Colangiopancreatografía retrógrada endoscópica asistida por enteroscopia de doble balón en un paciente con gastrectomía total y reconstrucción en Y-de-Roux: reporte de caso / Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in a patient with total gastrectomy and roux-en-y reconstruction: A case report

Resumen La colangiopancreatografía retrógrada endoscópica (CPRE) es un procedimiento útil en el manejo de enfermedades biliopancreáticas. Los pacientes con alteración anatómica del tracto gastrointestinal representan un desafío técnico por múltiples razones. Con técnicas como la enteroscopia de doble balón (EDB) es posible realizar una CPRE en estos pacientes. El caso que se presenta es el primero de este tipo publicado en Colombia sobre una paciente con gastrectomía total con reconstrucción en Y-de-Roux y coledocolitiasis.

Abstract Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable procedure in managing biliopancreatic diseases. Patients with anatomical alteration of the gastrointestinal tract represent a technical challenge for multiple reasons. With techniques such as double-balloon enteroscopy (DBE), it is possible to perform ERCP in these patients. The case was first published in Colombia on a female patient with total gastrectomy with Roux-en-Y reconstruction and choledocholithiasis.

Calidad de vida posterior a gastrectomía total laparoscópica versus abierta en cáncer gástrico / Quality of life after -laparoscopic versus open total gastrectomy in gastric cancer

Resumen Introducción: En los últimos años, la gastrectomía laparoscópica ha aparecido como una técnica quirúrgica con resultados oncológicos comparables a la técnica abierta, pero existe poca evidencia en cuanto a la calidad de vida posoperatoria de estos pacientes. Objetivo: Evaluar la calidad de vida posoperatoria de pacientes sometidos a gastrectomía total laparoscópica (GTL) en comparación a gastrectomia total abierta (GTA) en cáncer gástrico. Materiales y Método: Estudio retrospectivo, observacional en Hospital Militar de Santiago, entre enero de 2015 y junio de 2020. Se les aplicó 2 encuestas validadas para Chile: EORTC QLQ-30 y EORTC QLQ-OG25. Resultados: Se obtuvieron 60 pacientes; 30 sometidos a GTL y 30 a GTA. Promedio edad fue 66,3 ± 11 años para GTL y 68,2 ± 11 años en GTA (p = 0,5). Se obtuvo un score en GTL versus GTA: global 83,3 y 80,2 (p = 0,6), sintomático 17,1 y 25,5 (p = 0,2) y score funcional 87,9 y 70,9 (p = 0,03). Posterior a eso obtuvimos en funcionalidad GTL versus GTA; física 92,2 versus GTA 73,1 (p = 0,04), emocional 84,1 versus 78,5 (p = 0,6), cognitiva 84,9 versus 79,0 (p = 0,3) y social 80,9 versus 72,2 (p = 0,4). Al analizar síntomas destaco; fatiga 14,6 versus 33,1 (p = 0,04) y dolor 13,4 versus 24,3 (p = 0,05). Finalmente, en síntomas digestivos altos obtuvimos en disfagia 0,84 GTL versus 17,3 GTA (p = 0,04). Conclusión: La GTL logra resultados comparables a GTA en calidad de vida e incluso ofrece ventajas significativas en funcionalidad física como también en síntomas como dolor, fatiga y disfagia.

Introduction: In recent years, laparoscopic gastrectomy has appeared as a surgical technique with oncological results comparable to the open technique, but there is little evidence regarding the postoperative quality of life of these patients. Objective: To evaluate the postoperative quality of life of patients undergoing laparoscopic total gastrectomy (LTG) compared to open total gastrectomy (OTG) in gastric cancer. Materials and Method: Prospective, observational study at Hospital Militar of Santiago, between January 2015 and June 2020. Two surveys validated for Chile were applied: EORTC QLQ-30 and EORTC QLQ-OG25. Results: 60 patients were obtained; 30 subjected to LTG and 30 to OTG. Average age was 66.3 ± 11 years for LTG and 68.2 ± 11 years for OTG (p = 0.5). A score was obtained in LTG versus OTG: global 83.3 and 80.2 (p = 0.6), symptomatic 17.1 and 25.5 (p = 0.2) and functional score 87.9 and 70.9 (p = 0.03). After that we got LTG versus OTG functionality; physical 92.2 versus 73.1 (p = 0.04), emotional 84.1 versus 78.5 (p = 0.6), cognitive 84.9 versus 79.0 (p = 0.3) and social 80.9 versus 72.2 (p = 0.4). When analyzing symptoms I highlight; fatigue 14.6 versus 33.1 (p = 0.04) and pain 13.4 versus 24.3 (p = 0.05). Finally, in upper digestive symptoms, we obtained 0.84 LTG versus 17.3 OTG in dysphagia (p = 0.04). Conclusion: LTG achieves results comparable to OTG in quality of life and even offers significant advantages in physical functionality as well as symptoms such as pain, fatigue and dysphagia.

Predictors of anastomotic leak after total gastrectomy in patients with adenocarcinoma.

