Reseccion toracoscopica de una glandula paratiroidea hipersecretante mediastinal / Thoracoscopic resection of mediastinal hypersecretant parathyroid gland

In general experienced hands, the inferior parathyroid glands, localized in the thymus or low extrathymus are the main cause or surgical therapeutic failure. When they could not be approached through cervicotomy, or when they were diagnosed after surgery the sternotomy or the angiographic ablation were chosen as treatment. The limited number of thoracoscopic approach whit good results published so far, moved us to use this method. MATERIAL AND METHOD: Patient of 49 years with a 7 year secondary hiperprathyroidism due to CRI. After a sub total parathyroidectomy with bilateral thimectomy, the patient did not present clinical or laboratory improvement. Through a thoracic centellogram sixth MIBI, NMR and CAT, a tumor in the middle mediastinum was fond. The mediastinal structures have been easily identified through a left thoracoscopic approach. At the level of the aortopulmonary window, a tumoral mass is located and, with a simple dissection, et is easily extracted in bag. The biopsy through freezing confirms the parathyroid etiology of the gland. RESULT: Clinical and laboratory evolution has been favorable, with hospital discharged at the 3 day, and being asymptomatic after two years. CONCLUSION: The hipersecretant parathyroid glands, located in middle mediastinum, that can not be approach through cervicotomy, can be successfully approach through thoracoscopic technique.

Por lo general en manos experimentadas las paratiroides inferiores. de localización tímica o extratímica baja, son la principal causa de fracaso terapéutico quirúrgico. Cuando no son accesibles por cervicotomía o bien se diagnosticaron posteriormente. la esternotomía o la ablación angiográfica eran considerados como los tratamientos de elección. El haberse publicado limitadas experiencias de abordaje toracoscópico con buenos resultados nos motivo al empleo de esta VÍa. Material y método: paciente de 49 años con hiperparatiroidismo secundario por IRC de 7 años de evolución. Luego de una paratiroidectomía sub-total con timectomía bilateral. no presenta mejoría clínica ni de laboratorio. Al ser estudiada con centellograma sesta-MIBI. RMN y TAC torácica es localiza un tumor en mediastino meido. Abordaje toracoscópico izquierdo. identificándose con facilidad las estructuras mediastinales. A nivel de la ventana aortopulmonar se localiza una masa tumoral que con simples maniobras de disección es fácilmente extraída en bolsa. La biopsia por congelación confirma la etiología paratiroidea de la misma. Resultado: Evolución clínica y de laboratorio favorable con alta de sala al 3- día. encontrándose a los dos años asintomático. Conclusión: vemos con entusiasmo el abordaje toracoscópico de glándulas paratiroideas hipersecretantes ubicadas en medias tino medio que no hayan podido ser extraídas por cervicotomía.

Reseccion toracoscopica de una glandula paratiroidea hipersecretante mediastinal / Thoracoscopic resection of mediastinal hypersecretant parathyroid gland

In general experienced hands, the inferior parathyroid glands, localized in the thymus or low extrathymus are the main cause or surgical therapeutic failure. When they could not be approached through cervicotomy, or when they were diagnosed after surgery the sternotomy or the angiographic ablation were chosen as treatment. The limited number of thoracoscopic approach whit good results published so far, moved us to use this method. MATERIAL AND METHOD: Patient of 49 years with a 7 year secondary hiperprathyroidism due to CRI. After a sub total parathyroidectomy with bilateral thimectomy, the patient did not present clinical or laboratory improvement. Through a thoracic centellogram sixth MIBI, NMR and CAT, a tumor in the middle mediastinum was fond. The mediastinal structures have been easily identified through a left thoracoscopic approach. At the level of the aortopulmonary window, a tumoral mass is located and, with a simple dissection, et is easily extracted in bag. The biopsy through freezing confirms the parathyroid etiology of the gland. RESULT: Clinical and laboratory evolution has been favorable, with hospital discharged at the 3 day, and being asymptomatic after two years. CONCLUSION: The hipersecretant parathyroid glands, located in middle mediastinum, that can not be approach through cervicotomy, can be successfully approach through thoracoscopic technique.(AU)

