects with predisposing factors such as systemic infections and have high mortality rates. Aim: To report seven patients with splenic abscesses. Material and Methods: Retrospective review of medical records of patients with a splenic abscess treated between 1987 and 2005. Results: The records of four women and three males aged 20 to 74 years, were reviewed. The most common presenting symptoms were fever and abdominal pain and all had predisposing factors. Six patients had a leukocyte count of 19,500 x mm³. Mean erythrocyte sedimentation rate and C reactive protein values were 75 mm/h and 13.5 mg/dl. Diagnosis was made with ultrasound in two patients and CT scan in five. Six patients had an unique abscess and one patient had multiple lesions. A splenectomy was done in three patients as the first choice treatment and in one, due to medical treatment failure. In two patients, a CT guided percutaneous drainage was performed and one patient was subjected to medical treatment only. Abscess cultures were positive in 50 percent of patients subjected to percutaneous drainage and in 50 percent of splenectomized patients. No patient died and no complications were observed in the early or ¡ate postoperative period. Conclusion: Splenic abscesses are associated to predisposing conditions. The first choice is surgical treatment, but percutaneous drainage is also a therapeutic option.

Hernioplastia inguinal con técnica prolene hernia system: evaluación de los resultados a largo plazo / Long term results of inguinal hernia repair with prolene hernia system technique

Introducción: En múltiples trabajos se han evaluado los resultados a corto y mediano plazo de la reparación de la hernia inguinal con la técnica prolene hernia system PHS). Sin embargo, en pocos estudios se han reportado resultados a largo plazo. Objetivos: Evaluar los resultados a largo plazo de la reparación de la hernia inguinal con la técnica PHS. Material y método: Se realizó un estudio prospectivo de 62 enfermos operados con la técnica PHS entre 2001 y 2002. Las complicaciones inmediatas y el dolor fueron evaluadas en todos los enfermos. Se completaron 4 años de seguimiento en 53 pacientes que se analizan en este trabajo (90,1 por ciento). Se evaluó la recurrencia hemiaria, la presencia de dolor crónico (en reposo y en actividad), el rechazo de la malla y la satisfacción con la operación. Resultados: El grupo está formado por 50 hombres (94 por ciento) y 3 mujeres (6 por ciento), con una edad de 53,2 + 8,5 años. En 52 enfermos (98 por ciento) la hernia inguinal fue asintomática. Se repararon 58 hernias en 53 enfermos. Dos enfermos (2,5 por ciento) presentaron complicaciones inmediatas. En el seguimiento a largo plazo, no se ha observado recurrencia, dolor crónico, rechazo de la malla y todos los enfermos están satisfechos con los resultados obtenidos. Conclusiones: La hernioplastia inguinal con técnica PHS presenta buenos resultados en el seguimiento a largo plazo, sin recidiva ni dolor crónico. Los pacientes se encuentran satisfechos con los resultados obtenidos.

Background: Short and mid-term results of inguinal hernia repair with Prolene Hernia System (PHS) have been evaluated. However, few studies have reported long-term recurrence rates. Aim: To evaluate long-term outcomes among patients who underwent inguinal hernia repair with Prolene Hernia System technique. Material and Methods: A prospective study of 62 patients operated with PHS from 2001 to 2002. Pain and immediate complications were evaluated in all patients. Four years follow-up was completed in 53 (90.1 percent) patients, who are the analyzed group. The evaluated issues were hernia recurrence, chronic pain (at rest and in activity), alteration in sexual behavior, mesh rejection and overall satisfaction with the procedure. Results: Fifty men (94 percent) and three women (6 percent), aged 53.2 + 8.5 years were analyzed. In 52 patients (98 percent), inguinal hernia was symptomatic. Fifty eight hernias were repaired on the 53 patients. On immediate follow-up, postoperative complications were observed in two patients (2.5 percent). In long-term follow-up, no patient had hernia recurrence, chronic pain or alterations in sexual behavior. Conclusions: Inguinal hernia repair with PHS has satisfactory long term outcomes.

