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.

Calcitonin-Negative Neuroendocrine Carcinoma of the Thyroid Gland: Case Report and Literature Review.

Calcitonin-negative neuroendocrine tumor (CNNET) of the thyroid is an extremely rare entity. In some of the previously reported cases within the literature, the terms "atypical medullary thyroid carcinoma," "calcitonin-free oat cell carcinoma," and "a distinct clinical entity" were applied to NETs without definitive evidence of calcitonin production. In the English-language literature, not only are there only few reported cases of CNNET, but the criteria for diagnosis in these cases are also controversial. Most of the current published cases were also treated surgically for local disease. We describe a case of NET of the thyroid with calcitonin, chromogranin A and thyroglobulin negativity, synaptophysin and TTF-1 positivity, and a high Ki-67 proliferation index with metastases in the cervical region as well as mediastinal adenopathies. This case was considered an unresectable thyroid carcinoma, and chemotherapy including cisplatin and etoposide was started as neoadjuvant treatment at the department of medical oncology. Total thyroidectomy plus bilateral and central cervical dissection was performed, and the patient underwent 2 cycles of adjuvant radiotherapy. Currently, the patient's 18F-FDG-PET/CT findings show a complete response 17 months after diagnosis. In conclusion, CNNET of the thyroid is very rare and there is limited evidence regarding treatment in patients with metastases. Chemotherapy including cisplatin and etoposide as well as early aggressive surgical resection appears to positively impact patients' survival.

Total esophageal replacement by transmediastinal transposition of the stomach in a gastrointestinal stromal tumor of the thoracic esophagus: a rare surgical case report.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the digestive tract. A rare site of localization of these tumors is the esophagus. Evidence-based consensus regarding the type of surgery for patients with esophageal GIST remains unclear. CLINICAL CASE: A female without history of diseases experienced dysphagia, weight loss (6 kg) and malaise. Computed tomography revealed thickening of the esophagus. During the endoscopic ultrasonography a localized lesion was observed in the esophagus that depended on the muscularis propria. We opted to treat with an esophagectomy with replacement by transmediastinal transposition of the stomach. Patient recovered well from the surgery and she was discharged home in stable condition in post-operative day seven. At 6 months she has no symptoms. CONCLUSION: This case illustrates the clinical presentation of an esophageal GIST which represents only 1% of all sites where GISTs have been reported; open surgery was successfully performed with minimal morbidity, complete resolution of symptoms and improvement of the patient's quality of life. Esophagectomy with replacement by transmediastinal transposition of the stomach should be performed when the center has experience to do so with minimal morbidity and mortality.

ANTECEDENTES: Los tumores del estroma gastrointestinal (GIST) son las lesiones malignas mesenquimales más comunes del tracto digestivo. Un sitio raro de localización de estos tumores es el esófago. A la fecha actual no hay un consenso claro basado en evidencia científica con respecto al tipo de cirugía a realizar en pacientes con GIST en esta localización inusual. CASO CLÍNICO: Una mujer previamente sana presentó disfagia, pérdida de peso (6 kg) y malestar general. La tomografía computarizada reveló un engrosamiento del esófago y en la ultrasonografía endoscópica se observó una lesión localizada en el esófago dependiente de la muscular propia. Se optó por realizar esofagectomía con reemplazo mediante transposición transmediastinal del estómago. La paciente se recuperó bien de la cirugía y fue dada de alta en condición estable en el séptimo día del posoperatorio. A los 6 meses, se encuentra asintomática. CONCLUSIÓN: Este caso ilustra la presentación clínica de un GIST esofágico que representa solo el 1% de todos los sitios reportados. La cirugía se realizó con éxito, con morbilidad mínima, resolución completa de los síntomas y mejoría de la calidad de vida de la paciente. La esofagectomía con reemplazo mediante transposición transmediastinal del estómago (comúnmente llamado ascenso gástrico) debe realizarse cuando el centro tiene experiencia para hacerlo con morbilidad y mortalidad mínimas.

Neoadjuvant Chemotherapy Increases R0 Cytoreduction Rate But Does Not Improve Final Outcome in Advanced Epithelial Ovarian Cancer.

