PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) en el tratamiento de la carcinomatosis peritoneal: primeros casos en Chile / PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) in the treatment of peritoneal carcinomatosis: first cases in Chile

Resumen Introducción: PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) Es una técnica que, vía laparoscopía, permite administrar quimioterapia en aerosol intraperitoneal, para el tratamiento de la carcinomatosis, ya sea para disminuir masa tumoral y aumentar la resecabilidad, o como paliación sintomática. Objetivo: Presentar los dos primeros casos de PIPAC en Chile, las consideraciones técnicas y revisión de la literatura. Pacientes y Método: Se describe la forma en que un programa PIPAC fue implementado en Clínica Las Condes. Se describe la técnica. Este procedimiento se realizó en dos pacientes, ambas portadoras de carcinomatosis con ascitis refractaria. Resultados: No hubo complicaciones. Alta a las 24 h. Ambas pacientes presentaron disminución de la ascitis, la que se ha mantenido a los seis meses de seguimiento. Discusión: PIPAC es una técnica emergente, que ha demostrado ser segura, con escasas complicaciones, cuya indicación incluye carcinomatosis por cáncer de colon y ovario y que se está extendiendo a páncreas, vía biliar y estómago. Su rol exacto está por definirse. Conclusiones: PIPAC es una técnica factible de realizar en nuestro país; sus resultados preliminares son alentadores y exentos de complicaciones.

Introduction: PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy is a technique that allows laparoscopic administration of aerosol chemotherapy in the peritoneum. This procedure is utilized for treatment of carcinomatosis, for debulk abdominal tumors, increasing resectability, or for palliation of abdominal symptoms. Aim: To present the first two cases of PIPAC performed in Chile, technical considerations and review of the literature. Patients and Method: The way this program was started at Clínica Las Condes is presented. The technique is described. This procedure was performed in two females, both with refractory ascites due to carcinomatosis. Results: The procedure was uneventfully and patients were discharged 24 hours later. Both patients showed important reduction of ascites, maintained at 6 months of followup. Discussion: PIPAC is a safe emerging technique, with low complication rate. It is indicated in carcinomatosis of colonic and ovarían origin and in selected cases of pancreatic, bile duct and gastric carcinomatosis. More prospective, randomized studies should be done to stablish its exact role. Conclusions: PIPAC is a feasible technique to perform in our country. Preliminary results are encouraging and no complications were observed.

The relationship between chemokines CCL2, CCL3, and CCL4 with the tumor microenvironment and tumor-associated macrophage markers in colorectal cancer.

A complex network of chemokines can influence cancer progression with the recruitment and activation of hematopoietic cells, including macrophages to the supporting tumor stroma promoting carcinogenesis and metastasis. The aim of this study was to investigate the relation between tissue and plasma chemokine levels involved in macrophage recruitment with tumor-associated macrophage profile markers and clinicopathological features such as tumor-node-metastases stage, desmoplasia, tumor necrosis factor-α, and vascular endothelial growth factor plasma content. Plasma and tumor/healthy mucosa were obtained from Chilean patients undergoing colon cancer surgery. Chemokines were evaluated from tissue lysates (CCL2, CCL3, CCL4, CCL5, and CX3CL1) by Luminex. Statistical analysis was performed using Wilcoxon match-paired test ( p < 0.05). Macrophage markers (CD68, CD163, and iNOS) were evaluated by immunohistochemistry samples derived from colorectal cancer patients. Correlation analysis between chemokines and macrophage markers and clinicopathological features were performed using Spearman's test. Plasmatic levels of chemokines and inflammatory mediators' vascular endothelial growth factor and tumor necrosis factor-α were evaluated by Luminex. Tumor levels of CCL2 (mean ± standard deviation = 530.1 ± 613.9 pg/mg), CCL3 (102.7 ± 106.0 pg/mg), and CCL4 (64.98 ± 48.09 pg/mg) were higher than those found in healthy tissue (182.1 ± 116.5, 26.79 ± 22.40, and 27.06 ± 23.69 pg/mg, respectively p < 0.05). The tumor characterization allowed us to identify a positive correlation between CCL4 and the pro-tumor macrophages marker CD163 ( p = 0.0443), and a negative correlation of iNOS with desmoplastic reaction ( p = 0.0467). Moreover, we identified that tumors with immature desmoplasia have a higher CD163 density compared to those with a mature/intermediated stromal tissue ( p = 0.0288). Plasmatic CCL4 has shown a positive correlation with inflammatory mediators (tumor necrosis factor-α and vascular endothelial growth factor) that have previously been associated with poor prognosis in patients. In conclusion High expression of CCL4 in colon cancer could induce the infiltration of tumor-associated macrophages and specifically a pro-tumor macrophage profile (CD163+ cells). Moreover, plasmatic chemokines could be considered inflammatory mediators associated to CRC progression as well as tumor necrosis factor-α and vascular endothelial growth factor. These data reinforce the idea of chemokines as potential therapeutic targets or biomarker in CRC.

