The evolution of the treatment of esophageal achalasia. Chronicle of a 35-year journey.

Over the last few decades, significant improvement has been made in both the evaluation and treatment of esophageal achalasia. The Chicago classification, today in version 4.0, is now the standard for diagnosis of achalasia, providing a classification into 3 subtypes with important therapeutic and prognostic implications. Therapy, which was at first mostly limited to pneumatic dilatation, today includes minimally invasive surgery and peroral endoscopic myotomy, allowing for a more tailored approach to patients and better treatment of recurrent symptoms. This review chronicles my personal experience with achalasia over the last 35 years, describing the progress made in the treatment of patients with achalasia.

Ausencia de toracotomía mediante la sutura manual intratorácica y la extracción transabdominal de la pieza quirúrgica durante la esofagectomía robótica de Ivor Lewis / Absence of thoracotomy by intrathoracic manual suture and transabdominal removal of surgical specimen during Ivor Lewis robotic esophagectomy

En el tratamiento quirúrgico del cáncer de esófago, la cirugía robótica permite realizar una anastomosis manual intratorácica de manera más sencilla, rápida y cómoda para el cirujano que la cirugía abierta y la cirugía mínimamente invasiva tradicional. Con ello evitamos el uso de instrumentos de autosutura, algunos de los cuales precisan una pequeña toracotomía para su introducción. No obstante, la extracción de la pieza exige la práctica de esa toracotomía, de tamaño variable, y que puede asociar dolor torácico intenso. Describimos una sencilla modificación técnica del Ivor Lewis robótico clásico que permite la extracción de la pieza quirúrgica por una mínima incisión abdominal, evitando la necesidad de fracturar costillas de forma controlada, así como las posibles secuelas de practicar una incisión en la pared torácica.(AU)

In the surgical treatment of esophageal cancer, robotic surgery allows performing an intrathoracic hand-sewn anastomosis in a simpler, faster and more comfortable way for the surgeon than open surgery and traditional minimally invasive surgery. With this, we avoid the use of self-suture instruments, some of which require a small thoracotomy for their introduction. However, the retrieval of the specimen requires the practice of this thoracotomy, of variable size, that can be associated with intense chest pain. We describe a technical modification of the classic robotic Ivor Lewis that allows removal of the surgical piece through a minimal abdominal incision, thus avoiding controlled rib fracture, as well as the possible sequelae of making an incision in the chest wall.(AU)

Reemplazo esofágico mínimamente invasivo con tubo de Akiyama en un paciente pediátrico con quemadura esofágica / Minimally invasive esophageal replacement with Akiyama tube in a pediatric patient with esophageal burn

Introducción. La ingesta de cáusticos continúa siendo un problema de salud pública en los países en vía de desarrollo, por lo que a veces es necesario realizar un reemplazo esofágico en estos pacientes. Aún no existe una técnica estandarizada para este procedimiento. Caso clínico. Masculino de 10 años con estenosis esofágica por ingesta de cáusticos, quien no mejoró con las dilataciones endoscópicas. Se realizó un ascenso gástrico transhiatal por vía ortotópica mediante cirugía mínimamente invasiva como manejo quirúrgico definitivo .Discusión. Actualmente existen varios tipos de injertos usados en el reemplazo esofágico. La interposición colónica y gástrica son las que cuentan con mayores estudios, mostrando resultados similares. Conclusiones. La elección del tipo y posición del injerto debe ser individualizada, tomando en cuenta las características de las lesiones y la anatomía de cada paciente para aumentar la tasa de éxito.

Introduction. The ingestion of caustics continues to be a public health problem in developing countries, which is why sometimes is necessary to perform an esophageal replacement in these patients. There is still no standardized technique for this procedure. Clinical case. A 10-year-old male with esophageal stricture due to caustic ingestion, who did not improve with endoscopic dilations. A laparoscopic transhiatal gastric lift was performed orthotopically as definitive surgical management using minimally invasive surgery. Discussion. Currently there are several types of grafts used in esophageal replacement. Colonic and gastric interposition are the ones that have the most studies, showing similar results. Conclusions. Choice of type and position of the graft must be individualized, taking into account the characteristics of the lesions and anatomy of each patient, in order to increase the success rate.

The effect of perioperative mmunonutrition on patients undergoing esophagectomy: a systematic review and updated meta-analysis / Efectos de la inmunonutrición perioperatoria en pacientes sometidos a esofagectomía: revisión sistemática y metaanálisis actualizado

Background: immunonutrition has been introduced and proposed to have positive modulating effects on inflammatory and immune responses in surgical patients. This meta-analysis aimed to assess whether perioperative enteral immunonutrition (EIN) can reduce postoperative complications or reduce inflammatory responses in esophageal cancer (EC) patients undergoing esophagectomy. Methods: PubMed, Embase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of EIN before and/or after surgery in EC patients undergoing esophagectomy were identified. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. Results: ten RCTs involving 1,052 patients were included in the meta-analysis, including 573 patients in the EIN group and 479 patients in the enteral nutrition (EN) group. Overall, no significant difference was observed between the two groups in the incidence of postoperative pneumonia, surgical site infection, intra-abdominal abscess, septicemia, and urinary tract infection. No significant incidence of postoperative anastomotic leakage, acute respiratory distress syndrome (ARDS), and in-hospital mortality was found. Conclusions: perioperative enteral immunonutrition did not reduce the incidence of infectious complications and anastomotic leakage in EC patients undergoing esophagectomy, nor did it reduce postoperative CRP and IL-6, but did not increase in-hospital mortality.(AU)