BACKGROUND: Most epithelial ovarian cancers present in advanced stages. Traditional management is maximum cytoreductive effort followed by platinum-taxane-based chemotherapy. We hypothesized that providing all chemotherapy before surgery will increase the R0 cytoreductive rate and improve prognosis. METHODS: Patients with advanced epithelial ovarian carcinoma [International Federation of Gynecology and Obstetrics (FIGO) stages IIIC and IV without parenchymal metastasis] were included in a comparative study. Group A underwent cytoreductive surgery followed by six cycles of chemotherapy, and group B completed six cycles of preoperative systemic therapy followed by cytoreduction. Demographic, clinical, surgical and pathologic variables were recorded and analyzed. Main outcome end points were progression-free survival (PFS) and overall survival (OS). Complete cytoreduction (R0) was defined as absence of macroscopic disease. Kaplan-Meier curves were constructed for survival analysis and univariate and multivariate analysis was performed. Significance was considered at p < 0.05. RESULTS: One hundred five patients were included: 42 in group A and 63 in group B. Mean patient age was 56 years (range 32-85 years). There were no significant differences between groups regarding demographic, clinical, surgical or pathologic variables. Surgical morbidity was low and not different between groups and there was no surgical mortality. R0 cytoreduction was obtained in 35.5 versus 64.5% in groups A and B, respectively. Median PFS and OS for the entire cohort were 16.17 and 38 months, respectively. Median PFS were 14.71 and 17.52 months for groups A and B, respectively (p = NS), and OS were 33.59 and 56.4 months for groups A and B, respectively (p = 0.08). Factors significantly associated with decreased survival on multivariate analysis were non-R0 resection (p < 0.001), anemia (Hb < 12 g/dL; p = 0.004) and comorbidities (Charlson score > 2; p = 0.007). CONCLUSIONS: In spite of nearly doubling the rate of complete cytoreduction and reduce severe surgical complications, preoperative chemotherapy does not improve long-term outcome in advanced epithelial ovarian carcinoma.

Randomized Phase II Study of Talc Versus Iodopovidone for the Prevention of Seroma Formation Following Modified Radical Mastectomy.

BACKGROUND: The most common complication following modified radical mastectomy is seroma formation. Numerous approaches have been attempted to prevent this complication, ranging from the use of chemical substances to mechanical means, and none of these have proven to be consistently reliable. AIM: The aim of this study was to evaluate the safety and efficacy of talc in preventing postoperative seromas compared with iodine and standard care. METHODS: Patients with breast cancer undergoing modified radical mastectomy were randomly assigned to one of three study groups: control, subcutaneous talc, or iodine application. The primary endpoint was frequency of seroma formation. Secondary outcomes included wound complications (surgical site infection, flap necrosis, and wound dehiscence), analgesic use, postoperative pain, total drain outputs, and drainage duration. RESULTS: Of the 86 patients randomized in the study, 80 were analyzed. After interim analysis, the iodine intervention was discontinued because of increased adverse outcomes (drainage duration and total amount of fluid drained). Talc failed to demonstrate that its application in subcutaneous breast tissue prevents seroma formation (19.4% for talc group vs. 23.3% for control group; p = 0.70). However, patients who developed seroma in the talc group had fewer aspirations per patient seroma and less volume drained when compared with the control group (88.2 ± 73 vs. 158.3 ± 90.5; p = 0.17). CONCLUSIONS: Subcutaneous talc application was safe in the short term, but there was not sufficient evidence to support its use for seroma prevention following modified radical mastectomy in patients with breast cancer.

Liver segment IV hypoplasia as a risk factor for bile duct injury.

INTRODUCTION: Bile duct injury remains constant in the era of laparoscopic cholecystectomy and misidentification of structures remains one of the most common causes of such injuries. Abnormalities in liver segment IV, which is fully visible during laparoscopic cholecystectomy, may contribute to misidentification as proposed herein. METHODS: We describe the case of a 36-year-old female who had a bile duct injury during a laparoscopic cholecystectomy where the surgeon noticed an unusually small distance between the gallbladder and the round ligament. RESULTS: We define hypoplasia of liver segment IV as well as describe the variation of the biliary anatomy in the case. We also intend to fit it in a broader spectrum of developmental anomalies that have both hyopoplasia of some portion of the liver and variations in gallbladder and bile duct anatomy that may contribute to bile duct injury. DISCUSSION: To our knowledge, hypoplasia of liver segment IV has not been suggested in the literature as a risk factor for bile duct injury except in the extreme case of a left-sided gallbladder. Surgeons should be vigilant during laparoscopic cholecystectomy when they become aware of an unusually small distance between the gallbladder bed and the round ligament prior to beginning their dissection, variations in the common bile duct and cystic duct should be expected.

