Primera experiencia de cirugía laparoscópica en cáncer del tracto digestivo superior / First experience of minimally invasive surgery in the upper digestive tract

Introducción: El cáncer del tracto digestivo superior es responsable de gran parte de las muertes a nivel mundial y es ampliamente asociada a los hábitos en el estilo de vida así como factores genéticos. Los abordajes mínimamente invasivos para su tratamiento son aun controversiales con curvas de aprendizaje empinadas, tiempos quirúrgicos prolongados pero con evidentes ventajas en sangrado, manejo del dolor, retorno a actividades y menores complicaciones relacionadas con la incisión. Objetivo: Describir nuestra primera experiencia en el tratamiento quirúrgico mínimamente invasivo en el Instituto Nacional de Cancerología del cáncer de tracto digestivo superior. Materiales y métodos: Revisión prospectiva de una base datos retrospectiva. Análisis descriptivo de pacientes en quienes se realizaron procedimientos mínimamente invasivos en el Instituto Nacional de Cancerología de Bogotá, Colombia, para el tratamiento del cáncer de tracto digestivo superior. Resultados: En 44 pacientes se realizo cirugía mínimamente invasiva para el tratamiento del cáncer del tracto digestivo superior. En 16 pacientes (36,4%) se realizó resección en cuña gástrica, en 13 pacientes (29,6%) gastrectomía total, en 9 pacientes (24,4%) gastrectomía subtotal y en 6 pacientes (13,6%) esofagectomía. No se presentaron complicaciones durante la cirugía, en 8 pacientes se presentaron complicaciones posoperatorias (18,2%). La estancia hospitalaria tuvo una mediana de 7,5 días. Conclusiones: La cirugía mínimamente invasiva para el tratamiento del cáncer del tracto digestivo superior en una técnica segura, factible, con tiempos quirúrgicos aceptables y sangrados mínimos en pacientes con y sin comorbilidades.

Background: Upper gastrointestinal cancer is responsible of important numbers deaths worldwide and is widely associated with lifestyle and genetic factors. Minimally invasive surgery treatment is still controversial wit difficult learning curves, longer operative times but clear advantages in bleeding, postoperative pain, return to activities and less complications associated with de incision. Objective: Describe our first experience in minimally invasive surgery of the upper alimentary tract for cancer at the Instituto Nacional de Cancerología. Materials and methods: Retrospective review of a prospectively set database. We describe the outcomes of patients in whom minimally invasive procedures, for the treatment of cancer of the upper alimentary tract was performed, at the InstitutoNacional de Cancerología in Bogotá, Colombia. Results: In 44 patients video assisted procedures were performed. In 16 of the 44 patients (36,4%) was wedged gastric resection, in 13 patients (29,6%) total gastrectomy, in 9 patients (24,4%) subtotal gastrectomy and in 6 patients (13,6%) and esophagectomy was performed. No intraoperative complications were present. Eight patients had any postoperative complication (18,2%). The average hospital stay was 7,5 days. Conclusions: Minimally invasive surgery for treatment of the upper gastrointestinal cancer is a safety and factible procedure with acceptable operative times and minimally bleeding in patients with or without co morbidities.

Eficacia diagnóstica de la impedancia basal nocturna media, un nuevo parámetro para el estudio de la enfermedad por reflujo gastroesofágico / Diagnostic efficacy of mean nocturnal basal impedance, a new parameter for the study of gastroesophageal reflux disease