Relación entre el grado de incontinencia fecal y el daño del esfínter anal externo / Relationship between faecal incontinence severity and external anal sphincter disruption

Introduction: Faecal incontinence (FI) represents an important psychological and social condition for an individual. There are several causes for FI, therefore its study and management is complex. Among different aetiologies, anatomical disruption of the external anal sphincter (EAS) as a consequence of anorrectal surgery or obstetric injury can be studied by endoanal ultrasound (EAUS). This study focus on anatomical assessment of sphincter muscle injury of EAS and its relationship with clinical presentation con FI. Objective: Compare anatomical and disruption of EAS features studied by 3D-EAUS between patients with FI, according to its severity. Methods: 3D-EAUS images were obtained from selected patients studied for FI between January 2008 and July 2010 at Clínica las Condes. Wexner Score (SW) was used to evaluate severity of FI, dividing patients into two categories: Mild FI (SW < 9) and Severe FI (SW ≥ 9). A single observer evaluated different morphological variables: width, length, percentage and angle of EAS disruption. Parametrical and non-parametrical analysis was used as appropriate. P-value < 0.05 was considered statistically significant. Results: From 31 female patients studied, mean SW was 11.7 +/- 0.8 points, range from 5 to 20 points. When dividing into two groups, 9 patients had mild FI and 22 had severe FI. Studied variables in EAUS 3D cubes: width, length, percentage and angle of EAS disruption, did not reach statistical significance between groups. Conclusion: No relationship was found between external anal sphincter anatomic injury variables studied and severity of faecal incontinence.

Introducción: La incontinencia fecal (IF) se refleja en una condición psicológica y social importante para el individuo. Las causas de IF son múltiples, siendo su estudio y manejo complejo. La disrupción anatómica del esfínter anal externo (EAE), secundaria, entre otras, a cirugía anorrectal o lesión obstétrica, es posible de ser estudiada por endosonografía anal (EAUS). El presente artículo se centra en el daño anatómico del EAE y su relación con la presentación clínica de la IF. Objetivo: Comparar las características anatómicas y daño del EAE objetivadas mediante endosonografía en 3 dimensiones (EAUS3D), entre los pacientes con IF según su severidad. Material y Método: Se obtuvo las EAUS3D realizadas en Clínica Las Condes por estudio de IF entre enero de 2008 y julio de 2010. Se utilizó el score de Wexner (SW) para separar la población en dos grupos, IF leve (SW < 9) e IF grave (SW ≥ 9). Un único observador evaluó las diferentes variables: grosor, longitud, porcentaje de defecto y ángulo de lesión del EAE. Se utilizó estadística paramétrica o no-paramétrica según corresponda. Se consideró significativo p < 0,05. Resultados: De un total de 31 pacientes femeninas estudiadas, el SW promedio fue de 11,7 +/- 0,8 con rango entre 5 y 20 puntos. Al separar según grupos, 9 pacientes tenían IF leve y 22 IF grave. De las variables estudiadas por EAUS3D: el promedio, grosor, longitud, porcentaje de defecto y el ángulo de lesión del EAE no lograron diferencia estadística entre los grupos. Conclusión: No existe una relación directa entre las variables estudiadas de daño anatómico del EAE y el grado de IF.