BACKGROUND: Esophagojejunal anastomotic leakage (EJAL) is among the most feared complications after gastric cancer surgery; they entail an uncertain prognosis and relate with increased morbidity and mortality. Factors associated with their development are not well determined, and their diagnosis and treatment vary between institutions. MATERIAL AND METHODS: Retrospective case-control study of patients operated of total gastrectomy with Roux-en-Y esophagojejunostomy from January 2002 to December 2018. We divided our sample into two groups based on the presence of EJAL, and compared demographic, clinical, and histologic variables. We performed a logistic regression model to search risk factors associated with EJAL and described the management offered in our center. RESULTS: We included 58 patients of which 8 (13.7%) presented clinically relevant EJAL. On the comparative analysis, albumin levels and diffuse histology presented a statistically significant difference between groups and presented association with EJAL in the logistic regression model. Regarding treatment of EJAL, ten patients (55.5%) required only conservative measures, whereas eight patients (44.4%) warranted an endoscopic or surgical intervention. CONCLUSION: Our retrospective analysis identified some factors that may be associated with the development of EJAL after gastric cancer surgery. High suspicion and prompt identification of this complication is essential to improve postoperative outcomes in this group.

INTRODUCCIÓN: Las fugas de la anastomosis esófago-yeyunal se encuentran entre las más temidas complicaciones de la cirugía para cáncer gástrico. Estas conllevan un mal pronóstico con una alta mortalidad y morbilidad. Los factores asociados a su desarrollo no están bien determinados y su diagnóstico, y tratamiento varían ampliamente entre instituciones. MATERIAL Y MÉTODOS: Estudio retrospectivo de casos y controles en pacientes operados de gastrectomía total con esófago-yeyuno anastomosis en Y de Roux en el periodo de enero 2002 a diciembre 2018. Nuestra muestra fue dividida en dos grupos con base al desarrollo de fuga de anastomosis en el postoperatorio. Se realizó un análisis comparativo de características demográficas, clínicas y histológicas. Se realizó además una regresión logística para identificar factores de riesgo asociados al desarrollo de fuga de anastomosis en nuestra serie. RESULTADOS: Incluimos a 58 pacientes de los cuales 8 (13.7%) presentaron fuga de anastomosis clínicamente relevante. En el estudio comparativo: Niveles disminuidos de albúmina e histología difusa fueron significativamente mayores en el grupo de fuga y se asociaron en el modelo de regresión logística. En cuanto al tratamiento, diez pacientes (55%) requirieron únicamente tratamiento conservador, mientras que ocho pacientes (44.4%) fueron sometidos a maniobras endoscópicas o quirúrgicas. CONCLUSIÓN: Nuestro análisis retrospectivo identifico factores asociados al desarrollo de fuga de anastomosis posterior a cirugía de cáncer gástrico. Una alta sospecha diagnóstica es esencial para mejorar el pronóstico de estos pacientes.

Laparoscopic Prophylactic Total Gastrectomy for Hereditary Diffuse Gastric Cancer in CDH1 Mutation Carriers.

Background: Patients with hereditary diffuse gastric cancer (HDGC) and germline mutations in the E-cadherin gene, CDH1, have a very high cumulative lifetime risk of developing diffuse gastric cancer. In these patients, it is formally recommended to perform a prophylactic total gastrectomy (PTG). Materials and Methods: We analyzed the course of patients with HDGC who have undergone PTG in our institution. Pedigree analysis, preoperative screening results, operative course, postoperative data, and complete stomach pathologic examination were performed in all patients. Results: Seven patients with confirmed CDH1 mutation underwent PTG, five were women, and average age was 27 years (range 17-42). Signet ring cell carcinoma was found in 1 patient in the preoperative surveillance endoscopic biopsies. Laparoscopic PTG was performed in all patients. There were two complications, an intestinal obstruction that required reintervention and an asymptomatic esophagojejunal anastomosis leak that resolved with conservative treatment. In all gastrectomy specimens, intramucosal signet ring cell carcinoma foci limited to the lamina propria were found (range 1-31), 83.5% were in the body-fundus region. The mean follow-up was 28.5 months (range 8-72). The mean weight loss was 9% (range 2-18). Postoperative symptoms associated with Dumping syndrome were the most frequent. All the patients reported of being very satisfied with the procedure and of having a better quality of life than expected before the procedure. Conclusion: Laparoscopic PTG is an excellent resource to prevent the development of advanced diffuse gastric cancer (DGC) in patients with HDGC with CDH1 mutation. The procedure was well tolerated with a high satisfaction rate and very good functional results. It should be considered in these patients due to the high risk of developing advanced DGC and the lack of effective and reliable surveillance studies.

Emergency esophagojejunostomy in type IV hiatal hernia: A case report.

Reconstruction of the digestive tract is a surgical challenge; we propose a novel and successful alternative using a large vascularized pedicled jejunum anastomosed to the cervical esophagus in an emergency situation. A 65-year-old female patient in follow-up due to a gigantic type IV paraesophageal hernia, whom underwent surgical hernial defect correction, had friable gastric tissue and esophageal lesions that forced an urgent esophagojejunostomy. Immediate post-operative recovery had no incidents and during the outpatient follow-up no complications were reported. This case report represents a paradigm change in the impossibility of raising the vascularized pedicled jejunum to the neck in an emergency situation.