[Fine needle aspiration biopsy of breast lesions: institutional experience]. / Biopsia por aspiración con aguja fina en lesiones mamarias: experiencia institucional.

BACKGROUND: With the advent of new diagnostic technologies and the fear of low diagnostic accuracy, there has been a reduction in the use of fine needle aspiration (FNA) for diagnosis of breast lesions. The objectives of the present study were to establish the diagnostic accuracy and complications associated with FNA of breast lesions. MATERIAL AND METHODS: We retrospectively reviewed FNA of breast lesions done in a tertiary referral center in Mexico City from 1999 through 2001. We analyzed demographic, radiologic and pathological variables in order to establish diagnostic accuracy of FNA. The gold standard was considered the histopathologic study of the specimen or the clinical follow-up of benign lesions. Categorical variables were analyzed with the X2 method and statistical significance was considered at p < 0.05. RESULTS: We identified 300 patients with a mean age of 50 years (range, 20-86). Fifty-three percent were postmenopausal. In ninety-three percent of patients, FNA was performed in the outpatient clinic. Nonpalpable lesions were aspirated under ultrasound guidance. Mean size of the lesion was 2.27 cm (range 0.7-10 cm). Thirty-one percent of patients had definite diagnosis of malignancy. The only variables associated with cancer diagnosis were the BI-RADS category and the presence of palpable adenopathy. Cancer was diagnosed in 6.5% of lesions categorized as BI-RADS 0-3 compared to 56.2% for lesions BI-RADS 4-5 (p < 0.0001). Positive predictive value and specificity of FNA were 100%. Sensitivity, negative predictive value and accuracy were 82.6%, 92.8% and 94.7%, respectively. The most common diagnosis of false negative lesions were lobular and papillary carcinomas. There were no significant complications associated with FNA. CONCLUSIONS: Diagnostic accuracy of FNA for breast lesions is very high with minimal complications. Positive predictive value of 100% allows to establish therapy based on its results.

Biopsia por aspiración con aguja fina en lesiones mamarias: experiencia institucional / Fine needle aspiration biopsy of breast lesions: institutional experience

Background. With the advent of new diagnostic technologies and the fear of low diagnostic accuracy, there has been a reduction in the use of fine needle aspiration (FNA) for diagnosis of breast lesions. The objectives of the present study were to establish the diagnostic accuracy and complications associated with FNA of breast lesions. Material and methods. We retrospectively reviewed FNA of breast lesions done in a tertiary referral center in Mexico City from 1999 through 2001. We analyzed demographic, radiologic and pathological variables in order to establish diagnostic accuracy of FNA. The gold standard was considered the histopathologic study of the specimen or the clinical follow-up of benign lesions. Categorical variables were analyzed with the method and statistical significance was considered at p < 0.05. Results. We identified 300 patients with a mean age of 50 years (range, 20-86). Fifty-three percent were postmenopausal. In ninety-three percent of patients, FNA was performed in the outpatient clinic. Nonpalpable lesions were aspirated under ultrasound guidance. Mean size of the lesion was 2.27 cm (range 0.7-10 cm). Thirty-one percent of patients had definite diagnosis of malignancy. The only variables associated with cancer diagnosis were the BTRADS category and the presence of palpable adenopathy. Cancer was diagnosed in 6.5% of lesions categorized as BTRADS 0-3 compared to 56.2% for lesions BTRADS 4-5 (p < 0.0001). Positive predictive value and specificity of FNA were 100%. Sensitivity, negative predictive value and accuracy were 82.6%, 92.8% and 94.7%, respectively. The most common diagnosis of false negative lesions were lobular and papillary carcinomas. There were no significant complications associated with FNA. Conclusions. Diagnostic accuracy of FNA for breast lesions is very high with minimal complications. Positive predictive value of 100% allows to establish therapy based on its results.