Resección transanal de un adenoma velloso rectal a través de un trocar monopuerto / Excision of a rectal villous adenoma using a transanal single port trocar

Single port access for minimally invasive surgery is feasible nowadays. We report a 55 years old female presenting with hematochezia. During a colonoscopy, a villous adenoma of 2 cm in diameter located 5 cm above the anal margin, was found. This lesion was excised through the anus, using a single port trocar. The procedure lasted 45 minutes, the postoperative evolution was uneventful and the patient was discharged 24 hours after the procedure.

Posterior al advenimiento de la cirugía laparoscópica colorrectal, desde comienzos de la década de los 90, se han desarrollado diversos tipos de accesos minimamente invasivos, siendo hoy en día el acceso por un puerto único una alternativa factible. Se presenta el caso clínico de una paciente de 55 años, a la cual por sintomatología se le diagnóstica una lesión rectal, la que luego de ser estudiada endoscópica y endosonográficamente, es resecada por monopuerto via anal. La cirugía duró 45 minutos y no presentó eventos adversos intraoperatorios. Su evolución quirúrgica fue satisfactoria con alta hospitalaria al día siguiente de la cirugía.

Cirugía laparoscópica colorrectal en Chile / Laparoscopic colorectal surgery in Chile

The development of laparoscopic colorectal surgery began 20 years ago; however it took several years before gaining its acceptance by the international surgical community. The first report in Chile was published in 1995. However, were necessary many years, until the middle of this decade, to know the first prospective series experiences. Out of these reports, no reliable data exist regarding the development of laparoscopic colorectal surgery in Chile, related to the number of centers performing laparoscopic colorectal surgery or the number of procedures performed. For record these data, a standardized questionnaire was send to colorectal chairmans of all hospitals that had reported to be developing laparoscopic colorectal surgery in our country. Ten of 15 hospitals responded to the survey. Most of the procedures performed were hemicolectomies, principally for cancer and diverticular disease. The average conversion rate was 7 percent and hospital stay was 5 days. Morbidity and mortality rates were 12 percent and 0.4 percent respectively. In the last year was seen an increase in the number of laparoscopic procedures in relation to the previous period. In conclusion, laparoscopic colorectal surgery is a recent technique in Chile, which is being implemented progressively, with good overall results.

El desarrollo de la cirugía laparoscópica colorrectal (CLCR) se inició en la década de los 90, sin embargo, pasaron varios años antes de lograr su aceptación por la comunidad quirúrgica internacional. En Chile, los primeros relatos en congresos datan del año 1995 y las primeras experiencias de series prospectivas fueron publicadas 10 años más tarde. Fuera de estos reportes, no existe información fidedigna en relación al desarrollo de la cirugía laparoscópica colorrectal en Chile, relacionados con el número de centros que la realizan, la formación actual de los cirujanos colorrectales en esta técnica ni en cuanto al número de procedimientos realizados. Para conocer estos datos se envió una encuesta estandarizada a los jefes de equipo de los centros que habían comunicado estar desarrollando la CLCR en nuestro país. Diez de 15 centros respondieron la encuesta. La mayor parte de los procedimientos corresponden a hemicolectomías, siendo las principales indicaciones el cáncer y la enfermedad diverticular. La tasa de conversión promedio fue de 7 por ciento y la estadía hospitalaria de 5 días. La morbilidad y mortalidad fue de 12 por ciento y 0,4 por ciento respectivamente. En el último año se ha visto un aumento del número de procedimientos laparoscópicos en relación al período previo. En conclusión, La CLCR es una técnica de reciente incorporación en Chile, que está siendo implementada en forma progresiva, con buenos resultados globales.

Evaluación funcional y encuesta de satisfacción de los pacientes operados de hemorroides con técnica de PPH / Satisfaction survey of patients after hemorrhoid surgery using the procedure for prolapse and hemorrhoids (PPH) technique

Background: Hemorrhoidal disease is very common and approximately 10 percent of the patients require surgery. Within the different surgical techniques, the Longo procedure or PPH (procedure for prolapse and hemorrhoids) has gained importance. Aim: To evaluate the patients' perception of PPH hemorrhoidectomy in a medium term follow-up. Material and Methods: All patients undergoing PPH hemorrhoidectomy between January 2007 and January 2009 were identified. A survey was designed to assess the presence of specific symptoms before and after surgery, and applied to all patients. Results: Fifty-seven patients completed the survey, with a follow-up ranging from 8 to 31 months. Ninety-four percent of patients referred improvement of bleeding, 85 percent of hemorrhoidal prolapse and 68 percent of soiling after the intervention. On a scale of 1 to 7, 88 percent of patients rated the procedure with a score over 5, and 87 percent would recommend the use of this technique to other patients suffering from the disease. Conclusions: Most patients favorably assess PPH hemorrhoidectomy in terms of postoperative resolution of the symptoms, functional status and overall satisfaction in a medium-term follow-up.