La reconstrucción del tracto digestivo es un reto quirúrgico. Proponemos una alternativa novedosa y exitosa utilizando un gran yeyuno pediculado vascularizado anastomosado al esófago cervical en situación de emergencia. Una paciente de 65 años en seguimiento por una hernia paraesofágica tipo IV requirió corrección quirúrgica del defecto herniario; tenía tejido gástrico friable y lesiones esofágicas que forzaron una esofagoyeyunostomía urgente. La recuperación posoperatoria inmediata no tuvo incidentes y el seguimiento ambulatorio no mostró complicaciones. Este reporte de caso rompe el paradigma de la imposibilidad de ascender el yeyuno pediculado vascularizado al cuello en una situación de emergencia.

Margen positivo (R1) en la biopsia intraoperatoria durante una gastrectomía total por cáncer gástrico / Positive margin (R1) in the intraoperative biopsy during a total gastrectomy for gastric cancer

Resumen El cáncer gástrico es una patología de alta incidencia en Chile. Afortunadamente es baja la incidencia de márgenes R1 cuando se realiza una cirugía con intención curativa. Al tener un tumor subcardial o cardial es perentorio realizar una biopsia rápida (intraoperatoria), en caso que ésta resulte positiva, es difícil tomar una decisión sobre qué realizar a continuación, ya que el realizar una esofagoyeyunoanastomosis intratorácica aumenta el riesgo quirúrgico. Para esto, es de suma importancia tener la información de las características histopatológicas del tumor, el riesgo de filtración, la recurrencia, la sobrevida, las terapias adyuvantes y la realidad país. Se realizó una revisión de la literatura con el fin de poder guiar la toma de decisiones.

Gastric cancer is a pathology with a high incidence in Chile, fortunately, the incidence of R1 margins is low when performing surgery with curative intent. When having a sub cardial or cardial tumor, it is essential to perform a rapid (intraoperative) biopsy, if this is positive when cutting the esophagus just under the pillars, it is difficult to make the decision of what to do next, since performing an inthrathoracic esophagojejunostomy increases the surgical risk. For this, it is very important to have information about the histopathological characteristics of the tumor, the leakage risk, there currence, the survival, the adjuvant therapies and the reality of the country. A review of the literature was done in order to guide the decisions.

Contrast-enhanced swallow study sensitivity for detecting esophagojejunostomy leakage. / Sensibilidad del trago de contraste hidrosoluble para la detección de fugas de anastomosis esofagoyeyunal.

INTRODUCTION AND AIM: Sixty percent of the patients with gastric carcinomas are candidates for surgical resection through total gastrectomy and esophagojejunostomy, the latter of which is associated with leaks in up to 12.3% of cases. There is no standardized procedure for diagnosing anastomotic leaks. The aim of the present study was to establish the diagnostic sensitivity of the contrast-enhanced swallow study for detecting esophagojejunostomy leakage after total gastrectomy. MATERIALS AND METHODS: A retrospective analysis was conducted on patients that underwent total gastrectomy due to gastric adenocarcinoma, within the time frame of 2002 and 2017. Demographic, clinical, and laboratory factors were identified, emphasizing the clinical and radiologic detection of anastomotic leaks. Descriptive statistics were carried out and the sensitivity of the contrast-enhanced swallow study for diagnosing leakage was calculated. RESULTS: Fifty-eight patients were included in the study. Their mean age was 61.5 years. A total of 55.2% of the patients were men and 44.8% were women. Gastric adenocarcinoma was the indication for gastrectomy in 100% of the cases. Anastomotic leak presented in 31.01% of the patients. Diagnostic sensitivity of the contrast-enhanced swallow study for detecting leaks was 66%. CONCLUSIONS: According to our analysis, the contrast-enhanced swallow study had limited diagnostic efficiency for detecting anastomotic leaks, with a sensitivity of 66%. We suggest maintaining high diagnostic suspicion in patients with studies that are initially negative and basing decisions on a more extensive approach.

Resultados de la manometría del cuerpo esofágico y del asa de yeyuno en pacientes operados por cáncer gástrico con gastrectomía total 5 años después de la cirugía / Esophageal manometry in patients with total gastrectomy 5 years after surgery

Resumen Introducción: La técnica de elección para la reconstrucción del tránsito intestinal después de una gastrectomía total es la esófago-yeyuno anastomosis en Y de Roux, la cual evita el reflujo de jugo digestivo alcalino. El objetivo del presente estudio es el de analizar la motilidad del esófago y del asa de yeyuno en pacientes operados con gastrectomía total por cáncer gástrico. Pacientes y método: Se estudió prospectivamente una muestra de 17 pacientes intervenidos mediante gastrectomía total 5 años atrás. En todos ellos se realizaron manometrías esofágicas de alta resolución incluyendo los primeros 7 cm del asa de yeyuno. Resultados: Los resultados de la manometría demostraron motilidad esofágica normal a excepción de la presión máxima intrabolo, la cual se encontraba aumentada en todos los pacientes. La motilidad del asa de yeyuno fue desordenada e inefectiva. Conclusiones: La motilidad del cuerpo esofágico es normal 5 años después de la gastrectomía total. Sin embargo, la presión intrabolo máxima se encuentra aumentada; la causa más probable de este hecho estaría constituida por el asa de yeyuno, que ejerce resistencia al paso del bolo debido a que presenta una actividad motora desordenada y poco propulsiva. El impacto clínico de este hecho es, sin embargo, poco importante.