Antecedentes: se ha introducido y propuesto la inmunonutrición para regular activamente la inflamación y la respuesta inmune en pacientesquirúrgicos. El presente metaanálisis fue diseñado para evaluar si la inmunonutrición enteral perioperatoria (EIN, por sus siglas en inglés) puedereducir las complicaciones postoperatorias o la inflamación en pacientes con cáncer de esófago (CE) sometidos a esofagectomía.Métodos: se realizó una búsqueda sistemática en las bases de datos de PubMed, Embase, Web of Science, EBSCO y Cochrane Library. Se evaluóel efecto de la EIN preoperatoria y/o postoperatoria en un ensayo aleatorizado controlado (RCT) en pacientes con cáncer de esófago sometidosa esofagectomía. Dos investigadores buscaron independientemente artículos, extrajeron datos y evaluaron la calidad de los artículos incluidos.Resultados: el metanálisis incluyó diez ensayos controlados aleatorios en los que participaron 1.052 pacientes, de los cuales 573 fueronincluidos en el grupo EIN y 479, en el grupo de nutrición enteral (NE). En general, no hubo diferencia significativa en la incidencia de neumoníapostoperatoria, infección del sitio quirúrgico, absceso intraperitoneal, sepsis e infección del tracto urinario entre los dos grupos. No hubo diferenciasignificativa en la incidencia de fístula anastomótica postoperatoria, síndrome de distrés respiratorio agudo (SDRA) y mortalidad hospitalaria.Conclusión: la inmunonutrición enteral perioperatoria no puede reducir la incidencia de complicaciones infecciosas postoperatorias y fístulasanastomóticas, ni la PCR postoperatoria ni la IL-6. Pero no aumentó la mortalidad hospitalaria.(AU)

The effect of perioperative immunonutrition on patients undergoing esophagectomy: a systematic review and updated meta-analysis.

Introduction: Background: immunonutrition has been introduced and proposed to have positive modulating effects on inflammatory and immune responses in surgical patients. This meta-analysis aimed to assess whether perioperative enteral immunonutrition (EIN) can reduce postoperative complications or reduce inflammatory responses in esophageal cancer (EC) patients undergoing esophagectomy. Methods: PubMed, Embase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of EIN before and/or after surgery in EC patients undergoing esophagectomy were identified. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. Results: ten RCTs involving 1,052 patients were included in the meta-analysis, including 573 patients in the EIN group and 479 patients in the enteral nutrition (EN) group. Overall, no significant difference was observed between the two groups in the incidence of postoperative pneumonia, surgical site infection, intra-abdominal abscess, septicemia, and urinary tract infection. No significant incidence of postoperative anastomotic leakage, acute respiratory distress syndrome (ARDS), and in-hospital mortality was found. Conclusions: perioperative enteral immunonutrition did not reduce the incidence of infectious complications and anastomotic leakage in EC patients undergoing esophagectomy, nor did it reduce postoperative CRP and IL-6, but did not increase in-hospital mortality.

Introducción: Antecedentes: se ha introducido y propuesto la inmunonutrición para regular activamente la inflamación y la respuesta inmune en pacientes quirúrgicos. El presente metaanálisis fue diseñado para evaluar si la inmunonutrición enteral perioperatoria (EIN, por sus siglas en inglés) puede reducir las complicaciones postoperatorias o la inflamación en pacientes con cáncer de esófago (CE) sometidos a esofagectomía. Métodos: se realizó una búsqueda sistemática en las bases de datos de PubMed, Embase, Web of Science, EBSCO y Cochrane Library. Se evaluó el efecto de la EIN preoperatoria y/o postoperatoria en un ensayo aleatorizado controlado (RCT) en pacientes con cáncer de esófago sometidos a esofagectomía. Dos investigadores buscaron independientemente artículos, extrajeron datos y evaluaron la calidad de los artículos incluidos. Resultados: el metanálisis incluyó diez ensayos controlados aleatorios en los que participaron 1.052 pacientes, de los cuales 573 fueron incluidos en el grupo EIN y 479, en el grupo de nutrición enteral (NE). En general, no hubo diferencia significativa en la incidencia de neumonía postoperatoria, infección del sitio quirúrgico, absceso intraperitoneal, sepsis e infección del tracto urinario entre los dos grupos. No hubo diferencia significativa en la incidencia de fístula anastomótica postoperatoria, síndrome de distrés respiratorio agudo (SDRA) y mortalidad hospitalaria. Conclusión: la inmunonutrición enteral perioperatoria no puede reducir la incidencia de complicaciones infecciosas postoperatorias y fístulas anastomóticas, ni la PCR postoperatoria ni la IL-6. Pero no aumentó la mortalidad hospitalaria.

Early postoperative outcomes of the esophagectomy minimally invasive in esophageal cancer / Resultados pós-operatórios precoces da esofagectomia minimamente invasiva no câncer do esôfago

ABSTRACT BACKGROUND: The incidence of esophageal cancer is high in some regions and the surgical treatment requires reference centers, with high volume, to make surgery feasible. AIMS: To evaluate patients undergoing minimally invasive esophagectomy by thoracoscopy in prone position for the treatment of esophageal cancer and to recognize the experience acquired over time in our service after the introduction of this technique. METHODS: From January 2012 to August 2021, all patients who underwent the minimally invasive esophagectomy for esophageal cancer were retrospectively analyzed. In order to assess the factors associated with the predefined outcomes as fistula, pneumonia, and intrahospital death, we performed univariate and multivariate logistic regression analyses, accounting for age as an important factor. RESULTS: Sixty-six patients were studied, with mean age of 59.5 years. The main histological type was squamous cell carcinoma (81.8%). The incidence of postoperative pneumonia and fistula was 38% and 33.3%, respectively. Eight patients died during this period. The patient's age, T and N stages, the year the procedure was performed, and postoperative pneumonia development were factors that influenced postoperative death. There was a 24% reduction in the chance of mortality each year, associated with the learning curve of our service. CONCLUSIONS: The present study presented the importance of the team's experience and the concentration of the treatment of patients with esophageal cancer in reference centers, allowing to significantly improve the postoperative outcomes.