Resumen Introducción y objetivos: el análisis de la impedancia basal nocturna media (IBNM) se ha propuesto para incrementar la precisión diagnóstica de enfermedad por reflujo erosiva (ERGE). Nuestro objetivo fue evaluar el rendimiento diagnóstico de esta prueba en un grupo de pacientes con ERGE conocida. Materiales y métodos: incluimos 123 individuos (58 con ERGE y 65 controles sanos) a quienes se les realizó pH-impedanciometría (pH-IMM) consecutiva entre enero de 2015 y junio de 2017. Todos los pacientes tenían endoscopia tomada en los 6 meses previos. El tiempo de exposición ácida (TEA) anormal (>4,2%) y la presencia de pirosis y/o regurgitación en los 6 meses previos fueron los criterios para el diagnóstico de ERGE. Se encontraron 58 pacientes con ERGE, 24 con enfermedad por reflujo erosiva (ERE) y 34 con enfermedad por reflujo no erosiva (ERNE). Los 65 restantes fueron controles sanos (CS) asintomáticos con EGD y pH-IMM normales. Todos los trazos de pH-IMM se reanalizaron para medir la IBNM por un segundo observador que desconocía los datos previos. El análisis estadístico incluyó pruebas múltiples de Bonferroni para comparar los grupos; regresión lineal para variables continuas; y análisis de curva ROC para buscar valor IBNM con mayor rendimiento. Para los diferentes parámetros de precisión diagnóstica se utilizó el punto de corte de la IBNM. Se usó significancia estadística con valor de p <0,01 e intervalos de confianza de 95% (IC 95%) para todos los cálculos. Resultados: los pacientes con ERE y ERNE presentaron valores de IBNM significativamente más bajos que el grupo control (p <0,01). Se observó una correlación negativa entre los valores de la IBNM y TEA (r = 0,59; p = <0,001), y también entre la IBNM y número de eventos de reflujo (r = 0,37; p = <0,001). En el análisis de curva ROC, el área bajo la curva de la IBNM fue de 0,941 (IC 95%: 0,894-0,987) y el punto de corte con mayor eficiencia 1102 ohms (sensibilidad 98,5%; especificidad 84,5%). Usando este valor (<1,102), la IBNM tuvo una sensibilidad para detectar ERGE de 91% (ERNE 86% y ERE 100%) y una especificidad de 98%. Conclusión: la IBNM tiene alta sensibilidad y especificidad para el diagnóstico de la ERGE. Adicionar esta prueba al análisis convencional de la pH-impedancia y a los métodos actuales de estudio de la ERGE puede mejorar significativamente nuestra capacidad para diagnosticar la enfermedad.

Abstract Introduction and Objectives: Analysis of nocturnal basal impedance (IBNM) has been proposed as a way to increase accuracy of GERD diagnosis. Our objective was to evaluate the diagnostic performance of this test in a group of patients known to have GERD. Materials and methods: We included 123 individuals: 58 with GERD and 65 healthy controls. They underwent consecutive pH-impedance monitoring between January 2015 and June 2017. All had undergone endoscopy in the 6 months prior to testing. Criteria used for diagnosis of GERD were abnormal acid exposure time (AET > 4.2%), pyrosis and/or regurgitation in the previous 6 months. We found 58 patients with GERD of whom 24 had erosive reflux disease (ERE) and 34 had non-erosive reflux disease (NERD). The remaining 65 were asymptomatic healthy controls with normal endoscopic results and pH impedance monitoring. A second observer who did not know the previous data measurements analyzed all pH impedance monitoring traces for IBMN. Statistical analysis included multiple Bonferroni tests for comparison between groups, linear regression for continuous variables, and receiver operating characteristic (ROC) curve analysis to find high performance IBNM values. The IBNM cutoff point was used for diagnostic precision parameters. Statistical significance was set at p <0.01, and 95% confidence intervals were used for all calculations. Results: IBNM measures were significantly lower for patients with ERE and NERD than for the control group (p <0.01). A negative correlation was observed between IBNM and acid exposure time values ​​(r = 0.59, p = <0.001) and also between IBNM and number of reflux events (r = 0.37, p = <0.001). ROC curve analysis found that the area under the curve for IBNM was 0.941 (95% CI: 0.894-0.987), and the cutoff point with the highest efficiency was 1,102 ohms (sensitivity 98.5%, specificity 84.5%). Using this value (<1.102), the IBNM had a sensitivity for detecting GERD of 91% (NERD 86% and ERE 100%) and a specificity of 98%. Conclusion: IBNM has high sensitivity and specificity for diagnosis of GERD. Addition of this test to conventional pH-impedance analysis and current methods for studying GERD can significantly improve our ability to diagnose this disease.

Tuberculosis abdominal: patología infrecuente en un paciente joven: reporte de un caso / Abdominal tuberculosis: an unusual disease in a young patient: a case report

Resumen Introducción: La tuberculosis abdominal es un problema reemergente, y es una de las enfermedades transmisibles más importante en todo el mundo. A pesar de las expectativas acerca de su erradicación en países en desarrollo, ha sido recientemente declarada de nuevo como una patología de emergencia mundial. Con el aumento de su incidencia y prevalencia, su forma abdominal es una de las presentaciones de afectación extrapulmonar más comunes. Objetivo: Dado que la tuberculosis puede afectar diversos órganos, tiene una amplia gama y gran espectro de signos y síntomas que dificultan su diagnóstico y retrasan el tratamiento. Por esto, se realiza esta revisión de tema, concentrándonos en que el alto índice de sospecha debe ser un factor importante en el diagnóstico precoz, para que una vez establecido, se pueda iniciar el tratamiento ayudando a prevenir y disminuir las altas tasas de morbilidad y mortalidad evidenciadas en la actualidad. Caso Clínico: Paciente joven con presencia de ascitis secundaria a tuberculosis abdominal confirmada por una biopsia y el aumento de la adenosin deaminasa en el líquido peritoneal. Se describen los principales hallazgos clínicos, paraclínicos, estudios imagenológicos y tratamiento.