Pancreatectomía distal: indicaciones y resultados quirúrgicos inmediatos / Indications and early results of distal pancreatectomy

Introducción: Se denomina pancreatectomía distal a la resección pancreática a la izquierda del eje mesentérico portal. Los objetivos del trabajo son analizar las indicaciones y los resultados quirúrgicos de esta operación en enfermos con un tumor pancreático. Material y métodos: Estudio retrospectivo de 38 pacientes operados entre 1990 y 2005. Se analizaron las características clínicas, quirúrgicas y el estudio anatomopatológico. Resultados: Se operaron 29 mujeres y 9 hombres, de 52,9 + 5 años. El motivo de consulta más frecuente fue dolor abdominal en 26 enfermos. El diagnóstico se realizó con una ecografía en 7 pacientes y en 31 con una tomografía o una resonancia de abdomen. La indicación quirúrgica fue la presencia de un tumor pancreático en los 38 enfermos, quístico en 24 y sólido en 14. A 25 pacientes se les realizó una esplenectomía. Diez enfermos presentaron complicaciones postoperatorias; las más frecuentes fueron: fístula pancreática en 5, sepsis en 3 e infección del catéter central en 3. No hubo diferencias en la frecuencia de complicaciones ni en el desarrollo de una fístula pancreática entre los enfermos con y sin esplenectomía. Un enfermo falleció por sepsis abdominal. El estudio anatomopatológico mostró 28 tumores benignos y 10 tumores malignos, siendo los más frecuentes el cistoadenoma mucinoso y el adenocarcinoma, respectivamente. Conclusiones: Las pancreatectomías distales se realizaron principalmente por un tumor quístico benigno. La complicación más frecuente fue la fístula pancreática, la que llevó a la muerte a un paciente. Los enfermos esplenectomizados no presentaron más complicaciones postoperatorias que los sin esplenectomía.

Background: Resection of the pancreatic portion located to the left of the portal mesenteric axis is called distal pancreatectomy Aim: To analyze the indications and surgical results of distal pancreatectomy in patients with pancreatic tumors. Material and methods: Retrospective review of medical records of patients subjected to a distal pancreatectomy for pancreatic tumors, between 1990 and 2005. Patient features, and early complications were evaluated. Results: In the study period, 38 patients aged 53 + 5 years (29 females), were operated. The tumor was cystic in 24 patients and solid in 14. Ten patients had postoperative complications. The most common complications were pancreatic fistula in five patients, sepsis in three and catheter infection in three. No differences in the rate of complications or development of pancreatic fistula, were observed between patients subjected or not subjected to splenectomy. One patient died due to abdominal sepsis. Pathology showed 28 benign tumors (mucinous cystadenoma the most common) and 10 malignant tumors (adenocarcinoma the most common). Conclusions: The most frequent complication of distal pancreatectomy was pancreatic fistula. One patient died as a consequence of this complication. Patients subjected to splenectomy did not have a higher rate of complications.

Tumores del apéndice cecal: análisis anatomoclínico y evaluación de la sobrevida alejada / Appendiceal tumors: retrospective review of 67 patients

Introducción: Los tumores del apéndice cecal corresponden al 0,5 por ciento de las neoplasias gastrointestinales y su pronóstico depende del tipo de tumor. Objetivos: Analizar las características de los tumores apendiculares y los factores que influyen en su sobrevida. Material y Métodos: Estudio retrospectivo de los pacientes con un tumor apendicular operados entre 1981 y 2006 en el Hospital de la P. Universidad Católica. Se evaluaron las características clínicas, anatomopatológicas (AP) y la sobrevida alejada. Se utilizó la prueba de Fisher, el test de Wilcoxon y curvas de Kaplan-Meier. Resultados: Se operaron 67 enfermos, 39 mujeres y 28 hombres con una edad de 45,3 + 19,6 años. En 59 enfermos la operación se realizó por sospecha de apendicitis aguda, la que se confirmó en el estudio AP en 37 de ellos. En 36 pacientes se demostró un carcinoma neuroendocrino, en 18 un tumor benigno, en 7 un adenocarcinoma, en 5 un adenocarcinoide y en uno un carcinoma neuroendocrino y un cistoadenoma mucinoso. Se realizó una hemicolectomía en un segundo tiempo operatorio a 9 enfermos: 4 con un carcinoide, 3 con un adenocarcinoma, 1 con un adenocarcinoide y uno con un pseudomixoma peritoneal. La sobrevida a 5 años fue de 100 por ciento en los enfermos con un tumor benigno, 97 por ciento en los con un carcinoma neuroendocrino, 75 por ciento en los con un adenocarcinoide y 62 por ciento en los con un adenocarcinoma (p<0,05). Conclusiones: En la mayoría de los enfermos el diagnóstico de tumor se obtuvo como un hallazgo del estudio anatomopatológico en apendicectomías indicadas por sospecha de apendicitis aguda. En la sobrevida influyó fundamentalmente el tipo histológico del tumor.