RESUMO RACIONAL: A incidência do câncer de esôfago é elevada em algumas regiões e o tratamento cirúrgico requer centros de referência com alto volume para viabilizar a cirurgia. OBJETIVOS: Avaliar os pacientes submetidos à esofagectomia minimamente invasiva, por toracoscopia na posição prona, para o tratamento do câncer de esôfago e conhecer a experiência adquirida ao longo do tempo em nosso serviço após a introdução desta técnica. MÉTODOS: De janeiro de 2012 a agosto de 2021, foram analisados retrospectivamente todos os pacientes submetidos à esofagectomia minimamente invasiva para câncer de esôfago. Para avaliar os fatores associados aos desfechos predefinidos de fístula, pneumonia e óbito intra-hospitalar, realizamos análises de regressão logística univariada e multivariada considerando a idade como fator importante. RESULTADOS: Foram estudados 66 pacientes, com idade média de 59,5 anos. O tipo histológico mais frequente foi carcinoma espinocelular (81,8%). A incidência de pneumonia pós-operatória e fístula foi de 38% e 33,3%, respectivamente. Oito pacientes morreram durante este período. A idade do paciente, os estágios T e N, o ano da realização do procedimento e o desenvolvimento de pneumonia pós-operatória foram fatores que influenciaram o óbito. Houve uma redução de 24% na chance de mortalidade, ano a ano, associada à curva de aprendizado do nosso serviço. CONCLUSÕES: O presente estudo mostrou a importância da experiência da equipe e da concentração do tratamento de pacientes com câncer de esôfago em centros de referência, possibilitando melhorar significativamente o resultado pós-operatório.

Caracterización clinicoepidemiológica, diagnóstica e histopatológica de pacientes tratados con esofagectomía por cáncer de esófago / Clinical epidemiological, diagnostic, histological and pathological characterization of patients treated with esophagectomy due to esophagus cancer

Introducción: El cáncer de esófago se manifiesta clínicamente en etapas avanzadas y presenta gran letalidad. Objetivo: Caracterizar a los pacientes operados de cáncer de esófago según variables epidemiológicas, clínicas, diagnósticas e histopatológicas. Métodos: Se realizó un estudio observacional, descriptivo y transversal de 87 pacientes con cáncer de esófago, operados en el Servicio de Cirugía General del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora de Santiago de Cuba, en el periodo 2014-2018. Resultados: Dicha afección predominó en pacientes del sexo masculino (94,2 %) entre los 65 y 74 años de edad (37,9 %); el tipo histológico más frecuente fue el carcinoma epidermoide (89,6 %) y la localización en el tercio medio (49,4 %). Los hábitos tóxicos que primaron fueron el tabaquismo (87,4 %) y el consumo de alcohol (75,8 %). La disfagia y la pérdida de peso se manifestaron en 73,5 y 66,6 % de la serie, respectivamente. El diagnóstico se realizó mediante imágenes, tales como esofagograma, tomografía contrastada de tórax, abdomen y pelvis; así como por medio de endoscopia y biopsia. Conclusiones: Se demostró que los hombres son los más afectados y es más frecuente el diagnóstico en mayores de 60 años de edad. Se observó el vínculo con el hábito de fumar y el consumo de alcohol. La disfagia es el síntoma más común y tardío de la enfermedad. El estudio de las características clínico-histológicas de los pacientes con cáncer de esófago permite un adecuado enfoque diagnóstico de esta afección, así como el desarrollo de acciones de salud preventivas sobre los principales factores de riesgo identificados.

Introduction: The esophagus cancer is clinically manifested in advanced stages and presents great lethality. Objective: To characterize the patients operated on esophagus cancer according to epidemiological, clinical, diagnostic, histological and pathological variables. Methods: An observational, descriptive and cross-sectional study of 87 patients with esophagus cancer was carried out; they were operated in the General Surgery Service of Saturnino Lora Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba, in the period 2014-2018. Results: This affection prevailed in patients from the male sex (94.2 %) between the 65 and 74 years (37.9 %); the most frequent histhologic type was the squamous cell carcinoma (89.6 %) and the localization in the mean third (49.4 %). The toxic habits that prevailed were nicotine addiction (87.4 %) and consumption of alcohol (75.8 %). The dysphagia and loss of weight showed in 73.5 and 66.6 % of the series, respectively. The diagnosis was carried out by means of images, such as esophagogram, chest, abdomen and pelvis contrast tomography, as well as by means of endoscopy and biopsy. Conclusions: It was demonstrated that men are the most affected and it is more frequent the diagnosis in those over 60 years. The link with the habit of smoking and consumption of alcohol was observed. The dysphagia is the most common and late symptom of the disease. The study of clinical, histological and pathological characteristics of patients with esophagus cancer allows an appropriate diagnostic approach of this affection, as well as the development of preventive health actions about the main identified risk factors.