Introduction: Abdominal tuberculosis is a reemerging problem and is one of the most important communicable diseases in the world. Despite expectations about the eradication in developing countries, it has recently been re-declared as a global emergency pathology. The increased incidence and prevalence shows an abdominal shape as one of the most common extrapulmonary involvement presentations. Objective: Since tuberculosis can affect various organs, it has a wide range and spectrum of signs and symptoms that make diagnosis difficult and delay treatment. Therefore, this review of the topic is done, concentrating on the fact that the high suspicion index should be an important factor in the early diagnosis. Treatment can be initiated helping to prevent and reduce high morbidity and mortality rates. Case Report: We present a case of a young patient with ascites secondary to abdominal tuberculosis confirmed by biopsy and increased adenosine deaminase in the peritoneal fluid. The main clinical findings, paraclinic, imaging studies and treatment are described.

Cirugía gástrica laparoendoscópica cooperativa / Laparo-endoscopic cooperative gastric surgery

Antecedentes: La cirugía gástrica cooperativa utliza vías simultáneas intraluminal peroral e intraperitoneal transabdominal para localizar y tratar, en tempo real, lesiones de dificil manejo con procedimientos convencionales. Su objetivo es resecar lesiones con técnicas videoasistidas, simultáneas, conservando tejido y funcionalidad, con los beneficios de la cirugía mínimamente invasiva. Objetivos: Describir nuestra experiencia en la realización de procedimientos cooperativos gástricos en el Instituto Nacional de Cancerología. Material y métodos: Revisión prospectiva de una base datos retrospectiva. Análisis descriptivo de pacientes en quienes se realizaron procedimientos gástricos cooperativos en el Instituto Nacional de Cancerología de Bogotá, Colombia, intervenidos entre octubre de 2012 y noviembre de 2016. Resultados: Se realizaron 16 procedimientos gástricos laparoendoscópicos: ocho de las 16 lesiones resecadas fueron subepiteliales, 4 intervenciones se indicaron para ampliación de márgenes posterior a resección endoscópica, 2 fueron lesiones epiteliales y 2 procedimientos se realizaron para control del sangrado con intención paliativa. Catorce procedimientos fueron de tpo exogástrico, 1 intragástrico y 1 transgástrico. El tempo quirúrgico promedio fue de 91 minutos, con pérdidas sanguíneas en promedio de 42 mL con bordes de resección negativos en todos los casos. El tempo promedio de hospitalización fue de 4 días. La supervivencia libre de enfermedad a 22 meses fue del 100%. Conclusiones: Los resultados de nuestro estudio muestran que la cirugía gástrica cooperativa es una técnica segura, factible, con tempos quirúrgicos aceptables y sangrados mínimos en pacientes con comorbilidades y sin ellas, conservando los principios oncológicos y de la cirugía mínimamente invasiva en el tratamiento de las neoplasias gástricas.

Background: cooperative gastric surgery uses simultaneous, intraluminal peroral and intraperitoneal trans-abdominal pathways to localize and treat, in real tme, dificult tumors with conventonal proce-dures. The aim is to resect lesions of diferent etology with video assited techniques, simultaneous, preserving tssue and functonality, with the benefts of minimally invasive surgery. Objective: the aim of our study was describe our experience in cooperative gastric procedures at the Natonal Cancer Institute in Bogotá, Colombia. Materials and methods: prospective review of a retrospective database. Descriptive analysis of pa-tents in whom cooperative gastric procedures were performed at the Natonal Cancer Institute of Bogotá, Colombia, between October 2012 and November 2016. Results: sixteen laparoscopic endoscopic cooperative procedures were performed; eight of 16 resec-ted tumors were subepithelial; four cases were done for resecton of previous positive margins, two epithelial lesions and two for bleeding and palliative control. Fourteen procedures were exogastric, 1 intragastric and 1 transgastric. The operative tme was 91 minutes, the average bleeding was 42 cc and negative margins were present in all cases. The mean hospital stay was 4 days. Conclusions: Our study shows that laparoscopic endoscopic cooperative surgery is a safe and feasible technique with acceptable operative tmes and minimal bleeding in patents with and without comorbidites, preserving the oncological and minimally invasive principles in the treatment of gastric neoplasms.