Por lo general en manos experimentadas las paratiroides inferiores. de localización tímica o extratímica baja, son la principal causa de fracaso terapéutico quirúrgico. Cuando no son accesibles por cervicotomía o bien se diagnosticaron posteriormente. la esternotomía o la ablación angiográfica eran considerados como los tratamientos de elección. El haberse publicado limitadas experiencias de abordaje toracoscópico con buenos resultados nos motivo al empleo de esta VIa. Material y método: paciente de 49 años con hiperparatiroidismo secundario por IRC de 7 años de evolución. Luego de una paratiroidectomía sub-total con timectomía bilateral. no presenta mejoría clínica ni de laboratorio. Al ser estudiada con centellograma sesta-MIBI. RMN y TAC torácica es localiza un tumor en mediastino meido. Abordaje toracoscópico izquierdo. identificándose con facilidad las estructuras mediastinales. A nivel de la ventana aortopulmonar se localiza una masa tumoral que con simples maniobras de disección es fácilmente extraída en bolsa. La biopsia por congelación confirma la etiología paratiroidea de la misma. Resultado: Evolución clínica y de laboratorio favorable con alta de sala al 3- día. encontrándose a los dos años asintomático. Conclusión: vemos con entusiasmo el abordaje toracoscópico de glándulas paratiroideas hipersecretantes ubicadas en medias tino medio que no hayan podido ser extraídas por cervicotomía.(AU)

Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease.

BACKGROUND: Laparoscopic cholecystectomy has been successfully performed using epidural anesthesia. We evaluated our experience with this surgical approach in high-risk patients. METHODS: We present the results of 29 patients with gallstones who, between 1998 and 1999, underwent laparoscopic cholecystectomy with epidural anesthesia. All but 1 patient had chronic obstructive pulmonary disease. RESULTS: All 29 surgeries were successfully completed via laparoscopy and with the patients under epidural anesthesia. No patient required endotracheal intubation during surgery or pain medication afterward. Postoperatively, 1 patient developed a wound infection and 3 patients developed urinary retention. At last follow-up (12 months postop), all patients were in good health. CONCLUSION: In this series, laparoscopic cholecystectomy was feasible under epidural anesthesia and it eliminated the need for postoperative analgesia. We believe that this approach should be considered for patients who require biliary surgery but who are not good candidates for general anesthesia due to cardiorespiratory problems.

[Jejunostomy for enteral feeding in surgery. Technical contribution and experience]. / Yeyunostomía de alimentación en cirugía. Contribución técnica y experiencia.

UNLABELLED: The necessity to maintain the nutritional integrity in patients subjected to major surgery of the superior digestive tract has been broadly accepted. The enteral nutrition for yeyunostomy is accepted as more physiologic, sure and effective than the parenteral one. MATERIALS AND METHOD: 171 yeyunostomies were indicated in: 151 patients with malignant neoplasm of the superior digestive tract, 15 with infected pancreatic necrosis, 3 bile-duodenum-pancreatic traumatisms and in 1 stenosis for gastroesophagic reflux. Depending on the pathological type, a yeyunostomy using the Witzell technique was carried out with either local or general anesthesia at a 15 to 20 cm. of the Treitz angle. To facilitate the fixation of the catheter and to avoid the stenosis of the jejunum we have incorporated, as an original technical detail, the proximal serous section with cold scalpel in about 4 cm, that is to say in the sector to be tunneled. RESULTS: There was not mortality in relation to the yeyunostomy. Among the minor complications we emphasize the abdominal distension, colic pain and diarrhea, situations that were reverted, controlling the debit and the feeding characteristics. This approach could be maintained for period of 2 months and in some cases at home. CONCLUSIONS: We emphasize the great importance of the enteral feeding for yeyunostomy, for its of easy handling, security and low cost that, together with the suggested technical detail, has allowed us to obtain a deeding road almost without inherent complications.

Yeyunostomía de alimentación en cirugía. Contribución técnica y experiencia. / [Jejunostomy for enteral feeding in surgery. Technical contribution and experience]

The necessity to maintain the nutritional integrity in patients subjected to major surgery of the superior digestive tract has been broadly accepted. The enteral nutrition for yeyunostomy is accepted as more physiologic, sure and effective than the parenteral one. MATERIALS AND METHOD: 171 yeyunostomies were indicated in: 151 patients with malignant neoplasm of the superior digestive tract, 15 with infected pancreatic necrosis, 3 bile-duodenum-pancreatic traumatisms and in 1 stenosis for gastroesophagic reflux. Depending on the pathological type, a yeyunostomy using the Witzell technique was carried out with either local or general anesthesia at a 15 to 20 cm. of the Treitz angle. To facilitate the fixation of the catheter and to avoid the stenosis of the jejunum we have incorporated, as an original technical detail, the proximal serous section with cold scalpel in about 4 cm, that is to say in the sector to be tunneled. RESULTS: There was not mortality in relation to the yeyunostomy. Among the minor complications we emphasize the abdominal distension, colic pain and diarrhea, situations that were reverted, controlling the debit and the feeding characteristics. This approach could be maintained for period of 2 months and in some cases at home. CONCLUSIONS: We emphasize the great importance of the enteral feeding for yeyunostomy, for its of easy handling, security and low cost that, together with the suggested technical detail, has allowed us to obtain a deeding road almost without inherent complications.