Complicaciones de la esofagectomía por cáncer de esófago / Complications of Esophagectomy for Esophageal Cancer

Introducción: La esofagectomía es uno de los procedimientos con más alta morbilidad posoperatoria en cirugía oncológica digestiva. Objetivo: Describir las complicaciones relacionadas con la esofagectomía subtotal programada según variables de interés. Métodos: Se realizó un estudio descriptivo y transversal en los Servicios de Cirugía General de los hospitales "Saturnino Lora" y "Juan Bruno Zayas" de Santiago de Cuba, desde 2010 hasta 2019. La población estuvo conformada por 81 pacientes, de la cual se reclutó una muestra aleatoria de 68 enfermos sometidos a esofagectomía subtotal programada por cáncer de esófago. Fueron investigadas las siguientes variables: presencia de complicaciones posoperatorias y tipo de técnica quirúrgica utilizada. Además, se clasificaron en grados según Dindo Clavien. Resultados: Todos los enfermos fueron operados por técnica abierta mediante esofagectomía subtotal programada, donde la resección mediante la técnica de Ivor-Lewis se realizó en el 69,2 por ciento. Para todas las técnicas quirúrgicas empleadas predominó la atelectasia (39,7 por ciento) como complicación posquirúrgica, y entre las infecciosas la neumonía en 30 enfermos (44,1 por ciento), mientras que para las complicaciones quirúrgicas no infecciosas el neumotórax fue mayormente incidente, para el 25,0 por ciento. El mayor número de complicaciones se ubicó en el grado II de Dindo Clavien. Conclusiones: La presencia de complicaciones posquirúrgicas de la enfermedad es notable, en correspondencia a lo reflejado por la literatura médica. Existió relación significativa entre la presencia del hábito de fumar, de enfermedad pulmonar obstructiva crónica y la de toracotomía con algunas de las complicaciones encontradas(AU)

Introduction: Esophagectomy is one of the procedures with the highest postoperative morbidity in digestive cancer surgery. Objective: To describe the complications related to scheduled subtotal esophagectomy according to variables of interest. Methods: A descriptive and cross-sectional study was carried out in the General Surgery Services at Saturnino Lora and Juan Bruno Zayas hospitals in Santiago de Cuba, from 2010 to 2019. The population consisted of 81 patients, out of which a random sample of 68 patients undergoing elective subtotal esophagectomy for esophageal cancer was selected. The variables investigated were presence of postoperative complications and type of surgical technique used. In addition, they were classified in grades according to Clavien-Dindo. Results: All the patients were operated by open technique by programmed subtotal esophagectomy, the resection by the Ivor-Lewis technique was performed in 69.2 percent. For all the surgical techniques used, atelectasis (39.7 percent) prevailed as a postsurgical complication, and among the infectious complications, pneumonia prevailed in 30 patients (44.1 percent), while for non-infectious surgical complications, pneumothorax was mostly incidental for 25.0 percent. The highest number of complications was in Clavien-Dindo grade II. Conclusions: The presence of post-surgical complications of the disease is notable, corresponding to what is reflected in the medical literature. There was significant relationship between the presence of smoking, chronic obstructive pulmonary disease and thoracotomy with some of the complications found(AU)

Predictores de complicaciones y muerte en pacientes con esofagectomía por cáncer de esófago / Predictors of complications and death in patients with esophagectomy due to esophagus cancer

Introducción: La morbilidad y la mortalidad continúan siendo altas a escala mundial como consecuencia de la esofagectomía programada por cáncer de esófago. Objetivo: Identificar los factores predictores de complicaciones posquirúrgicas y de muerte, la estadía hospitalaria y las causas de muerte en la población estudiada. Método: Se efectuó un estudio de cohorte de 81 pacientes con diagnóstico de cáncer de esófago, atendidos en los hospitales Saturnino Lora y Dr. Juan Bruno Zayas Alfonso de la provincia de Santiago de Cuba desde enero de 2010 hasta diciembre de 2019, de los cuales se escogió una muestra aleatoria de 68. Para identificar los factores predictivos asociados con las complicaciones y la mortalidad se definieron 2 cohortes de enfermos: los expuestos y los no expuestos a los factores de interés, tales como la realización de toracotomía, las reintervenciones, además de las complicaciones médicas y quirúrgicas infecciosas. Se utilizó el método estadístico de bondad de ajuste de Hosmer-Lemeshow con un nivel de significación α= 0,10. Resultados: Si se realiza toracotomía, la probabilidad de que se desarrollen complicaciones quirúrgicas infecciosas es 2,3 veces mayor que si no se lleva a cabo el proceder; asimismo, el riesgo de fallecer por dichas complicaciones (p=0,024), en contraposición a cuando no se presentan, asciende a 370,0 % (IC 90 %: 1,5-14,8). Conclusión: La realización de toracotomía se establece como factor predictor de complicaciones y la presencia de reintervenciones y de complicaciones médicas y quirúrgicas infecciosas como predictores de muerte en la esofagectomía programada.

Introduction: Morbidity and mortality continue being high worldwide as consequence of the esophagectomy programmed due to esophagus cancer. Objective: To identify the predictor factors of postsurgical and death complications, hospitalization and death causes in the studied population. Method: A cohort study of 81 patients with diagnosis of esophagus cancer was carried out. They were assisted in Saturnino Lora and Dr. Juan Bruno Zayas Alfonso hospitals in the province of Santiago de Cuba from January, 2010 to December, 2019, of which a random sample of 68 was chosen. To identify the prediction factors associated with the complications and mortality 2 cohorts of sick patients were defined: the exposed and those not exposed to interest factors, such as the thoracotomy realization, reinterventions, besides the infectious medical and surgical complications. The statistical method of Hosmer-Lemeshow was used with a significance level of α = 0,10. Results: If thoracotomy is carried out, the probability that infectious surgical complications are developed is 2.3 times more that if it is not carried out; also, the risk of dying due to this complications (p=0.024), in opposition to when they are not presented, ascends to 370.0 % (IC 90 %: 1.5-14.8). Conclusion: The thoracotomy realization is established as predictor factor of complications and the presence of reinterventions and infectious medical and surgical complications as death predictors in the programmed esophagectomy.