[First experience of minimally invasive surgery in the upper digestive tract]. / Primera experiencia de cirugía laparoscópica en cáncer del tracto digestivo superior.

BACKGROUND: Upper gastrointestinal cancer is responsible of important numbers deaths worldwide and is widely associated with lifestyle and genetic factors. Minimally invasive surgery treatment is still controversial wit difficult learning curves, longer operative times but clear advantages in bleeding, postoperative pain, return to activities and less complications associated with de incision. OBJECTIVE: Describe our first experience in minimally invasive surgery of the upper alimentary tract for cancer at the Instituto Nacional de Cancerología. MATERIALS AND METHODS: Retrospective review of a prospectively set database. We describe the outcomes of patients in whom minimally invasive procedures, for the treatment of cancer of the upper alimentary tract was performed, at the InstitutoNacional de Cancerología in Bogotá, Colombia. RESULTS: In 44 patients video assisted procedures were performed. In 16 of the 44 patients (36,4%) was wedged gastric resection, in 13 patients (29,6%) total gastrectomy, in 9 patients (24,4%) subtotal gastrectomy and in 6 patients (13,6%) and esophagectomy was performed. No intraoperative complications were present. Eight patients had any postoperative complication (18,2%). The average hospital stay was 7,5 days. CONCLUSIONS: Minimally invasive surgery for treatment of the upper gastrointestinal cancer is a safety and factible procedure with acceptable operative times and minimally bleeding in patients with or without co morbidities.

Hernia hiatal recidivante: la visión del cirujano: Revisión de la literatura / Literature Review: A Surgeon’s View of Recurrent Hiatal Hernia

Las hernias hiatales recidivantes constituyen una patología común que generan un reto diagnóstico y terapéutico para cirujanos y gastroenterólogos. Generalmente se presentan de forma asintomática o con síntomas atípicos y se asocian a factores fisiológicos, propios del paciente y de la técnica quirúrgica. Su tratamiento es complejo y dependiendo de la causa de los síntomas pueden requerir manejo médico o quirúrgico. En este artículo, se pretenden definir pautas para la identificación y manejo de esta patología, así como establecer claves para el tratamiento desde un enfoque quirúrgico.

Recurrent hiatal hernias are a common pathology that generate a diagnostic and therapeutic challenge for surgeons and gastroenterologists. They are generally asymptomatic or present with atypical symptoms and are associated with the patient’s own physiological factors and the surgical technique. Treatment is complex and, depending on the cause of the symptoms, will require either medical or surgical management. This article starts from a surgical approach to define guidelines for identification and management of this condition and to establish keys to treatment.

Is resection of an esophageal epiphrenic diverticulum always necessary in the setting of achalasia?

BACKGROUND: Esophageal epiphrenic diverticulum (ED) is usually secondary to a primary esophageal motility disorder, such as achalasia. Whereas the recommended surgical treatment includes esophageal myotomy and diverticulectomy, the outcome of patients in whom a myotomy without ED resection is performed is not known. The purpose of this study was to compare the outcome of ED patients who underwent ED resection and myotomy and those of ED patients who had a myotomy only. METHODS: Retrospective review of a prospective database. Thirteen ED patients had symptom evaluation, barium swallow, endoscopy, and esophageal high-resolution manometry (HRM). All patients underwent laparoscopic myotomy and Dor fundoplication. In six patients, the ED was resected (excised ED group), whereas in seven it was left in place (nonexcised ED group): in three because it was small and in four for technical reasons. RESULTS: Preoperatively all patients had dysphagia and 85 % had regurgitation. The mean preoperative Eckardt score was 6.5 ± 2.1 in excised ED group and 6.6 ± 3.3 in nonexcised ED group (p = 0.95). HRM showed type II esophageal achalasia in 85 % of patients. One excised ED group patient had a staple line leak (17 %). At a median follow-up of 2 years, the Eckardt score was 0 in excised ED group and 0.1 in nonexcised ED group (p = 0.56). CONCLUSIONS: The results of this study showed that patients in whom a myotomy without ED resection was performed had resolution of their symptoms. These findings suggest that in patients with achalasia and ED the underlying motility disorder rather than the ED may be the cause of symptoms. Studies with a larger number of patients and a longer follow-up will determine the validity of this approach.