Abstract Introduction: The most preferred technique to reconstruct the intestinal transit after total gastrectomy for gastric cancer is the Roux-en-Y esophagus-gastrostomy which prevents the reflux of alkaline intestinal juice. The purpose of this study was to analyze the esophageal motility and the motility of the jejunal loop in patients subjected to total gastrectomy. Patients and method: A prospective sample of 17 total gastrectomy patients operated on 5 years before was studied using high resolution esophageal manometry including the first 7 cm of the jejunal loop. Results: Manometry results showed normal esophageal body motility with the exception of the maximum intrabolus pressure that was elevated in all patients. The jejunal loop motility was disordered and ineffective. Conclusions: Esophageal body motility was normal 5 years after the surgical procedure. However, maximum intrabolus pressure was elevated and the most plausible reason would be the jejunal loop that exerts resistance to the bolus passage due to its ineffective motility. However, this fact does not have a significant clinical impact.

Hiatal Hernia as a Total Gastrectomy Complication.

INTRODUCTION: According to the Brazilian National Institute of Cancer, gastric cancer is the third leading cause of death among men and the fifth among women in Brazil. Surgical resection is the only potentially curative treatment. The most serious complications associated with surgery are fistulas and dehiscence of the jejunal-esophageal anastomosis. Hiatal hernia refers to herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm, though this occurrence is rarely reported as a complication in gastrectomy. CASE REPORT: A 76-year-old man was diagnosed with intestinal-type gastric adenocarcinoma. He underwent a total laparoscopic-assisted gastrectomy and D2 lymphadenectomy on May 19, 2015. The pathology revealed a pT4pN3 gastric adenocarcinoma. The patient became clinically stable and was discharged 10 days after surgery. He was subsequently started on adjuvant FOLFOX chemotherapy; however, 9 days after the second cycle, he was brought to the emergency room with nausea and severe epigastric pain. A CT scan revealed a hiatal hernia with signs of strangulation. The patient underwent emergent repair of the hernia and suffered no postoperative complications. He was discharged from the hospital 9 days after surgery. CONCLUSION: Hiatal hernia is not well documented, and its occurrence in the context of gastrectomy is an infrequent complication.

Robotic digestive tract reconstruction after total gastrectomy for gastric cancer: a simple way to do it.

BACKGROUND: Intracorporeal digestive tract reconstruction after minimally invasive total gastrectomy may be challenging, even when using the da Vinci® Surgical System. This may be due to intrinsic difficulties during oesophago-jejunal anastomosis (EJA). The aim of this study was to describe a simple way to perform digestive tract reconstruction after robotic total gastrectomy (RTG) for gastric cancer and the results of its application in a small series of cases. METHODS: In the last 2 years, six patients with gastric adenocarcinoma have been treated by RTG, four male and two female, with mean age of 59.8 (range 48-74) years. The tumour was located in the gastric body in three patients, the gastric antrum in two patients and the fundus in one patient with no need of splenectomy. In all cases, D2 lymphadenectomy was completed. A modified robotic reconstruction technique proposed by the authors was used in these operations, which consists in a latero-lateral EJA using a linear stapler. An entero-enterostomy is also performed in the upper abdomen. RESULTS: The mean operative time was 408 (range 340-481) min. The mean time for digestive tract reconstruction was 57 (range 47-68) min. There were no conversions to open or laparoscopic surgery. The number of lymph nodes removed varied in the range 28-52 (average 40). There was no mortality. Postoperative staging showed three T1N0M0s, one T2N0M0, one T3N0M0 and one T3N2M0. CONCLUSION: This series, which despite being small, demonstrates that this robotic reconstruction technique is safe, with no major complications, demands a relatively short time for its accomplishment, even when dealing with initial experience. Copyright © 2015 John Wiley & Sons, Ltd.

Comparison of laparoscopic total gastrectomy and laparotomic total gastrectomy for gastric cancer / Comparação entre a gastrectomia total laparoscópica e a gastrectomia total laparotômica para o câncer gástrico

BACKGROUND: The use of laparoscopy for the treatment of gastric cancer suffered some resistance among surgeons around the world, gaining strength in the past decade. However, its oncological safety and technical feasibility remain controversial. AIM: To describe the results from the clinical and anatomopathological point of view in the comparative evaluation between the surgical videolaparoscopic and laparotomic treatments of total gastrectomy with linphadenectomy at D2, resection R0. METHOD: Retrospective analyses and comparison data from patients submitted to total gastrectomy with D2 linphadenectomy at a sole institution. The data of 111 patients showed that 64 (57,7%) have been submitted to laparotomic gastrectomy and 47 (42,3%) to gastrectomy entirely performed through videolaparoscopy. All variables related to the surgery, post-operative follow-up and anatomopathologic findings have been evaluated. RESULTS: Among the studied variables, videolaparoscopy has shown a shorter surgical time and a more premature period for the introduction of oral and enteral nourishment than the open surgery. As to the amount of dissected limph nodes, there has been a significant difference towards laparotomy with p=0,014, but the average dissected limph nodes in both groups exceed 25 nodes as recommended by the JAGC. Was not found a significant difference between the studied groups as to age, ASA, type of surgery, need for blood transfusion, stage of the disease, Bormann classification, degree of differentiation, damage of the margins, further complications and death. CONCLUSION: The total gastrectomy with D2 lymphadenectomy performed by laparoscopy presented the same benefits known of laparotomy and with the advantages already established of minimally invasive surgery. It was done with less surgical time, less time for re-introduction of the oral and enteral diets and lower hospitalization time compared to laparotomy, without increasing postoperative ...

RACIONAL: A utilização da videolaparoscopia para o tratamento das neoplasia gástricas sofreu certa resistência entre os cirurgiões ao redor do mundo, ganhando força na década passada. Porém, sua segurança oncológica e viabilidade técnica continuam controversas. OBJETIVO: Demonstrar os resultados do ponto de vista clínico e anatomopatológico na avaliação comparativa entre o tratamento cirúrgico videolaparoscópico e laparotômico da gastrectomia total com linfadenectomia a D2, ressecção R0. MÉTODOS: Estudo retrospectivo dos dados dos prontuários dos pacientes submetidos à gastrectomia total com lindadenectomia a D2, em uma única instituição. Dos 111 prontuários, 64 (57,7%) foram submetidos à gastrectomia laparotômica e 47 (42,3%) à gastrectomia totalmente vídeolaparoscópica. Foram avaliadas variáveis relacionadas ao ato cirúrgico, a evolução pós-operatória e a achados anatomopatológicos. RESULTADOS: A técnica videolaparoscópica demonstrou tempo cirúrgico menor e período para re-introdução alimentar oral e enteral mais precoce que a operação laparotômica. Quanto ao número de linfonodos dissecados, houve diferença significante a favor da laparotômica (p=0,014); porém, a média de linfonodos dissecados em ambos os grupos ultrapassou os 25 preconizados pela JAGC. Não foi encontrada diferença significante entre os grupos estudados no que diz respeito à idade, gênero, ASA, tipo de operação, necessidade de hemotransfusão, estadiamento, classificação de Bormann, grau de diferenciação, comprometimento de margens, complicações e óbito. CONCLUSÕES: A gastrectomia total com linfadenectomia a D2 realizada por videolaparoscopia apresenta os mesmos benefícios conhecidos da cirurgia laparotômica e com as vantagens já estabelecidas da cirurgia minimamente invasiva. Ela apresentou menor tempo cirúrgico, menor tempo para a re-introdução das dietas oral e enteral e tempo de alta menor em relação à laparotômica, sem aumentar as complicações pós-operatórias. .

Blood count and C-reactive protein evolution in gastric cancer patients with total gastrectomy surgery / Evolução do hemograma e proteína C-reativa em pacientes com câncer gástrico operados por gastrectomia total

BACKGROUND: The complete blood count (CBC) and C-reactive protein (CRP) are useful inflammatory parameters for ruling out acute postoperative inflammatory complications. AIM: To determine their changes in gastric cancer patients submitted to total gastrectomy. METHODS: This is a prospective study, with 36 patients with gastric cancer who were submitted to elective total gastrectomy. On the first, third and fifth postoperative day (POD), blood count and CRP changes were assessed. Patients with postoperative complications were excluded. RESULTS: Twenty-one (58%) were men and 15 (42%) women. The mean age was 65 years. The leukocytes peaked on the 1st POD with a mean of 13,826 u/mm³, and decreased to 8,266 u/mm³ by the 5th POD. The bacilliforms peaked on the 1st POD with a maximum value of 1.48%. CRP reached its maximum level on the 3rd POD with a mean of 144.64 mg/l±44.84. Preoperative hematocrit (HCT) was 35% and 33.67% by the 5th POD. Hemoglobin, showed similar values. CONCLUSIONS: Leukocytes increased during the 1st POD but reached normal values by the 5th POD. CRP peaked on the 3rd POD but did not reach normal values by the 5th POD. .

RACIONAL: O hemograma completo (CBC) e a proteína C-reativa (PCR) são úteis para excluir parâmetros inflamatórios e complicações inflamatórias agudas pós-operatórias. OBJETIVO: Determinar mudanças nesses parâmetros em pacientes com câncer gástrico submetidos à gastrectomia total. MÉTODOS: Estudo prospectivo com 36 pacientes com câncer gástrico submetidos todos à gastrectomia eletiva. No primeiro, terceiro e quinto dias pós-operatórios (PO), alterações do hemograma e as mudanças de PCR foram avaliadas. Os pacientes com complicações pós-operatórias foram excluídos. RESULTADOS: Vinte e um (58%) eram homens e 15 (42%) mulheres. A média de idade era de 65 anos. Os leucócitos atingiram o pico no primeiro PO com média de 13.826 u/mm³​​, e decresceram para 8.266 u/mm³ no quinto. Os bastonetes atingiram o pico no primeiro PO com valor máximo de 1,48%. O nível máximo da PCR foi no 3º PO, com média de 144,64 mg/l±44,84. O hematócrito pré-operatório (HCT) foi de 35% e de 33,67% até o 5o PO. A hemoglobina não apresentou alterações. CONCLUSÕES: Houve aumento de leucócitos no 1o PO mas atingiram valores normais até o 5o PO. PCR atingiu o pico no 3º PO, mas não atingiu os valores normais até o quinto. .

Complicações pós-operatórias após gastrectomia total no câncer gástrico: análise de 300 doentes / Postoperative complications after total gastrectomy in the gastric cancer: analysis of 300 patients

RACIONAL: A gastrectomia total é considerada um procedimento de alto nível de complexidade, apresenta taxas de complicações elevadas, tanto locais como gerais, pois os doentes na sua maioria estão com as condições clínicas e nutricionais comprometidas pela doença. OBJETIVOS: analisar os resultados imediatos e complicações da gastrectomia total no período de 1972 a 2007. MÉTODOS: Foram revisados os prontuários médicos de 300 doentes portadores de adenocarcinoma gástrico, subdivididos em dois períodos: 1972 a 1992 - compreendendo 108 doentes (36 por cento) e 1993 a 2007 - compreendendo 192 doentes (64 por cento). Eram 67,3 por cento do sexo masculinos, 70,7 por cento brancos e com faixa etária variando de 25 a 86 anos (média de 63,4 anos). As lesões estavam localizadas em cárdia - 40 casos (13,3 por cento); fundo gástrico - 83 casos (27,6 por cento); corpo gástrico - 77 casos (25,6 por cento); linite plástica - 45 casos (15 por cento); côto gástrico - 33 casos (11 por cento) e antro/corpo gástrico - 22 casos (7,3 por cento). A gastrectomia total ampliada com linfadenectomia até nível D2 foi realizada em 246 casos (82 por cento). RESULTADOS: A técnica de reconstrução mais utilizada foi a anastomose esôfago-jejunal término-lateral em Y-Roux em 257 doentes (86,7 por cento). As complicações gerais no período de 1972-92 totalizaram 47 casos (43,5 por cento), compreendendo principalmente as respiratórias (28 casos - 25,9 por cento) e as urinárias (10 casos - 9,2 por cento). No período 1993-2007 totalizaram 48 casos (25 por cento), principalmente complicações respiratórias (27 casos - 14 por cento), seguidas também das urinárias (12 casos - 6,2 por cento). No período de 1972-92 estas complicações locais totalizaram 45 casos (30,8 por cento) e no período de 1993-2007 atingiram 28 casos (14,5 por cento), sendo as fistulas digestivas as mais frequentes. A mortalidade operatória até o 30º dia foi de 18 casos (6 por cento), sendo que no período de 1972-92 totalizou...

BACKGROUND: A total gastrectomy is considered a procedure with a high level of complexity, has high complication rates, both local and general, because patients are mostly with clinical conditions and nutritional compromised by disease. AIM: To analyse the results and complications of the total gastrectomy in gastric cancer in the period from 1972 to 2007. METHODS: Were reviewed the medical records of 300 patients with gastric adenocarcinoma, divided into two periods: from 1972 to 1992 - comprising 108 patients (36 percent) and from 1993 to 2007 - comprising 192 patients (64 percent). They were 67.3 percent males, 70.7 percent whites, with ages ranging from 25 to 86 years (mean 63.4 years). The lesions were located in cardia - 40 cases (13.3 percent), gastric fundus - 83 cases (27.6 percent), gastric body - 77 cases (25.6 percent); plastic linitis- 45 cases (15 percent); gastric stump - 33 cases (11 percent) and antrum and body gastric - 22 cases (7.3 percent). A total gastrectomy with extended lymphadenectomy to level D2 was performed in 246 cases (82 percent). RESULTS: The reconstruction technique used was the esophagus-jejunal anastomosis end-to-side Roux-en-Y in 257 patients (86.7 percent). The general complications in the period from 1972 to 1992 totalized 47 cases (43.5 percent), mainly involving the respiratory (28 cases - 25.9 percent) and urinary tract (10 cases - 9.2 percent). In the period from 1993 to 2007 amounted to 48 cases (25 percent), mainly respiratory complications (27 cases - 14 percent), followed by urinary (12 cases - 6.2 percent). The local complications from 1972 to 1992 totalized 45 cases (30.8 percent) and in the period from 1993 to 2007 amounted to 28 cases (14.5 percent), being the most frequent the digestive fistulas. The operative mortality through 30 days was 18 cases (6 percent), while in the period from 1972 to 92 a total of 12 cases (11.1 percent) and in the period from 1993 to 2007 were 7 cases (3.6 percent)...

Comparación entre nutrición enteral precoz y nutrición enteral tardía en el estado nutricional de pacientes gastrectomizados / Comparison between early enteral nutrition and late enteral nutrition in the nutritional status of patients with gastrectomy

Enteral nutrition (EN) is an effective method to meet the nutritional requirements in patients who have a deteriorated nutritional status. Objectives: To compare clinical and nutritional performance of two groups: Early Enteral Nutrition (EEN) versus Late Enteral Nutrition (LEN) of patients undergoing to total gastrectomy for gastric cancer. Material and Methods: 18 patients with resectable gastric cancer were studied with anthropometric, functional and biochemical parameters to assess nutritional status in the preoperative and postoperative period. They received a polimeric enteral formula (1 kcal/ml) in the postoperative period. They were randomly assigned to the type of nutrition (early or late). Results: The group with EEN had a significant improvement in the bicipital fold adequacy percentage and dynamometry. The LEN group had a significant decrease of albumin. The bloating was more frequent in the group with EEN. Conclusion: Early enteral nutrition is a safe nutritional support, effective and that brings nutritional benefits compared with late enteral nutrition in patients undergoing to total gastrectomy for gastric cancer.

La nutrición enteral (NE) es un método efectivo para cubrir los requerimientos nutricionales en pacientes que presentan un estado nutricional deteriorado. Objetivos: Comparar la Nutrición Enteral Precoz (NEP) versus Nutrición Enteral Tardía (NET) en la evolución clínica y nutricional de pacientes sometidos a gastrectomía total por Cáncer Gástrico. Material y Método: 18 pacientes con cáncer gástrico resecable, fueron estudiados con parámetros antropométricos, funcionales y bioquímicos que evalúan el estado nutricional, en el período preoperatorio y postoperatorio. Recibieron una fórmula enteral polimérica (1 kcal/ml) en el período postoperatorio. De manera aleatoria fueron asignados al tipo de nutrición (precoz o tardía). Resultados: El grupo con NEP presentó mejoría significativa del porcentaje de adecuación del pliegue bicipital y dinamometría. El grupo con NET presentó disminución significativa de la albuminemia. La distensión abdominal fue más frecuente en grupo con NEP. Conclusión: La Nutrición Enteral Precoz es un soporte nutricional seguro, eficaz y que trae consigo ventajas nutricionales en comparación con la Nutrición Enteral Tardía en el grupo de pacientes gastrectomizados totales por presentar cáncer gástrico.

Total gastrectomy with substitution of stomach by jejunal pouch with and without duodenal passage: study in rats

PURPOSE: A comparison was done between the F. Paulino jejunal pouch (FP) and a jejunal pouch (JP) as esophagus-duodenum interpositional graft, for replacing the stomach after total gastrectomy. It was investigated the effect of the two procedures on esophagus histology, nutritional state and serum gastrin in rats. METHODS: Male Wistar rats weighing 282±17g were randomly submitted to sham operation (S), FP and JP after total gastrectomy. After eight weeks the rats were killed with overdose of anesthetic and tissue was taken from the distal esophagus for histology. Serum levels of total proteins, albumin, iron, transferring, folate, cobalamine, calcium, as well as serum gastrin were determined. Survival was considered. RESULTS: Fourty six rats were operated and thirty survived for eight weeks. Five (33.3%) died after FP and 11 (52.3%) after JP (p 0.05). Postoperative esophagitis occurred in 6 JP rats. At 8th week, no difference was observed on body weight when compared FP and JP rats (p>0.05). The JP rats had a significant decrease in serum albumin, glucose, transferrin, iron, folate and calcium, compared to sham (p 0.05). Serum gastrin, iron and calcium were significantly higher in JP rats than in FP rats (p 0.05). In FP rats, transferrin and cobalamine showed significant decrease comparing the preoperative with 8th week levels (p 0.05). CONCLUSION: F. Paulino pouch in rats had lower mortality than JP, and esophagitis was not detected in it. JP rats had serum gastrin, iron and calcium unaffected, possibly because of preservation of duodenal passage.

OBJETIVO: Estudo comparativo foi realizado entre a bolsa jejunal de Fernando Paulino (FP) e uma bolsa jejunal (JP) interposta entre o esôfago e duodeno, para substituir o estômago após gastrectomia . Foi investigado o efeito dos dois procedimentos na histologia do esôfago, estado nutricional e gastrinemia sérica em ratos. MÉTODOS: Quarenta e seis ratos Wistar pesando 282±17g foram aleatoriamente submetidos a sham operation (S), FP e JP após gastectomia total. Decorridas 8 semanas, foi colhido sangue por punção cardíaca para dosagem de proteínas totais, albumina, ferro, transferrina, folato, cobalamina, calcio, e gastrina. Os animais receberam dose letal de anestésico e tecido do esôfago terminal foi retirado para histologia. Foi observada a mortalidade operatória dos animais. RESULTADOS: Quarenta e seis ratos foram operados e 30 sobreviveram por 8 semanas. Cinco (33,3 %) morreram após FP e 11 (52,3%) após JP (p 0.05). Esophagitis pós-operatória ocorreu em 6 ratos JP. Na 8ª semana o peso corporal foi maior nosratos submetidos a FP do que JP (p>0.05). Os ratos submetidos a JP tiveram uma diminuição significativa na albumina, glucose, transferrina, ferro, folato e cálcio, comparado com o sham (p 0.05). Os níveis de gastrina sérica, ferro e calcio mostraram-se significantemente maiores nos ratos submetidos a JP do que nos FP (p 0.05). Nos ratos FP a transferrina e a cobalamina estiveram significantemente diminuídas comparando-se os níveis do pré-operatório com a 8ª semana (p 0.05). CONCLUSÃO: A bolsa jejunal de F. Paulino, em ratos, resultou em mortalidade operatória e incidência de esofagite de refluxo menor do que a interposição de JP. A JP não afetou a dosagem sérica de gastrina, ferro e cálcio, provavelmente devido à preservação da passagem dos alimentos pelo duodeno.

Total gastrectomy with substitution of stomach by jejunal pouch with and without duodenal passage: study in rats

PURPOSE: A comparison was done between the F. Paulino jejunal pouch (FP) and a jejunal pouch (JP) as esophagus-duodenum interpositional graft, for replacing the stomach after total gastrectomy. It was investigated the effect of the two procedures on esophagus histology, nutritional state and serum gastrin in rats. METHODS: Male Wistar rats weighing 282±17g were randomly submitted to sham operation (S), FP and JP after total gastrectomy. After eight weeks the rats were killed with overdose of anesthetic and tissue was taken from the distal esophagus for histology. Serum levels of total proteins, albumin, iron, transferring, folate, cobalamine, calcium, as well as serum gastrin were determined. Survival was considered. RESULTS: Fourty six rats were operated and thirty survived for eight weeks. Five (33.3%) died after FP and 11 (52.3%) after JP (p 0.05). Postoperative esophagitis occurred in 6 JP rats. At 8th week, no difference was observed on body weight when compared FP and JP rats (p>0.05). The JP rats had a significant decrease in serum albumin, glucose, transferrin, iron, folate and calcium, compared to sham (p 0.05). Serum gastrin, iron and calcium were significantly higher in JP rats than in FP rats (p 0.05). In FP rats, transferrin and cobalamine showed significant decrease comparing the preoperative with 8th week levels (p 0.05). CONCLUSION: F. Paulino pouch in rats had lower mortality than JP, and esophagitis was not detected in it. JP rats had serum gastrin, iron and calcium unaffected, possibly because of preservation of duodenal passage.

OBJETIVO: Estudo comparativo foi realizado entre a bolsa jejunal de Fernando Paulino (FP) e uma bolsa jejunal (JP) interposta entre o esôfago e duodeno, para substituir o estômago após gastrectomia . Foi investigado o efeito dos dois procedimentos na histologia do esôfago, estado nutricional e gastrinemia sérica em ratos. MÉTODOS: Quarenta e seis ratos Wistar pesando 282±17g foram aleatoriamente submetidos a sham operation (S), FP e JP após gastectomia total. Decorridas 8 semanas, foi colhido sangue por punção cardíaca para dosagem de proteínas totais, albumina, ferro, transferrina, folato, cobalamina, calcio, e gastrina. Os animais receberam dose letal de anestésico e tecido do esôfago terminal foi retirado para histologia. Foi observada a mortalidade operatória dos animais. RESULTADOS: Quarenta e seis ratos foram operados e 30 sobreviveram por 8 semanas. Cinco (33,3 %) morreram após FP e 11 (52,3%) após JP (p 0.05). Esophagitis pós-operatória ocorreu em 6 ratos JP. Na 8ª semana o peso corporal foi maior nosratos submetidos a FP do que JP (p>0.05). Os ratos submetidos a JP tiveram uma diminuição significativa na albumina, glucose, transferrina, ferro, folato e cálcio, comparado com o sham (p 0.05). Os níveis de gastrina sérica, ferro e calcio mostraram-se significantemente maiores nos ratos submetidos a JP do que nos FP (p 0.05). Nos ratos FP a transferrina e a cobalamina estiveram significantemente diminuídas comparando-se os níveis do pré-operatório com a 8ª semana (p 0.05). CONCLUSÃO: A bolsa jejunal de F. Paulino, em ratos, resultou em mortalidade operatória e incidência de esofagite de refluxo menor do que a interposição de JP. A JP não afetou a dosagem sérica de gastrina, ferro e cálcio, provavelmente devido à preservação da passagem dos alimentos pelo duodeno.

Esôfago de barrett após gastrectomia total com reconstrução em Y de roux / Barrett's esophagus after total gastrectomy with roux-en-Y reconstruction

Reflux esophagitis and Barrett's esophagus after total gastrectomy is related to reconstructive procedure of intestinal continuity. The Roux-en-Y operation with length of limb of 40 cm occasionally is not enough to prevent biliary reflux to distal esophagus. Barrett's esophagus is thought to develop as a consequence of biliary reflux and has a malignant potential. Symptoms of retroesternal burning and dysphagia that does not improve with conservative management has to be treated by an operative procedure. To prevent biliary reflux to distal esophagus after total gastrectomy the lenght of limb of Roux-en-Y should be at lest 60 cm.