Antecedentes. El advenimiento de nuevas tecnologías diagnósticas, así como el temor a baja exactitud diagnóstica, han reducido el papel de la biopsia por aspiración con aguja fina (BAAF) en lesiones mamarias. El objetivo del presente estudio fue el establecer la exactitud diagnóstica y complicaciones de la BAAF en esta indicación. Material y métodos. Estudio retrospectivo de BAAF de lesiones mamarias realizadas en nuestra institución de 1999 a 2001. Se analizaron variables demográficas, radiológicas e histopatológicas para establecer la exactitud diagnóstica. Se definió como estándar diagnóstico al análisis histopatológico del tejido o bien al seguimiento clínico en caso de lesiones benignas dejadas para observación. Las variables categóricas se analizaron con la prueba de . Se estableció como significativa a una p < 0.05. Resultados. Fueron identificados 300 pacientes con una edad promedio de 50 años (20-86). Fueron posmenopáusicas 53.3%. En 93.3% de los casos se realizó BAAF de lesión clínicamente palpable y en el resto de una lesión visible por ultrasonido. El tamaño promedio de la lesión fue de 2.27 cm (0.7-10 cm). De las pacientes, 30.7% tuvieron diagnóstico definitivo de lesión maligna. Las únicas variables asociadas al diagnóstico de cáncer fueron la clasificación radiológica de BI-RADS y la presencia de adenomegalias palpables. La incidencia de cáncer en pacientes con BI-RADS de 0 a 3 fue de 6.5% vs. 56.2% en aquellas con BI-RADS 4 o 5 (p < 0.0001). Tanto el valor predictivo positivo como la especificidad de la BAAF fueron de 100%, con una sensibilidad de 82.6% y valor predictivo negativo de 92.8%, para una exactitud diagnóstica de 94.7%. Las causas más frecuentes de falsos negativos fueron el carcinoma lobulillar infiltrante y el carcinoma papilar. No se presentaron complicaciones significativas en ningún caso asociadas con la BAAF. Conclusiones. La exactitud diagnóstica de la BAAF en lesiones mamarias es muy elevada, con una incidencia mínima de complicaciones. Un valor predictivo positivo de 100% permite basar la terapéutica en sus resultados. El diagnóstico de benignidad por BAAF permite el seguimiento seguro de lesiones mamarias.

[Validation of sentinel node in breast cancer]. / Validación del ganglio centinela en cáncer de mama con dos técnicas.

BACKGROUND: The sentinel lymph node biopsy in breast cancer can be used instead of axillary dissection when the node is negative because the sentinel lymph node (SLN) represents the first node that receive lymphatic drainage and may predict the tumor status of the entire lymph node group, so it may avoid a more morbid procedure. The objective of this study was to determinate the accuracy of this procedure and to evaluate techniques using blue dye, radiocolloid or both. MATERIALS AND METHODS: Sixty-one women underwent sentinel lymphadenectomy followed by axillary lymph node dissection. Thirty-one patients underwent breast conserving surgery and 30 modified radical mastectomy. We studied three groups of patients: the first group was injected with isosulfan blue dye, the second group was injected with technetium-99m-labeled sulfur colloid and the third received both. From the patients marked with isosulfan blue, twenty two patients were injected subareolar (43.2%) and 29% into the breast parenchyma immediately surrounding the primary tumor or biopsy cavity (56.8%). Technetium-99m-labeled sulfur colloid was injected into the breast parenchyma immediately surrounding the primary tumor. Standard axillary lymphadenectomy including level I and level II was performed in all patients. Statistical analysis was performed with the SPSS 10.0 statistical software. Significance was considered at p < 0.05. RESULTS: At least one SLN was identified in all patients (100%). The SLN predicted the tumor status of the entire lymph node group in 59 patients (96.77%). There were two false negative sentinel nodes (3.3%), each one using isosulfan blue dye injected subareolar and surrounding a primary tumor. The mean number of SLNs removed were 1.06 in the group 1, 2.2 in the group 2 and 2.37 in the group 3 (p = 0.0001 for group 1 vs. 2 and 3). The sensitivity and negative predictive value were 91 and 95%, respectively. CONCLUSIONS: This procedure has enough accuracy to justify avoidamce of standard axillary lymphadenectomy when the sentinel node is negative for me- tastases. Both isosulfan blue dye injected techniques may be used indistinctly. When the radiocolloid technique is used there are an increase in the mean number of SLNs removed per patient.

Resection of an esophageal metastasis from a renal cell carcinoma.