Estado actual del tratamiento quirúrgico de la úlcera péptica perforada en el Hospital Regional de Talca: Experience of a regional hospital / Emergency surgical treatment of perforated peptic ulcer

La perforación de una úlcera péptica corresponde a una infrecuente y siempre grave complicación de la enfermedad ulcerosa. El tratamiento quirúrgico es la terapia de elección. Se operaron 22 pacientes (21 hombres) con una edad promedio de 50 años. Tres enfermos tenían el diagnóstico de úlcera péptica previo a la emergencia actual. El síntoma más frecuente de consulta fue el dolor epigástrico de inicio súbito en 21 (95,4 por ciento) pacientes. El diagnóstico se realizó con radiografía de tórax de pie o de abdomen simple en 11 enfermos. Se realizó sutura simple de la úlcera en 12 (54,5 por ciento) pacientes, sutura más epiploplastía en 7 (31,8 por ciento) y resección gástrica en tres enfermos (13,6 por ciento). Siete (31,8 por ciento) pacientes presentaron complicaciones post operatorias, de los cuales fallecieron 2 (9,1 por ciento) como consecuencia de la sepsis asociada. Se realizó un seguimiento endoscópico a 9 pacientes (45 por ciento) sobrevivientes al episodio agudo. En 5 de ellos se demostró que la úlcera péptica aun permanecía activa. A dos de estos últimos pacientes se les realizó, en forma electiva una cirugía resectiva definitiva. Se concluye que la perforación de una úlcera péptica corresponde a un cuadro grave, que se asocia a una morbilidad y mortalidad significativa. El tratamiento quirúrgico local es la terapia de elección para el episodio agudo, sin embargo este no es definitivo y no evita la recidiva.

Background: Peptic ulcer perforation is an uncommon by devastating complication that requires emergency surgical treatment. Aim: To review the results of surgical treatment of peptic ulcer perforation in a Chilean Regional Hospital. Material and Methods: Retrospective review of medical records of 22 patients (age range 21-88 years, 21 males) operated for a perforated peptic ulcer, between 1995 and 2000. Results: The most common presentation symptom was acute epigastric pain in 21 patients. The diagnosis was done with a plain abdominal X ray obtained in the standing position, in 11 patients. A simple suture of the ulcer was done in 12 patients, suture plus epiploplasty in seven and gastric resection in three. Seven patients (32 percent) had postoperative complications and two (9 percent) died as a consequence of an associated septic process. An endoscopic follow up was done in nine patients and in two, the peptic ulcer remained active. These two patients were subjected to an elective excisional surgery. Conclusions: Local surgical correction of peptic ulcer perforation is the emergency treatment of choice but does not avoid ulcer relapse.

Tumores estromales del estómago / Gastric stromal tumors

Los tumores estromales son poco frecuentes y constituyen la segunda neoplasia no epitelial más frecuente, luego del linfoma en el estómago. Su comportamiento no es fácil de predecir y depende la mayoría de las veces del tamaño del tumor y del número de mitosis. El tratamiento habitual es la cirugía. Se presentan 13 enfermos operados, 7 hombres y 6 mujeres, con una edad de 63,4 ± 14,8 años. La manifestación clínica más frecuente fue la hemorragia digestiva alta en 8 pacientes. Se sospechó, luego del estudio endoscópico, un tumor estromal en 5 (38,5%) de ellos. Se realizaron 9 resecciones gástricas en cuña (una por vía laparoscópica), 2 gastrectomías totales y 2 subtotales. El estudio anatomopatológico mostró 7 tumores benignos y 6 malignos. La sobrevida a 54 meses de seguimiento promedio fue de 92%.

Background: Digestive tract stromal tumors are uncommon and are the second most common non epithelial digestive cancer, after gastric lymphoma. Their behavior is unpredictable and depends on the size of the tumor and its number of mitoses. Aim: To report our experience with gastric stromal tumors. Patients and Methods: Retrospective review of medical records of 13 patients operated for gastric stromal tumors (aged 63 ± 15 years. six women). The condition of the patients was revised after a mean of 54 months of follow up. Results: Eight patients consulted for upper gastrointestinal bleeding. A stromal tumor was suspected in five patients during endoscopy. A wedge gastric resection was performed in nine patients (one was done by laparoscopy), a total gastrectomy in two and subtotal gastrectomy in two. The pathological study showed a benign tumor in seven patients and a malignant tumor in six. Mean survival after 54 months of follow up was 92%. Conclusions: In this group of patients with gastric stromal tumors, the surgical treatment performed allowed a good control of the disease.