Caracterización de pacientes con cáncer de esófago operados mediante esofagectomía programada

RESUMEN Introducción: El cáncer de esófago es la octava neoplasia diagnosticada con más frecuencia a nivel mundial, con 456 mil nuevos casos al año. Objetivo: Caracterizar a pacientes con cáncer de esófago que se les realiza esofagectomía subtotal programada. Métodos: Se realizó un estudio observacional, descriptivo de una serie de casos en los servicios de cirugía general de los Hospitales Provincial "Saturnino Lora" y General "Juan B. Zayas" de Santiago de Cuba desde 2010 al 2019. El universo estuvo conformado por 81 pacientes con diagnóstico de cáncer de esófago, de los cuales se seleccionaron 68 por cumplir con los criterios de inclusión. Fueron investigadas variables epidemiológicas, clínicas y quirúrgicas. Se calcularon porcentajes, media aritmética y desviación estándar. Resultados: Se observó predominio de los hombres (88,2 %); dentro de los factores epidemiológicos hubo predominio del hábito alcohólico (75,0 %) y del tabaquismo (58,8 %), la disfagia fue el síntoma más frecuente (48 enfermos). Las lesiones tumorales localizadas en el tercio medio e inferior fueron las más frecuentes. Predominó el carcinoma epidermoide en 52 pacientes y la localización del tumor en el tercio medio esofágico. En cuanto al tipo de resección quirúrgica la más utilizada fue la de McKeown (87,2 %). Conclusión: El cáncer de esófago es más frecuente en varones de la tercera década de la vida, fumadores, consumidores de alcohol y con mal estado nutricional. El patrón histológico predominante es el carcinoma epidermoide vegetante. La esofagectomía transhiatal es la variante técnica más utilizada en su tratamiento quirúrgico.

ABSTRACT Introduction: Esophageal cancer is the eighth most frequently diagnosed neoplasm worldwide with 456 thousand new cases per year. Objective: To characterize patients with esophageal cancer who undergo programmed subtotal esophagectomy. Methods: An observational, descriptive study of a case series was carried out in the general surgery services of the Provincial Hospital "Saturnino Lora" and General "Juan B. Zayas" of Santiago de Cuba from 2010 to 2019. The universe was made up of 81 patients diagnosed with esophageal cancer, of which 68 were selected agreeing inclusion criteria. Epidemiological, clinical and surgical variables were investigated. Percentages, arithmetic mean and standard deviation were calculated. Results: A predominance of men was observed (88.2 %); among the epidemiological factors, there was a predominance of alcoholic habit (75.0 %) and smoking (58.8 %), dysphagia in 48 patients was the most frequent symptom. Tumor lesions located in the middle and lower third were the most frequent. Squamous cell carcinoma predominated in 52 patients and the tumor was located in the middle third of the esophagus. Regarding the type of surgical resection, the most used was that of McKeown (87.2 %). Conclusion: Esophageal cancer is more frequent in men in the third decade of life, smokers, chronic alcoholics and poor nutritional status. The predominant histological pattern is vegetative squamous cell carcinoma. Transhiatal esophagectomy is the most widely used technical variant in its surgical treatment.

Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap / Tratamento da fístula anastomótica cervical refratária após esofagectomia utilizando retalho miocutâneo do músculo peitoral maior

Abstract Introduction A refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear. Objective This study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review. Methods Six patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed. Results All patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months. Conclusion The satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.

Resumo Introdução Uma fístula anastomótica cervical refratária, que permanece sem cicatrização por mais de 2 meses sob cuidados conservadores, afeta gravemente a qualidade de vida do paciente e potencialmente causa estenose anastomótica após a cicatrização da fístula. É amplamente aceito que as fístulas anastomóticas cervicais refratárias devem ser submetidas a tratamentos mais agressivos. No entanto, quando e qual intervenção cirúrgica deve ser considerada ainda é incerto. Objetivo Avaliar o papel do retalho miocutâneo do peitoral maior no manejo de fístula anastomótica cervical refratárias com base em nossa experiência de 6 casos e uma revisão da literatura. Métodos Foram incluídos no estudo seis pacientes diagnosticados com fístula anastomótica cervical refratária após esofagectomia tratados com transferência de retalho miocutâneo do peitoral maior. Os dados clínicos, detalhes cirúrgicos e resultado do tratamento foram analisados retrospectivamente. Resultados Todos os pacientes sobreviveram às cirurgias. Um paciente com defeito anastomótico circunferencial, resultante da exploração cirúrgica, desenvolveu uma fístula leve no sítio neoanastomótico no 5° dia de pós-operatório, que foi resolvida após 7 dias de tratamento conservador. Esse paciente desenvolveu uma estenose anastomótica parcialmente aliviada por uma dilatação endoscópica anastomótica. Todos os outros 5 pacientes tiveram recuperações sem intercorrências após as cirurgias, restabeleceram a ingestão oral 10 ou 15 dias após a operação e toleraram dietas normais sem sequelas subsequentes no seguimento. Um paciente desenvolveu recorrência local e pulmonar e morreu 15 meses após a cirurgia, enquanto os outros 5 pacientes sobreviveram com bom controle tumoral durante o seguimento de 25 a 53 meses. Conclusão O resultado satisfatório do tratamento em nosso estudo demonstra que a reconstrução com o retalho miocutâneo do peitoral maior é uma modalidade de manejo confiável para as fístula anastomótica cervical refratárias após a esofagectomia, particularmente nos pacientes que apresentaram falha após o tratamento conservador das feridas cirúrgicas e com fechamento repetido delas.

Esophagocele due to two times caustic ingestions: resection through videothoracoscopy / Esofagocele por duas ingestões cáusticas: ressecção por videotoracoscopia

ABSTRACT BACKGROUND: Caustic ingestion is still a health problem of utmost importance in the West. In developing countries, this incident remains at increase and it is associated with unfavorable factors like social, economic, and educational handicaps, besides a lack of prevention. Esophagocele is a rare consequence of caustic ingestion. AIM: We aimed to describe a patient with multiple caustic ingestions who presented an esophagocele resected by videothoracoscopy. METHODS: A woman ingested caustic soda when she was only 17 years old in a suicidal attempt during a depressive crisis. Initially, she was submitted to a retrosternal esophagocoloplasty with the maintenance of her damaged esophagus. After 1 year of this first surgery, she ingested caustic soda again in a new suicidal attempt. Her transposed large bowel in the first surgery became narrow, being replaced in a second surgery by a retrosternal esophagogastroplasty. Still, at the second surgery, her damaged esophagus remained in its original position in the posterior mediastinum. However, after 5 years, she developed an esophagocele. RESULTS: The esophagocele was resected through videothoracoscopy in a prone position, employing four trocars. The postoperative was uneventful. CONCLUSION: Esophageal exclusion must always be recorded because esophagocele presents unspecific symptoms. The videothoracoscopy in a prone position is an excellent technical option to resect esophagoceles.

RESUMO RACIONAL: A ingestão de produtos cáusticos ainda é um problema de saúde de extrema importância no Ocidente. Nos países em desenvolvimento, este incidente continua em ascensão e está associada a fatores desfavoráveis como sociais, econômicos e educacionais, além da falta de prevenção. A esofagocele é uma consequência rara da ingestão de cáusticos. OBJETIVO: Nosso objetivo é descrever um paciente com múltiplas ingestões cáusticas que apresentou uma esofagocele ressecada por videotoracoscopia. MÉTODOS: Doente feminina que ingeriu soda cáustica com 17 anos de idade, como tentativa de suicídio, durante uma crise depressiva. Inicialmente, foi submetida a esofagocoloplastia retroesternal com manutenção do esôfago lesado. Após um ano desta primeira cirurgia, voltou a ingerir soda cáustica, em nova tentativa de suicídio. Seu intestino grosso transposto na primeira cirurgia tornou-se estenosado, sendo substituído em uma segunda cirurgia, por esofagogastroplastia retroesternal. Ainda assim, nesta segunda cirurgia, o esôfago lesado permaneceu em sua posição original no mediastino posterior. No entanto, após cinco anos, ela desenvolveu uma esofagocele. RESULTADOS: A esofagocele foi ressecada por videotoracoscopia, em decúbito ventral, empregando-se quatro trocartes. O pós-operatório transcorreu sem intercorrências. CONCLUSÕES: A exclusão esofágica deve ser sempre registrada, pois a esofagocele apresenta sintomas inespecíficos. A videotoracoscopia em posição prona é uma excelente opção técnica para ressecção de esofagoceles.

Algunas consideraciones en torno al cáncer de esófago / Some specificities around esophageal cancer

RESUMEN Introducción: El cáncer de esófago es una enfermedad presente a escala mundial, sobre todo en naciones en vías de desarrollo. Se realizó una revisión bibliográfica en bases de datos biomédicas mediante el motor de búsqueda de información Google académico. Se seleccionaron 24 de 62 artículos; 22 (91,6 %) del último quinquenio, publicados en español e inglés, relacionados con el objetivo propuesto. Objetivo: Describir algunos aspectos del cáncer de esófago, con énfasis en los epidemiológicos, etiopatogénicos y del tratamiento quirúrgico. Desarrollo: El cáncer de esófago es más frecuente en varones, con proporción hombre/mujer de 6:1, aunque en poblaciones de alto riesgo la incidencia es igual en ambos sexos; aunque algunos refieren que la relación es de 3 a 10 hombres por cada mujer, en dependencia de la zona geográfica. Las áreas de alta frecuencia son: Asia, África Central y del Sur. El carcinoma epidermoide y el adenocarcinoma representan el 95,0 % de todos los tumores esofágicos. La esofagectomía abierta o mínimamente invasiva constituye el pilar básico del tratamiento quirúrgico. Conclusiones: En la etiología del cáncer de esófago, los factores moleculares, genéticos y ambientales juegan un papel importante. El diagnóstico en etapas avanzadas predomina debido a lo tardío de la aparición de los síntomas y a las insuficiencias en el cribaje. El tratamiento quirúrgico constituye un pilar fundamental para los tres primeros estadios de la enfermedad, acompañada o no de quimio-radioterapia adyuvante o de neoadyuvancia (en el estadio II).

ABSTRACT Introduction: Esophageal cancer is a disease present worldwide, especially in developing nations. A bibliographic review was carried out in biomedical databases using the Google Scholar search engine. 24 of 62 articles were selected; 22 (91.6 %) of the last five years, published in Spanish and English, related to the proposed objective. Objective: To describe some aspects of esophageal cancer, with emphasis on the epidemiological, etiopathogenic and surgical treatment. Development: Esophageal cancer is more common in men, with a male/female ratio of 6:1, although in high-risk populations the incidence is the same in both sexes; although some report that the ratio is between 3 and 10 men for every woman, depending on the geographical area. High frequency areas are: Asia, Central and South of Africa. Squamous cell carcinoma and adenocarcinoma represent 95.0 % of all esophageal tumors. Open or minimally invasive esophagectomy is the basic pillar of surgical treatment. Conclusions: In the etiology of esophageal cancer, molecular, genetic and environmental factors play an important role. Diagnosis in advanced stages predominates due to the late onset of symptoms and insufficient screening. Surgical treatment is a fundamental pillar for the first three stages of the disease, accompanied or not by adjuvant or neoadjuvant chemo-radiotherapy (in stage II).

Caracterización de pacientes operados por cáncer del esófago en Cuba / Characterization of Patients Operated on for Esophageal Cancer in Cuba

Introducción: El cáncer en Cuba constituye un grave problema de salud debido a sus altas tasas de incidencia y mortalidad. Representa la primera causa de años de vida potencialmente perdidos y en el esófago es poco frecuente, su comportamiento es más agresivo y la supervivencia es baja. Objetivo: Caracterizar los pacientes operados por cáncer de esófago en Cuba en el periodo de 1988 al 2020. Métodos: Se realizó una investigación observacional clínico epidemiológica multicéntrica, no randomizada, en el periodo de 1988 al 2020. El universo y la muestra quedaron constituido por 595 enfermos de 9 centros hospitalarios. Algunas variables estudiadas incluyeron sexo, edad, variedad histológica, intervención quirúrgica realizada y presencia de comorbilidades asociadas. Resultados: Predominó el sexo masculino (66,1 por ciento), la edad promedio fue 62,8 años. La hipoproteinemia estuvo presente en el 46,1 por ciento. El 43,2 por ciento fueron fumadores y el 35,8 por ciento ingería bebidas alcohólicas. El epidermoide fue la variedad histológica más frecuente (64,6 por ciento). Las técnicas quirúrgicas más utilizadas fueron la de Ivor Lewis (68,4 por ciento) y la transhiatal (63,6 por ciento). Predominó la anastomosis en un plano, término-lateral, de localización torácica para el epidermoide (68,4 por ciento) y la cervical para el adenocarcinoma (71,4 por ciento), realizada de forma manual en cara posterior. Conclusiones: El cáncer de esófago predominó en hombres mayores de 55 años fumadores y con hipoproteinemia. Las técnicas quirúrgicas más utilizadas fueron la de Ivor Lewis y la transhiatal(AU)

Introduction: Cancer in Cuba is a serious health concern due to its high incidence and mortality rates. It represents the first cause of years of life potentially lost and. Esophageal cancer is rare, but its behavior is more aggressive and its survival rate is low. Objective: To characterize patients operated on for esophageal cancer in Cuba in the period from 1988 to 2020. Methods: A nonrandomized, multicenter, clinical-epidemiological and observational research was carried out in the period from 1988 to 2020. The universe and the sample consisted of 595 patients from nine hospital institutions. Some of the variables studied included sex, age, histological variety, surgical intervention performed, and presence of associated comorbidities. Results: There was a predominance of the male sex (66.1 percent). The average age was 62.8 years. Hypoproteinemia was present in 46.1 percent. 43.2 percent of patients were smokers and 35.8 percent drank alcoholic beverages. Epidermoid was the most frequent histological variety (64.6 percent). The most widely used surgical techniques were Ivor Lewis (68.4 percent) and transhiatal (63.6 percent) esophagectomies. There was a predominance of one-plane, termino-lateral anastomosis of thoracic location for epidermoid cases (68.4 percent) and the cervical one for adenocarcinoma cases (71.4 percent), performed manually on the posterior face. Conclusion: Esophageal cancer prevailed in men over 55 years of age, smokers and with hypoproteinemia. The most used surgical techniques were Ivor Lewis and transhiatal esophagectomies(AU)

Caracterización de la fuga anastomótica en operados por cáncer del esófago en Cuba / Characterization of Anastomotic Leak in Patients Operated on for Esophageal Cancer in Cuba

Introducción: La fuga anastomótica es la principal complicación de la cirugía del esófago, con altos índices de incidencia y mortalidad. Objetivo: Identificar los factores involucrados en la aparición de la fuga anastomótica en pacientes operados de cáncer de esófago en Cuba en el periodo de 1988 al 2020. Métodos: Se realizó una investigación observacional clínico epidemiológica multicéntrica, no randomizada, en el periodo de 1988 al 2020. El universo y la muestra quedaron constituidos por 2844 y 595 enfermos de 9 centros hospitalarios. Algunas variables estudiadas incluyeron sexo, edad, variedad histológica, intervención quirúrgica realizada, comorbilidades y su interrelación con la fuga anastomótica. Resultados: La fuga anastomótica predominó en el grupo de mayores de 55 años (17,8 por ciento), en el sexo femenino 65 (10,9 por ciento), en los no fumadores 79 (13,3 por ciento) y en los que no ingerían bebidas alcohólicas con 100 pacientes (16,8 por ciento). En enfermos con niveles de albúmina normales 98 (16,5 por ciento), con proteínas bajas 94 (15,7por ciento) y cifras normales de hemoglobina 105 (17,6 por ciento). En la variedad histológica adenocarcinoma 65 (10,9 por ciento), la técnica quirúrgica transhiatal 69 (11,6 por ciento), realizada de forma manual 123 (20,7 por ciento), de localización cervical 111 (18,6 por ciento), en cara anterior 57 (9,6 por ciento), en un plano 78 (13,1 por ciento), en la variante término-lateral 120 (20,2 por ciento). Conclusiones: La fuga anastomótica predominó en mujeres mayores de 50 años, con adenocarcinoma, operadas con técnicas transhiatales, manuales, en un plano, termino-laterales, en cara anterior y con hipoproteinemia(AU)

Introduction: Anastomotic leak is the main complication of esophageal surgery, with high incidence and mortality rates. Objective: To identify the factors involved in the appearance of anastomotic leak in patients operated on for esophageal cancer in Cuba in the period from 1988 to 2020. Methods: A nonrandomized, multicenter, clinical-epidemiological and observational investigation was carried out in the period from 1988 to 2020. The universe and the sample consisted of 2844 and 595 patients from nine hospital centers. Some of the variables studied included sex, age, histological variety, surgical intervention performed, comorbidities, and their interrelation with anastomotic leak. Results: Anastomotic leak prevailed in the group aged over 55 years (17.8 percent), in the female sex (65; 10.9 percent)), in nonsmokers (79; 13.3 percent)) and in those who did not ingest alcoholic beverages (100, 16.8; as well as in patients with normal albumin levels (98; 16.5), with low proteins (94; 15.7 percent) and with normal levels of hemoglobin (105; 17.6 percent). In the histological variety of adenocarcinoma (65; 10.9 percent), there was a predominance of the transhiatal surgical technique (69; 11.6 percent), performed manually (123; 20.7 percent), of cervical location (111; 18.6 percent), in the anterior face (57; 9.6 percent), in one plane (78; 13.1 percent), and in the termino-lateral variant (120; 20.2 percent). Conclusions: Anastomotic leak prevailed in women aged over 50 years, with adenocarcinoma, operated on through transhiatal techniques, manually, in one plane, using the termino-lateral variant, in the anterior face and with hypoproteinemia(AU)

Propuesta de protocolo ERAS en cirugía esofágica / An ERAS Protocol Proposal after Esophageal Surger

La rehabilitación multimodal constituye un conjunto de medidas perioperatorias que sustituye prácticas tradicionales. Su implementación está fundada en criterios de medicina basada en la evidencia. El objetivo del artículo es implementar el protocolo ERAS (Enhanced Recovery After Surgery) por sus siglas en inglés, en la cirugía esofágica electiva por cáncer. Se tuvo en cuenta como documento base el protocolo ERAS del servicio. Se apoyó en la sistemática revisión de la evidencia. Se amplió la búsqueda bibliográfica en las bases de datos Biblioteca Cochrane Plus (Cochrane Library) y Medline desde el 2000 hasta 2018. Las medidas a aplicar se dividen en 3 bloques: preoperatorio, perioperatorio y postoperatorio. Su conjunto da lugar al documento de consenso que integra todas las medidas. La aplicación de protocolos de rehabilitación multimodal en cirugía esofágica reducirá la morbimortalidad postoperatoria, la estancia y los costes hospitalarios(AU)

Multimodal rehabilitation involves a set of perioperative measures that substitutes traditional practices. Its implementation is founded upon evidence-based medicine criteria. The objective of the article is to implement of the ERAS (Enhanced Recovery After Surgery) protocol for elective esophageal cancer surgery. The ERAS protocol of the service was taken into account as a base document. It was supported by systematic evidence review. The bibliographic search was broadened in the Cochrane Library and the Medline databases, from 2000 to 2018. The measures to be applied are divided into three blocks: preoperative, perioperative and postoperative. This set gives rise to the consensus document that integrates all the measures. The application of multimodal rehabilitation protocols in esophageal surgery will reduce postoperative morbidity and mortality, hospital stay and costs(AU)

Comparación de la anastomosis cervical manual versus mecánica en una serie prospectiva de pacientes con esofagectomía por cáncer

Objetivos : La escasa literatura existente sugiere haber una menor tasa de fugas anastomóticas y una menor formación tardía de estenosis después de la anastomosis esofagogástrica con grapas comparada con la técnica de anastomosis manual. El objetivo del presente estudio es comparar los resultados quirúrgicos de la anastomosis cervical manual termino-lateral versus la anastomosis mecánica por grapado laterolateral luego de una esofagectomía transhiatal por cáncer. Materiales y métodos : Se realizó una revisión retrospectiva de los pacientes sometidos a esofagectomía transhiatal con anastomosis manual o mecánica por neoplasia en tres instituciones de Medellín, entre 2011 y 2018. Los criterios de valoración incluyeron la tasa de fuga anastomótica, la morbilidad, la mortalidad, la estancia hospitalaria y anastomóticas identificadas las estenosis por endoscopia que requirieran dilatación. Resultados : se evaluaron 68 pacientes (40 hombres, 59%), 37 con anastomosis manual y 31 con anastomosis mecánica con características demográficas similares. Se produjeron fugas anastomóticas en 13 pacientes (19,1%), sin encontrarse una diferencia entre la anastomosis manual y mecánica (18,9 frente a 19,3%; p = 0,93). La morbilidad global (61%), la mortalidad intrahospitalaria (3%) y la duración de la estancia hospitalaria (mediana de 12 días) no se vieron afectadas por la técnica anastomótica. Se dispuso de una evaluación endoscópica de seguimiento en todos los pacientes y se detectó una estenosis anastomótica asociada o no a fugas de la anastomosis en 18 pacientes (22%), los casos de estenosis sin fuga fueron más frecuente con la técnica de anastomosis manual que la mecánica (21,6 vs 6,4%; p=0,07) con una duración mayor del procedimiento quirúrgico en caso de la anastomosis manual (p=0,05). Conclusiones : Nuestro estudio no aleatorizado sugiere que la técnica de anastomosis mecánica cursa con un tiempo quirúrgico menor y una menor tasa de estenosis que la anastomosis manual en la reconstrucción esofagogástrica cervical tras la esofagectomía transhiatal, con una tasa de fuga anastomótica, estancia hospitalaria y morbimortalidad similares.

Objectives : The scarce existing literature suggests having a lower rate of anastomotic leakage and less late stricture formation after stapled esophagogastric anastomosis compared to the manual anastomosis technique. The aim of the present study is to compare the surgical outcomes of termino-lateral manual cervical anastomosis versus mechanical anastomosis by later lateral stapling, after transhiatal esophagectomy for cancer. Materials and methods : A retrospective review of patients undergoing transhiatal esophagectomy with manual or mechanical anastomosis for neoplasia was performed at three institutions in Medellin, between 2011 and 2018. