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.

Ictericia obstructiva secundaria a migración de fragmentos de hepatocarcinoma a la vía biliar / Obstructive jaundice secondary to hepatocellular carcinoma fragments migrated to common bile duct

Obstructive j aundice is a rare presentation of hepatocellular carcinoma (HC), and when it occurs, usually is due to progressive damage from cirrhosis, or extensive tumor infiltration. Tumor growth through the bile duct is being described with increasing frequency as a cause of obstructive j aundice. Rarely, it may be hepatocarcinoma fragments that migrate to the bile duct, obstructing it. We present a case of obstructive jaundice due to migration of fragments of hepatocellular carcinoma to the bile duct in a patient treated 7 years before, for an HC with a curative resection.

La ictericia obstructiva es una presentación poco común en un hepatocarcinoma (HC). Cuando en estos casos existe ictericia, habitualmente se debe a daño progresivo por cirrosis, o a infiltración tumoral extensa. El crecimiento o vaciamiento tumoral hacia la vía biliar se ha descrito ocasionalmente como causa de ictericia obstructiva. En raras ocasiones, puede tratarse de fragmentos de hepatocarcinoma que migran hacia la vía biliar, obstruyéndola. Presentamos un caso de ictericia obstructiva por migración de fragmentos de hepatocarcinoma a la vía biliar, en un paciente tratado 7 años antes por un HC, con resección curativa.

Falla hepática fulminante en niños / Acute liver failure in children: experience of a liver transplant center

Background: Acute liver failure (ALF) in childhood is defined as biochemical evidence of liver injury, absence of known chronic liver disease and coagulopathy not corrected by vitamin K administration, with INR greater than 1.5 if the patient has encephalopathy or greater than 2.0 if the patient does not have encephalopathy. Objective: Report the experience of a single liver transplant center (LT) in the treatment of 8 children with ALF and review the literature. Method: Retrospective review of clinical charts of patients with ALF. Results: The median age was 8 years-old (range 0-11), three females. Five patients underwent LT. Two patients died, one of them LT. The etiologies were 4 undetermined, 1 autoimmune, 1 Wilson Disease, 1 Parvo virus and 1 chronic graft rejection. All grafts were from cadaver donor, 3 of them reduced. Two out of five patients with encephalopathy grade III-IV died. The one year survival rate was 75 percent. Conclusions: Children with ALF should be treated in experienced centers with facilities for liver transplant. Transplantation should be offered only if the underlying disease is treatable by liver replacement and if transplant prognosis is better than that of the underlying disease.

Falla hepática fulminante (FHF) en la infancia se define como evidencia bioquímica de daño hepático, sin antecedentes conocidos de enfermedad hepática crónica, coagulopatía no corregida por la administración de vitamina K e INR superior a 1,5 si el paciente tiene encefalopatía o superior a 2 si no tiene encefalopatía. Objetivo: Presentar la experiencia de un centro de trasplante hepático (TH) en el tratamiento de 8 niños con FHF y revisar la literatura. Pacientes y Método: Revisión retrospectiva de la historia clínica de pacientes con FHF. Resultados: La edad media fue de 8 años, rango 0-11, tres sexo femenino. Cinco pacientes fueron sometidos a TH. Dos pacientes fallecieron, uno de ellos con TH. La etiología fue indeterminada en 4 pacientes, 1 autoinmune, 1 enfermedad de Wilson, 1 parvovirus y 1 rechazo crónico del injerto. Todos los injertos fueron de donante cadáver, 3 de ellos reducidos. Dos de cinco pacientes con encefalopatía grado III-IV fallecieron. La tasa de sobrevida al año fue de 75 por ciento. Conclusión: El manejo de la FHF debe realizarse en un centro con capacidad de realizar TH, aunque no todos los pacientes requerirán finalmente esta terapia. El TH debiera ser ofrecido sólo si la enfermedad subyacente es tratable con reemplazo hepático y si el pronóstico del TH es mejor que el de la enfermedad misma.

[Use of Sirolimus in five pediatric patients undergoing solid organ transplantation]. / Sirolimus en trasplante de órgano sólido pediátrico: Experiencia en 5 casos.

BACKGROUND: Sirolimus (SRL) is an immunosuppressive drug increasingly used in children undergoing solid organ transplantation. SRL does not cause glucose intolerance, hypertension, nephrotoxicity or neurotoxicity offering significant potential advantages over calceneurin inhibitors (CM). AIM: To report five children treated with SRL. MATERIAL AND METHODS: A retrospective review of four children undergoing orthotopic liver transplantation (OLT) and one undergoing renal transplantation with recurrent acute rejection (RAR), chronic rejection (CR) or toxicity due to CM, treated with SRL between June 2001 and November 2006. RESULTS: As primary immunosuppressive therapy, all patients received 3 drugs: CM (Tacrolimus (FK) or Cyclosporine), mycophenolate mofetil and steroids. Mean age at treatment with SRL was 98 months. Children undergoing OLT had a late introduction of SRL (mean time after OLT: 37 months), and mean follow-up was 24 months. In this group rescue indications of SRL were RAR in one, CR in one, thrombotic thrombocytopenic purpura (TTP) in one, food allergy in one and other CM toxicity in three. Only one did not experience adverse events due to SRL, but no one required discontinuation of SRL. There were remissions of RAR, CR, TTP and food allergy. The patient with RT was switched from FK to SRL at day 18th after RT, but he had severe neutropenia that led to discontinuation of SRL. CONCLUSIONS: SRL may be useful in pediatric solid organ transplant recipients suffering from RAR, CR, TTP, food allergy and CM toxicity. Careful attention should be directed to detect side effects and avoid severe complications.

Sirolimus en trasplante de órgano sólido pediátrico: Experiencia en 5 casos / Use of Sirolimus in five pediatric patients undergoing solid organ transplantation

Sirolimus (SRL) is an immunosuppressive drug increasingly used in children undergoing solid organ transplantation. SRL does not cause glucose intolerance, hypertension, nephrotoxicity or neurotoxicity offering significant potential advantages over calceneurin inhibitors (CM). Aim: To report five children treated with SRL. Material and methods: A retrospective review of four children undergoing orthotopic liver transplantation (OLT) and one undergoing renal transplantation with recurrent acute rejection (RAR), chronic rejection (CR) or toxicity due to CM, treated with SRL between June 2001 and November 2006. Results: As primary immunosuppressive therapy, all patients received 3 drugs: CM (Tacrolimus (FK) or Cyclosporine), mycophenolate mofetil and steroids. Mean age at treatment with SRL was 98 months. Children undergoing OLT had a ¡ate introduction of SRL (mean time after OLT: 37 months), and mean follow-up was 24 months. In this group rescue indications of SRL were RAR in one, CR in one, thrombotic thrombocytopenic purpura (TTP) in one, food allergy in one and other CM toxicity in three. Only one did not experience adverse events due to SRL, but no one required discontinuation of SRL. There were remissions of RAR, CR, TTP and food allergy. The patient with RT was switched from FK to SRL at day 18th after RT, but he had severe neutropenia that led to discontinuation of SRL. Conclusions: SRL may be useful in pediatric solid organ transplant recipients suffering from RAR, CR, TTP, food allergy and CM toxicity. Careful attention should be directed to detect side effects and avoid severe complications.

Rescate con Sirolimus por rechazo agudo recurrente y diabetes mellitus en trasplante hepático: caso clínico pediátrico / Sirolimus for rescue of recurrent acute rejection and diabetes mellitus after liver transplantation: report of one case

Sirolimus (SRL) is a new immunosuppressive drug approved for renal transplantation, but is being used increasingly in orthotopic liver transplantation (OLT). Compared with the calcineurin inhibitors, SRL has different mechanisms of action and side effects profile. Thus, this drug offers significant potential advantages over other immunosuppressive agents. SRL does not cause glucose intolerance, hypertension or renal failure, but it may cause dyslipidemia, hepatic artery thrombosis, thrombocytopenia, anemia, leukopenia, oral mucosa ulcers, edema, arthralgias and wound complications. SRL inhibits the signal of interleukin 2 at a post-receptor level, inhibiting lymphocyte proliferation and fibroblast proliferation. It also has antineoplastic and antifungal effects. We report a 10 years old girl who underwent OLT, experiencing a biopsy-proven recurrent acute rejection (AR) in spite of using three immunosuppressive agents (tacrolimus, mofetil micofenolate and steroids). She developed diabetes mellitus as a consequence of the immunosuppressive therapy. She was rescued with SRL, not experiencing AR again. Mofetil micofenolate, steroids and insulin could be discontinued and tacrolimus doses were reduced, without experiencing severe complications. SRL is a new and safe immunosuppressive agent for rescue in patients with OLT and recurrent AR.

Falla hepática fulminante por parvovirus B 19 y trasplante hepático, caso clínico / Acute liver failure by Parvovirus B19 and liver transplant: case report

Introducción: La infección por parvovirus humano B19 (PHB 19) produce un amplio rango de enfermedades que van desde eritema infeccioso en niños hasta artritis aguda en adultos. Algunos estudios sugieren un rol patogénico del PHB 19 en el desarrollo de la hepatitis aguda (HA) y falla hepática fulminante (FHF) en niños y adultos. La Anemia aplástica (AA) es una complicación reconocida de la HA y FHF por PHB 19. Objetivo: Reportar un caso de FHF por infección por PHB 19 y revisar la literatura. Caso clínico: Niña de 7 años de edad con HA que en una semana desarrolló FHF con serología IgM anti-PHB 19 positiva. Otras causas virales, autoinmunes, metabólicas o toxicas fueron descartadas. Fue sometida a trasplante hepático ortotópico (THO) y un año después no ha presentado complicaciones. Conclusiones: El PHB 19 puede causar HA y FHF, su oportuno diagnóstico y tratamiento, que en el caso de la FHF incluye el THO puede resultar en un pronóstico favorable.

Trasplante combinado hepato-renal: a propósito de un caso / Combined liver-kidney transplantation: report of one case

End stage renal disease is not an absolute contraindication for liver transplantation (LT) in patients with end stage liver disease. Actuarial patient and graft survival are comparable for children and adults who undergo LT alone and liver-kidney transplantation (LKT). The most common indications for LKT are the primary hyperoxaluria type I (PH1) and the liver and renal polycystic disease. We report a 12 years old boy with congenital hepatic fibrosis with severe portal hypertension, encephalopathy and polycystic kidney disease with end stage renal disease on dialysis that underwent LKT. During the second postoperative week, he had a biopsy-proven acute liver and renal rejection, that had a good response to corticosteroids. Thirty days after surgery, the liver biopsy was without rejection. No other complications were observed (Rev Méd Chile 2003; 131: 1309-12).

Trasplante hepático en adultos: casuística de Clínica Alemana de Santiago / Adult liver transplantation: a single center experience from Chile

Background: The success of orthotopic liver transplantation (OLT) has resulted in its widespread use for different liver diseases. Aim: To report our 8 years experience with adult OLT at Clinica Alemana de Santiago. Patients and methods: In all transplantations done at the center, we recorded patient's overall data and survival, postoperative medical and surgical complications and causes of death. Results: Between November 1993 and September 2001, 51 consecutive OLT were performed in 44 patients (22 females, median age 45 years old). Thirty eight patients presented with chronic and 6 with acute or sub-acute liver failure. Cryptogenic cirrhosis and hepatitis C infection were the most common causes for OLT. Postoperative bleeding and extra-hepatic biliary complications were seen in 17.6 and 21.5 percent of cases respectively. Acute rejection, bacterial infections, CMV infection or disease and post OLT hemodialysis were the most common medical complications (51, 31, 19.6 and 19.6 percent of cases respectively). The overall 1 and 5 years survival rates were 80 percent and 73 percent respectively. Considering exclusively the last 22 OLT performed since January 1999, the 1 year survival rate has improved to 91 percent. Conclusions: Liver transplantation in Chile provides a good long term survival with acceptable morbidity, due to a multidisciplinary approach management. The survival rates have improved over the last few years probably due to better surgical techniques, ICU care and immunosuppression. These overall results are comparable with those from other Centers in developed countries

Determinación de variables asociadas a coledocolitiasis y su valor predictivo / Determination of choledocolithiasis associated factors and it predictive value

El diagnóstico de la coledocolitiasis (CDL) en el preoperatorio sigue siendo un gran desafío para el cirujano. Con el objetivo de determinar cuáles son las variables asociadas a CDL y su valor predictivo, se escogieron al azar las fichas clínicas de 400 pacientes (p) sometidos a colecistectomía laparoscópica entre enero de 1991 y noviembre de 1993, seleccionando 180 que tenían evaluación radiológica de la vía biliar (VB) (ERCP preoperatoria y/o colangiografía intraoperatoria). Esto permitió documentar CDL en 55 p y descartarla en 125. Se realizó un análisis estadístico univariado, con test chi cuadrado, cálculo del Odds-Ratio, sensibilidad (S), específicidad (E) y valor predictivo positivo (VPP). Las variables que se asociaron a CDL en forma estadísticamente significativa fueron: edad > 55 años. dolor abdominal al momento de la cirugía, ictericia clínica, aumento de la bilirrubina total y fosfatasas alcalinas, dilatación ecográfica de la VB y litiasis vesicular múltiple (ò cálculos). Los valores más altos de S, E y VPP se encontraron en: Nº cálculos vesiculares (83 por ciento), ictericia (98 por ciento) y dilatación VB ò 7 mm e ictericia (87 por ciento), respectivamente.

Resultados de la colecistectomía por laparoscopia / Results of laparoscopic cholecistectomy

Se comunica los resultados de la colecistectomía por laparoscopia en 245 pacientes. El procedimiento se completó en 223. La conversión a colecistectomía abierta fue necesaria en 22 pacientes (8,9%) debido a dificultades anatómicas y principalmente coledocolitiasis. Diez pacientes presentaron complicaciones quirúrgicas, 4 de ellas de importancia (1,8%). Hay un fallecido a los 18 días postoperatorios por embolia pulmonar. La incidencia de lesión de la vía biliar fue de 1 en 223 casos (0,4%). El promedio de días de estada intrahospitalaria fue de 2,4 días y el retorno a la actividad laboral fue de 10,2 días