[Amplifying right colectomy: place in the treatment of obstructive proximal left colon cancer]. / Colectomía derecha ampliada. Lugar en el tratamiento del cáncer de colon izquierdo proximal obstructivo.

The results obtained about nineteen (19) patients operated by left colon cancer with variable grade obstruction have been analysed. Seventeen (17) patients operated due to obstructive left colon cancer situated: five (5) in distal transverse colon, other five (5) at splenic flexure and seven (7) in proximal descending colon but three of them with right synchronic neoplasias. The remaining two (2) that showed a cancer located at splenic flexure and the other one in proximal descending colon were reoperated three weeks later than a transverse colostomy had been performed owing to an obstructive condition. One patient had to be reoperated because a generalised peritonitis from a fistula with partial disruption on end to end ileo-colic anastomosis. Exteriorization of both ends was carried out with favourable evolution and subsequent reanastomosis. An exteriorized patient by splenic flexure cancer also had to be drained ten days later for a retroperitoneal abscess through a percutaneous puncture and a lesion grade 1 in lower pole of spleen was resolved with electrofulguration. No patient has showed invalidating diarrhea and all themselves have been stabilised with two or three stools daily about two month after surgery. Amplifying right colectomy is a safe procedure with low surgical morbimortality and take privileged place in the treatment of the patients undergoing synchronical neoplasias and/or carcinomas associated with polyps, specially in all those cases when a variable grade of obstruction have occurred.

[Zenker diverticulum: therapeutic approach]. / Diverticulo de Zenker: conducta terapéutica.

BACKGROUND: Pharyngoesophageal or Zenker diverticula are a few frequent pathology that could represent between 1 and 3% of the patients with dysphagia and their physiopathology even at present is scarcity clear. OBJECTIVE: Therapeutic procedures results about this pathology were analyzed. SETTING: Caraffa and Sucre Clinic. DESIGN: Retrospective observational study. METHOD: It analyzed 13 patients operated by Zenker diverticula 9 of which were male and 4 were female sex with an average age of 55.6 years. Dysphagia occurred in 100% of the cases. Besides clinical finding the diagnosis was made evident by esophageal X-ray with contrast medium and endoscopy. Diverticulectomy by one stage through a left cervicotomy was the surgical procedure of choice. RESULTS: There was no surgical mortality. Related with morbility 2 patients presented fistulas managed medically and in other 2 patients abscesses of surgical wound occurred. The follow-up was carried on 6 months, 4 and 7 years respectively without relapses and with a good posterior evolution. CONCLUSIONS: Based on our short experience and the results attained we think the treatment of Zenker or pharyngoesophageal diverticulum by diverticulectomy through a left cervicotomy is safe and effective procedure to control this pathology.

Diverticulo de Zenker: conducta terapéutica. / [Zenker diverticulum: therapeutic approach]

BACKGROUND: Pharyngoesophageal or Zenker diverticula are a few frequent pathology that could represent between 1 and 3

of the patients with dysphagia and their physiopathology even at present is scarcity clear. OBJECTIVE: Therapeutic procedures results about this pathology were analyzed. SETTING: Caraffa and Sucre Clinic. DESIGN: Retrospective observational study. METHOD: It analyzed 13 patients operated by Zenker diverticula 9 of which were male and 4 were female sex with an average age of 55.6 years. Dysphagia occurred in 100

of the cases. Besides clinical finding the diagnosis was made evident by esophageal X-ray with contrast medium and endoscopy. Diverticulectomy by one stage through a left cervicotomy was the surgical procedure of choice. RESULTS: There was no surgical mortality. Related with morbility 2 patients presented fistulas managed medically and in other 2 patients abscesses of surgical wound occurred. The follow-up was carried on 6 months, 4 and 7 years respectively without relapses and with a good posterior evolution. CONCLUSIONS: Based on our short experience and the results attained we think the treatment of Zenker or pharyngoesophageal diverticulum by diverticulectomy through a left cervicotomy is safe and effective procedure to control this pathology.