Introducción: La patología hemorroidal es una condición muy frecuente en la población general y aproximadamente un 10 por ciento de los afectados requerirá cirugía. Existen distintas técnicas para su abordaje, siendo la operación de Longo o PPH (procedimiento para el prolapso y las hemorroides) una alternativa que ha cobrado relevancia. Existe poca evidencia de los resultados desde el punto de vista de la satisfacción de los pacientes. El objetivo de nuestro trabajo es dar a conocer la evaluación y percepción de los pacientes operados de hemorroides con la técnica de PPH en un seguimiento a mediano plazo. Material y Métodos: Se identificaron todos los pacientes operados con la técnica de PPH entre enero de 2007 y enero de 2009. Se aplicó una encuesta diseñada para consignar la presencia de algunos síntomas antes y después de la cirugía. Resultados: 57 pacientes completaron la encuesta, con un seguimiento promedio de 17,6 meses (extremos 8-31). Un 94 por ciento de los pacientes refirió la desaparición del sangrado, el 85 por ciento del prolapso hemorroidal y un 68 por ciento del ensuciamiento (soiling) tras la intervención. En una escala de evaluación de 1 a 7, el 88 por ciento de los pacientes calificó el procedimiento con nota > 5 y el 87 por ciento recomendaría el uso de esta técnica a otros pacientes afectados por esta patología. Conclusión: El uso de la técnica de PPH es evaluada favorablemente por la mayoría de los pacientes en relación a la resolución de sus síntomas, al estado funcional y al grado de satisfacción en un seguimiento postoperatorio a mediano plazo.

Neuromodulación central y periférica en incontinencia fecal: presentación de 2 casos y revisión de la literatura / Central and peripheral neuromodulation for fecal incontinence: report of 2 cases and review of the literature

Fecal incontinence is a condition that creates a huge impact on quality of life, it affects up to 45 percent of patients of the elderly. Treatment is initially conservative with dietary changes, drugs and perineal biofeedback. Surgery is reserved for those who do not respond to medical treatment. The most frequently performed procedure is anal sphincteroplasty, useful in patients with proven lesions of the external anal sphincter. Other alternatives include the implantation of an artificial anal sphincter and dynamic graciloplasty, which are very expensive techniques with high rate of complications. If there is no other alternative, a permanent ostomy can be done. In recent years, less invasive techniques have been developed for the treatment of fecal incontinence. Among these, central neuromodulation or sacral root stimulation (SRS) and peripheral neuromodulation or posterior tibial nerve stimulation (PTNS) have shown promising results. The aim of this paper is to present 2 cases of patients with fecal incontinence refractory to conventional treatment (medical and surgical) that are successfully treated with central and peripheral neuromodulation respectively. We present 2 cases and a review of the literature available to date.

La incontinencia fecal (IF) es una patología que genera un enorme impacto en la calidad de vida, afectando hasta el 45 por ciento de los pacientes de la tercera edad. El tratamiento es inicialmente conservador mediante cambios dietéticos, fármacos y rehabilitación perineal. La cirugía se reserva para quienes no responden a tratamiento medico. El procedimiento efectuado con más frecuencia es la esfinteroplastía anal, de utilidad en pacientes con lesión demostrada del esfínter anal externo. En casos de IF grave, otras alternativas son la instalación de un esfínter anal artificial y/o la graciloplastía dinámica, procedimientos de alto costo y con un alto porcentaje de complicaciones. En caso de no existir otra alternativa se puede realizar una ostomía definitiva. Durante los últimos años se han desarrollado técnicas mínimamente invasivas para el tratamiento de la incontinencia fecal. Entre éstas, la neuromodulación central o de las raíces sacras (NMS) y últimamente la neuromodulación periférica o estimulación del nervio tibial posterior (ENTP) han mostrado resultados promisorios. Los objetivos de este trabajo son presentar 2 casos clínicos de pacientes con incontinencia fecal refractaria al tratamiento convencional (medico y quirúrgico) que son tratados exitosamente con neuromodulación central y periférica, respectivamente, y realizar una revisión de la literatura disponible a la fecha.

[Distal intestinal obstruction syndrome: report of two cases with cystic fibrosis]. / Síndrome de obstrucción intestinal distal en pacientes adultos con fibrosis quística: Casos clínicos.

Distal Intestinal Obstruction Syndrome (DIOS) has a 16% incidence among patients with Cystic Fibrosis (CF). It is characterized by an intestinal obstruction secondary to fecal impaction in distal ileum or cecum. We report two adult patients with DIOS. A female with CF and subjected to lung transplantation at the age of 13 years old. Five years later, she consulted for an intestinal obstruction. She was treated conservatively with a good clinical evolution. She had a new episode of DIOS eight months later that was also treated conservatively. A 31 year-old mole, subjected to bilateral lung transplantation nine years before, that was admitted to the hospital for a bronchiolitis. Three days after admission he started with an intestinal obstruction that was diagnosed as a DIOS. He was managed conservatively with a good clinical response.

Recidiva en intestino delgado de tumor de GIST de bajo riesgo: caso clínico y revisión de la literatura / Recurrence of low risk small bowel GIST tumor: case report and revision of the literature

Gastrointestinal stromal tumors (GIST) are the most common mesenchymatic neoplasm in the digestive tract, representing about 1 percent of malignant gastrointestinal lesions. Seventy to eighty percent are benign according to their size and mitotic index as predictors of malignancy. However, in the presence of relapses in patients with low risk according to the current classification and in light of new adjuvant therapies (Imatinib Mesylate), have defined new parameters for estimation of malignant potential.

Los tumores del estroma gastrointestinal (GIST) son las neoplasias mesenquemáticas más comunes del tracto digestivo representando cerca del 1 por ciento de las lesiones neoplásicas gastrointestinales. El 70 por ciento-80 por ciento de ellas son benignas siendo clasificados según su tamaño e índice mitótico como predictores de malignidad. Sin embargo, ante la presencia de recidivas en pacientes con bajo riesgo según la clasificación actual y a la luz de nuevas terapias adyuvantes (Mesilato de Imatinib), se han definido nuevos parámetros para su estimación de potencial maligno.

Síndrome de obstrucción intestinal distal en pacientes adultos con fibrosis quística: Casos clínicos / Distal intestinal obstruction syndrome: Report of two cases with cystic fibrosis

Distal Intestinal Obstruction Syndrome (DIOS) has a 16 percent incidence among patients with Cystic Fibrosis (CF). It is characterized by an intestinal obstruction secondary to fecal impaction in distal ileum or cecum. We report two adult patients with DIOS. A female with CF and subjected to lung transplantation at the age of 13 years old. Five years later, she consulted for an intestinal obstruction. She was treated conservatively with a good clinical evolution. She had a new episode of DIOS eight months later that was also treated conservatively. A 31 year-old mole, subjected to bilateral lung transplantation nine years before, that was admitted to the hospital for a bronchiolitis. Three days after admission he started with an intestinal obstruction that was diagnosed as a DIOS. He was managed conservatively with a good clinical response.

Hemicolectomía derecha laparoscópica por puerto único para cáncer de colon / Single-port access right laparoscopic hemicolectomy for colon cancer

La tendencia a una menor invasión en el acto quirúrgico ha sido un objetivo desde los inicios de la cirugía y en la actualidad se buscan continuamente caminos que cumplan este principio. En el último año han surgido publicaciones de una nueva técnica laparoscópica a través de un acceso umbilical único que permitiría disminuir el trauma de la pared abdominal, el dolor postoperatorio y además, mejorar el resultado cosmético. El objetivo de este reporte es dar a conocer nuestra experiencia con la primera hemicolectomía derecha laparoscópica (HCDL) reportada a través de un puerto único para una neoplasia maligna de colon. Se trata de un paciente con un adenocarcinoma cecal originado en un pólipo (< 2 cm) abordado por vía laparoscópica introduciendo el puerto único SILS (SILSÕ Port, Covidien, Autosuture) con lugar para trabajar con 3 trocares a través de una incisión paraumbihcal de 3 cm, por la cual se realizó toda la disección y extracción de la pieza operatoria. La cirugía se llevó a cabo sin incidentes, respetando todos los principios oncológicos y el paciente evolucionó en forma satisfactoria. La pieza operatoria confirmó un adenocarcinoma con invasión de submucosa (SM3) sin metástasis en 30 ganglios examinados. Se concluye que la realización de una HCDL con puerto único es factible y pudiera ser segura desde el punto de vista oncológico. Tiene ventajas cosméticas evidentes y ademßs podría disminuir la morbilidad de la pared abdominal, los costos totales quirúrgicos y eventualmente las tasas de conversión.

A new laparoscopic technique allows a peritoneal access through a single umbilical port with less abdominal wall trauma and pain. We report a 64 years old male with a right colon adenocarcinoma, detected during a routine colonoscopy. The patient was subjected to a right laparoscopic hemicolectomy through a single SILS® Multiple Instrument Access Port, that can accommodate up to three instruments introduced through a 3 cm paraumbihcal incision. The surgical procedure was uneventful and the patient had a good postoperative evolution. The pathological study of the surgical piece confirmed the presence of an adenocarcinoma with invasion of the submucosa and without lymph node involvement.

Reparación con malla de hernia paracolostómica por vía laparoscópica: presentación de dos casos clínicos y revisión de la literatura / Parastomal hernia repair with mesh: case Report and review of the literature

La Hernia Paracolostómica (HP) es una patología frecuente en pacientes portadores de una ostomía definitiva y presenta grandes desafíos en su tratamiento, lo que está determinado principalmente por el alto porcentaje de recidiva a pesar de las distintas técnicas utilizadas en su reparación. Dentro de las más recientes, la reparación con malla intraperitoneal por vía laparoscópica aparece como una alternativa promisoria dada las características del procedimiento: Mínima tensión y mínima invasión. Se presentan dos pacientes, con colostomías definitivas y hernias paracolostómicas secundarias, en quienes se reparó el defecto con una malla para uso intraperitoneal mediante técnica laparoscópica. Ninguno de los pacientes presentó complicaciones intra ni postoperatorias. En un seguimiento a corto plazo no se ha observado recidiva. Se revisa y discute bibliografía reciente al respecto.

Parastomal hernias are frecuent pathology in patients with definitive colostomy. Laparoscopic repair with a composed mesh technique seems to be a promising procedure for these patients. We present two patients with a mesh installation by laparoscopy. We did not observe intraoperative or postoperative complications, and after a short follow-up, no recurrence has been observed.

[Ileal pouch-anal anastomosis for ulcerative colitis: complications and long term functional results]. / Reservorio ileal con anastomosis reservorio anal por colitis ulcerosa: Complicaciones y resultados funcionales a largo plazo.

BACKGROUND: The ileo anal-pouch-anastomosis (IPAA) is the treatment of choice for patients with ulcerative colitis (UC). AIM: To analyze the surgical outcomes, long term evolution and functional results of IPAA. MATERIAL AND METHODS: All patients subjected to an IPAA, from 1984 to 2006 were identified from a prospectively constructed inflammatory bowel disease database. Surgical variables, postoperative complications and functional evaluation, using Oresland score were analyzed. Chi square, Fischer exact test, T Student, Mann Whitney and binary logistic regression were included in the statistical analysis. RESULTS: In the study period 107 patients, aged 14 to 62 years (61 females), subjected to an IPAA, were identified in this period. All patients, except 4, had a J pouch. All were protected with a loop ileostomy. Thirteen patients (12.1%) had specific postoperative complications: pelvic collections in five (4.6%), wound infection in four (3.7%), fistula of the anastomosis in two (1.8%), hemoperitoneum and pouch necrosis in one each. Three (2.7%) patients were reoperated. There was no post-operative (30 days) mortality. A complete follow-up was obtained in 106 of 107 patients: four evolved as Crohn disease; four lost their pouch and two died for other causes. One patient required an ileostomy due to a vaginal fistula. Seventy two patients were followed more than 36 months after ileostomy closure and 92% have a satisfactory intestinal function. In the univariate analysis, poorest intestinal function was related to age of diagnosis of UC and presence of chronic pouchitis. In the multivariate analyses age of diagnosis was associated with poor function. CONCLUSIONS: IPAA has a low rate of complications. The long term intestinal function is satisfactory in most patients. A poorer intestinal function was observed in older patients and those with chronic pouchitis).

Cirugía laparoscópica en cáncer de colon / Laparoscopic surgery for colorectal cancer

El cáncer colorrectal es una importante causa de muerte en los países desarrollados. Chile, siendo un país en vías de desarrollo, ha presentando un marcado incremento en la tasa de mortalidad por este cáncer durante la última década. La cirugía laparoscópica ha significado un importante avance terapéutico en estos pacientes, demostrando ser una técnica segura en términos oncológicos y con mejores resultados en cuanto a morbilidad en comparación con los pacientes operados en forma convencional.

Colorectal cancer is an important cause of death in the developed countries. Chile a developing country has shown an important in crease of the mortality rate of this cancer during the last decade. Laparoscopic surgery has meant a significant therapeutic advance for the treatment of these patients which is safe from the oncologic point of view, and also is associated to a lawer morbidity compared to patients operated on by open surgery.

Bases genéticas del cáncer colorrectal hereditario / Genetic basis of hereditary colorectal cancer

Las variantes hereditarias representan aproximadamente el 5 por ciento de los casos de cáncer colorrectal. Las formas más frecuentes son la Poliposis Adenomatosa Familiar (PAF) y el Cáncer Colorrectal Hereditario No Polipósico (HNPCC) o Síndrome de Lynch. Esta revisión analiza los genes relacionados, sus mecanismos moleculares y la importancia de los estudios genéticos en el manejo de los pacientes y las familias comprometidas. En la PAl; diferentes mutaciones del gen APC son responsables del desarrollo de cientos de pólipos en colon y recto, y sus manifestaciones extracolónicas como tumores desmoides, pólipos gástricos y duodenales. En el HNPCC, mutaciones principalmente en los genes MLH1, MSH2 Y MSH6 son la causa de tumores en el colon, endometrio, ovario, estómago, urotelio e intestino delgado.

Hereditary variants account for approximately 5 percent of colorectal cancers. Within them, Familiar Adenomatous Polyposis (FAP) and Hereditary Non Polyposis Colorectal Cancer (HNPCC) or Lynch's syndrome are the most frequent. The underlyinggenes and their molecular pathways are reviewed, and the importance of genetic testing for the clinical management of patients and their families is analyzed. In FARmutations on the APC gene are responsible for the development of hundreds of colorectal polyps and extracolonic manifestations such as desmoid tumors, gastric and duodenal polyps. In HNPCC, mutations on MLH1, MSH2 and MSH6 genes are the most frequent causes of colonic, endometrial, ovarian, gastric, urothelial and small bowel tumors.

Reservorio ileal con anastomosis reservorio anal por colitis ulcerosa: Complicaciones y resultados funcionales a largo plazo / Ileal pouch-anal anastomosis for ulcerative colitis: Complications and long term functional results

Background: The ileo anal-pouch-anastomosis (IPAA) is the treatment of choice for patients with ulcerative colitis (UC). Aim To analyze the surgical outcomes, long term evolution and functional results of IPAA. Material and methods: All patients subjected to an IPAA, from 1984 to 2006 were identified from a prospectively constructed inflammatory bowel disease database. Surgical variables, postoperative complications and functional evaluation, using Oresland score were analyzed. Chi square, Fischer exact test, T Student, Mann Whitney and binary logistic regression were included in the statistical analysis. Results: In the study period 107 patients, aged 14 to 62 years (61 females), subjected to an IPAA, were identified in this period. All patients, except 4, had a J pouch. All were protected with a loop ileostomy Thirteen patients (12.1 percent) had specific postoperative complications: pelvic collections in five (4.6 percent), wound infection in four (3.7 percent), fistula of the anastomosis in two (1.8 percent), hemoperitoneum and pouch necrosis in one each. Three (2.7 percent) patients were reoperated. There was no post-operative (30 days) mortality. A complete follow-up was obtained in 106 of 107 patients: four evolved as Crohn disease; four lost their pouch and two died for other causes. One patient required an ileostomy due to a vaginal fistula. Seventy two patients were followed more than 36 months after ileostomy closure and 92 percent have a satisfactory intestinal function. In the univariate analysis, poorest intestinal function was related to age of diagnosis of UC and presence of chronic pouchitis. In the multivariate analyses age of diagnosis was associated with poor function. Conclusions: IPAA has a low rate of complications. The long term intestinal function is satisfactory in most patients. A poorer intestinal function was observed in older patients and those with chronic pouchitis).

Factores pronósticos de pacientes con metástasis hepáticas de cáncer de colon y recto / Prognostic factors of patients with colorectal liver metastases

Introducción: Las metástasis hepáticas (MH) son causa frecuente de muerte en el cáncer colo-rectal (CaCR). El objetivo del trabajo es evaluar los factores que determinan la sobrevida de pacientes con MH de CaCR. Material y Método: Análisis retrospectivo a partir de los registros de biopsias, ficha clínica y base de datos especialmente diseñada de 122 pacientes con MH de CaCR evaluados entre 1978 y 2002. Se analizó demografía, características del tumor primario, de las MH y del tratamiento utilizado. Se evaluó factores pronósticos y sobrevida a 5 años según Kaplan-Meier con el test de log-rank. Resultados: De los 122 pacientes, [71 (58,2 por ciento) hombres; edad: 65 + - 13 años], en 73 (59,8 por ciento) la MH fue sincrónica con el tumor primario; en 46 (37,7 por ciento) bilobar; en 70 (57,4 por ciento) múltiple con > 4 nodulos metastásicos y en 34 (27,9 por ciento) la MH fue única. En 65 (53,3 por ciento) pacientes, el tratamiento quirúrgico del primario se consideró curativo. Las MH de CaCR fueron resecadas en 42 de estos pacientes (64,6 por ciento). Hubo recurrencia del canceren 18 pacientes a los 18 meses promedio. La sobrevida a 5 años de todos los pacientes fue de 14,6 por ciento. Los enfermos con más de una metástasis, con compromiso bilobar y que no fueron resecadas, tuvieron un peor pronóstico (p<0,0001). En los enfermos resecados R0 se obtuvo una sobrevida de 46,2 por ciento. Conclusiones: A un tercio de los pacientes con MH de CaCR de esta serie se le resecó la MH. La mejor sobrevida se obtuvo cuando la resección fue curativa (R0).

Introduction: Liver metastases (LM) are frequent cause of death in patients with colorectal cancer (CRCa). Our aim was to evaluate factors determining overall survival in colorectal cancer liver metastases. Material and Methods: Data from 122 patients with LM of CRCa evaluated between 1978 and 2002 were retrospectively analyzed. Data was obtained from pathologic reports, patient's records and from a specially designed database. We studied demographic data, primary tumors, its treatment and liver metastases characteristics. Prognostic factors, recurrence and 5-year survival specific curves, calculated according to Kaplan-Meier were obtained. Results: Among the 122 patients [71 (58.2%) were men; mean age: 65 ± 13 years old], 73 (59.8%) had synchronic LM with the primary tumor. In 46 (37.7%) cases there were bilateral tumors; and in 70 (57.4 %) patients there were 4 or more lesions. Only 34 (27.9%) cases had a solitary LM. In 65 (53.3%) patients the primary tumor surgical treatment was considered curative (RO). In 42 (64.6%) of these patients LM were surgically resected. Eighteen patients developed cancer recurrence after liver resection at a mean time of 18 month. The overall 5-year survival of all patients was 14.6 %. Patients with more than one nodule, metastatic bilateral LM and no curative resection had the worst prognosis (p<0.0001). The 5-year survival rate of patients who underwent a RO liver resection was 46.2%. Conclusions: One third of this series were treated by liver resection. The best survival was obtained with a RO (negative margins) liver resection.