Surgery for patients with isolated metastases from renal cell carcinoma has been shown to improve survival. Isolated esophageal metastases are very uncommon among patients with renal cell carcinoma and there are no reports addressing the outcome of their resection. A 60-year-old woman who had previous history of renal cell carcinoma was admitted to the hospital with progressive dysphagia. Esophagography and endoscopy showed an esophageal tumor and biopsies were consistent with adenocarcinoma. No other site with tumor was identified on CT-scan. Resected specimen showed metastasis from renal cell carcinoma and the patient survived for an 11-month period. Although resection of metastatic renal cell carcinoma has been shown to improve long-term survival, the presence of esophageal metastases can be considered an adverse prognostic factor.

Surgery for stage IV gastric cancer.

BACKGROUND: Surgical treatment for stage IV gastric cancer is controversial. METHODS: We analyzed the surgical experience with advanced gastric carcinoma in a tertiary referral center in Mexico City from 1995 through 2000. We analyzed surgical morbidity, mortality, and factors associated with prognosis. Survival was analyzed with the Kaplan-Meier method, and the curves were compared with the log-rank test. Significance was assigned at P <0.05. RESULTS: Seventy-six cases were identified. Mean patient age was 56 +/- 14.5 years. Thirty-nine patients (51.3%) were women. Patients were grouped according to surgical procedure: group 1 underwent resection (40 patients), group 2 underwent bypass procedures (10 patients), and group 3 underwent either celiotomy and biopsy alone or jejunostomy placement (26 patients). Twenty patients (26%) developed operative complications, but most were minor. There was no difference in morbidity between surgical groups and no difference according to patient's age. Operative mortality was 2.6%. Good palliation of symptoms was significantly more common in group 1 patients (82%) than in group 2 patients (60%) (P = 0.0001). Median survival was 8 months (95% confidence interval 4 to 12) for the entire cohort and 13, 5, and 3 months for groups 1, 2, and 3, respectively (P = 0.00001 for group 1 vs groups 2 and 3). CONCLUSIONS: Surgical resection for stage IV gastric cancer can be done with low operative mortality and acceptable morbidity rates, and it provides patients with good symptomatic relief. Advanced patient age is not a contraindication for surgical treatment.

Expression of p53 and proliferation index as prognostic factors in gastrointestinal sarcomas.

BACKGROUND: Sarcomas arising in the gastrointestinal (GI) tract are rare tumors. Molecular markers could be associated with prognosis in these types of tumors. METHODS: We performed a retrospective analysis of adult patients with sarcomas arising in the GI tract at the National Institute of Medical Sciences in Mexico City and the University of Alabama at Birmingham Hospital. All histological types were included. Patient, tumor, and treatment factors were analyzed, with overall survival as the main outcome variable. Expression of p53 and cellular proliferation antigen Ki-67 was also analyzed. Statistical analysis was performed by log-rank test and Cox regression. Significance was defined as P <.05. RESULTS: Forty-seven patients were analyzed. The median patient age was 53 years (range, 16-82 years). Twenty-five patients (53%) were women. The stomach was the most common site of presentation. The mean tumor size was 14 cm (2-45 cm). A complete resection was achieved in 40 patients. With a median follow-up of 30 months, the actuarial 3-year survival was 68%. Univariate analysis identified overexpression of p53 and Ki-67, high tumor grade, tumor size >10 cm, and incomplete resection as significant negative prognostic factors. Hispanic race and good performance status were significantly associated with prolonged survival. On multivariate analysis, overexpression of p53 was the only independent negative prognostic factor. CONCLUSIONS: Overexpression of p53 is the strongest predictor of poor prognosis in patients with sarcomas of the GI tract.

Adenocarcinoma gigante de células acinares de tipo quístico papilar en parótida / Giant acinic cell adenocarcinoma with papillary-cystic pattern of the parotid gland

Se presenta el caso de un hombre de 38 años de edad con un adenocarcinoma de células acinares de 22 cm de tipo quístico papilar, originado en la glándula parótida. El interés del caso radica en: 1) el tamaño del tumor que supera en 9 cm al adenocarcinoma de células acinares más grande hasta ahora informado; y 2) la rara variedad histológica quística y papilar demandó estudios de histoquímica, inmunohistoquímica y microscopía electrónica para su diagnóstico

Cáncer de esófago / Esophageal cancer

El cáncer del esófago es una de las patologías neoplásicas con mayor variabilidad geográfica, en donde el común denominador parece ser la pobreza. La incidencia habitualmente reportada de 3 x 100,000 en países occidentales, contrasta con un 140 x 100,000 en el denominado cinturón del cáncer esofágico en Asia Central. Entre los muchos agentes causales destacan por su consistencia el consumo de alcohol y de tabaco. La variedad histológica más frecuentemente reportada sigue siendo el carcinoma epidermoide, aunque en las últimas décadas, se ha observado un viaje hacia el adenocarcinoma, fenómeno que se puede explicar al incluir tumores de la unión esofagogástrica así como la participación del epitelio metaplásico de barrett y la enfermedad por reflujo. Al igual que la mayoría de esta enfermedad es habitualmente tardió, explicando de esta manera el mal pronóstico que en general tiene. Dentro de las manifestaciones clínicas más frecuentes, sigue siendo la disfagia el síntoma pivote, acompañada de odinofagia, hemorragia, síntomas respiratorios, disfonía y ataque al estado general. Los estudios diagnósticos en estadios avanzados son habitualmente confirmatorios. La combinación de los estudios contrastados y la endoscopia proporciona el diagnóstico centero en más del 95 por ciento y éstos no deben ser excluyentes entre sí sino complementarios. La tomografía axial computada resulta ser el método convencional para la etapificación clínica, siendo además un estudio fundamantal que puede definir cambios en el abordaje terapéutico. La confirmación de progresión tumoral extraesofágica justifica el tratamiento no quirúrgico. El ultrasonido transendoscópico está siendo considerado como una mejor alternativa en el proceso etapificador en cáncer del esófago. Se requiere para su aplicación, que la lesión permita el paso del instrumento y hoy en día sólo algunos centros en nuestro país cuentan con esta tecnología que lo excluye como un estudio rutinario. Salvo algunas excepciones, el tratamiento para la mayoría de los pacientes tiene un fin paliativo. De las múltiples alternativas quirúrgicas existentes, es la esofagectomía transhiatal sin toracotomía la que más se utiliza en los padecimientos obstructivos del esófago. La controversia continúa en torno al concepto de que esta técnica no cumple con los principios oncológicos de hacer una buena linfadenectomía mediastinal. Sin embargo, también es aceptado que el pronóstico depende más de la biología y estadio del tumor...

Tratamiento quirúrgico del divertículo farinfoesofágico de Zenker / Surgical treatment of Zenker's diverticulum

Antecedentes: Existen diversas modalidades de tratamiento quirúrgico, lo cual es motivo de controversia. Objetivo: Analizar los resultados del tratamiento quirúrgico del divertículo faringoesofágico o de Zenker. Método: Se revisaron en forma retrospectiva los expedientes de los pacientes sometidos al tratamiento quirúrgico del divertículo analizándose las características demográficas y clínicas las indicaciones los procedimientos morbilidad y mortalidad operatorias y los resultados. Resultados: Se reunieron 15 pacientes, 12 hombres y 3 mujeres con edad promedio de 68 años todos tenían disfagia el 93 por ciento regurgitaciones y el 60 por ciento tos, aunque sólo en la mitad de estos últimos se documentó broncoaspiración. El diagnóstico se hizo con el esofagograma y el 60 por ciento tenían alteración cardiopulmonar asociada. En todos los pacientes se realizó miotomía del cricofaríngeo y se acompaño en el 60 por ciento de diverticulopexia y en el 40 por ciento restante de diverticulectomía sólo se perforó la mucosa en una ocasión pero hubo 3 fístulas (20 por ciento) siendo esto más frecuente después de la diverticulectomía (33 por ciento vs. 11 por ciento). Como complicación mayor sólo se presentó infarto agudo del miocardio en 1 paciente (11 por ciento); no hubo fallecimientos. Se logró la eliminación de los síntomas en 14 pacientes (93.3 por ciento) y el restante sólo refirió disfagia leve con un seguimiento que osciló entre 1 y 6 años. Conclusiones: El tratamiento quirúrgico del divertículo de Zenker está indicado en los pacientes sintomáticos; el esofagograma es el mejor método diagnóstico. Es básico efectuar la miotomía del cricofaríngeo que se puede acompañar de invaginación diverticulectomía o diverticulopexia dependiendo de las características del divertículo y del paciente; sus resultados son buenos en más del 90 por ciento de los pacientes con morbilidad baja y mortalidad nula.