Nuestra experiencia en colecistitis aguda por videolaparoscopía: aspectos tácticos y técnicos / Laparoscopic cholecystectomy for acute cholecystitis: our experience, tactical and technical aspects

Antecedentes: La colecistectomía por vía laparoscópica ha sido progresivamente aceptada para el tratamiento de las CA. Ciertos aspectos tácticos y técnicos a nuestro entender no han sido bien precisados. Objetivo: Definir dificultades operatorias, sobre todo en relación al tiempo evolutivo del cuadro flogósico agudo y a las características anatomopatológicas. destacar el valor del concepto de Pribran. Lugar de aplicación: Departamento de Cirugía General, de dos Instituciones Médicas Privadas. Diseño: Estudio observacional retrospectivo. Población: Ciento treinta y cinco pacientes sobre un total de 820 colecistectomías por video laparoscopía fueron operadas de una CA, excluyendo sólo los pacientes críticos. Para la indicación quirúrgica, no se tuvo en cuenta el tiempo de evolución de los síntomas, la edad ni el peso. A tres pacientes ictéricos se les practicó previamente una CPER con papiloesfinterectomía más litotomía. Método: Revisión de un protocolo diseñado en 1990 para la cirugía biliar por video laparoscopía, hasta diciembre de 1996, de los pacientes con CA. Se destacan hallazgos ecográficos, anatomopatológicos y el tiempo de evolución del cuadro clínico agudo preoperatorio, tratando de correlacionarlo con las dificultades intraoperatorias y los resultados finales. Resultados: No hubo mortalidad, ni morbilidad mayor, excepto por un absceso retroperitoneal de etiología poco clara. Nueve pacientes (6,6 por ciento) fueron convertidos: dos por sangrado de la arteria cística, uno por gangrena de la pared vesicular y sangrado, dos por litiasis de la vía biliar principal, dos por fallas técnicas del equipo y dos por hemorragia a partir del lecho vesicular ocasionadas por traumatismo al intentar disección de la placa. Este fue el principal estímulo para realizar cuarenta colecistectomías parciales siguiendo el concepto de Pribran con excelentes resultados. Las mismas fueron realizadas en su mayoría (35/40) en pacientes con una colecistitis crónica activa evolucionada. Conclusiones: Los resultados del presente trabajo demuestran que las CA pueden resolverse con seguridad en la gran mayoría de los casos por video cirugía independientemente del tiempo evolutivo del proceso flogósico agudo, debiendo tener presente la colecistectomía parcial a lo Pribran para evitar el sangrado y la lesión del parénquima hepático al disecar la vesícula de la placa...

Nuestra experiencia en colecistitis aguda por videolaparoscopía: aspectos tácticos y técnicos / Laparoscopic cholecystectomy for acute cholecystitis: our experience, tactical and technical aspects

Antecedentes: La colecistectomía por vía laparoscópica ha sido progresivamente aceptada para el tratamiento de las CA. Ciertos aspectos tácticos y técnicos a nuestro entender no han sido bien precisados. Objetivo: Definir dificultades operatorias, sobre todo en relación al tiempo evolutivo del cuadro flogósico agudo y a las características anatomopatológicas. destacar el valor del concepto de Pribran. Lugar de aplicación: Departamento de Cirugía General, de dos Instituciones Médicas Privadas. Diseño: Estudio observacional retrospectivo. Población: Ciento treinta y cinco pacientes sobre un total de 820 colecistectomías por video laparoscopía fueron operadas de una CA, excluyendo sólo los pacientes críticos. Para la indicación quirúrgica, no se tuvo en cuenta el tiempo de evolución de los síntomas, la edad ni el peso. A tres pacientes ictéricos se les practicó previamente una CPER con papiloesfinterectomía más litotomía. Método: Revisión de un protocolo diseñado en 1990 para la cirugía biliar por video laparoscopía, hasta diciembre de 1996, de los pacientes con CA. Se destacan hallazgos ecográficos, anatomopatológicos y el tiempo de evolución del cuadro clínico agudo preoperatorio, tratando de correlacionarlo con las dificultades intraoperatorias y los resultados finales. Resultados: No hubo mortalidad, ni morbilidad mayor, excepto por un absceso retroperitoneal de etiología poco clara. Nueve pacientes (6,6 por ciento) fueron convertidos: dos por sangrado de la arteria cística, uno por gangrena de la pared vesicular y sangrado, dos por litiasis de la vía biliar principal, dos por fallas técnicas del equipo y dos por hemorragia a partir del lecho vesicular ocasionadas por traumatismo al intentar disección de la placa. Este fue el principal estímulo para realizar cuarenta colecistectomías parciales siguiendo el concepto de Pribran con excelentes resultados. Las mismas fueron realizadas en su mayoría (35/40) en pacientes con una colecistitis crónica activa evolucionada. Conclusiones: Los resultados del presente trabajo demuestran que las CA pueden resolverse con seguridad en la gran mayoría de los casos por video cirugía independientemente del tiempo evolutivo del proceso flogósico agudo, debiendo tener presente la colecistectomía parcial a lo Pribran para evitar el sangrado y la lesión del parénquima hepático al disecar la vesícula de la placa... (AU)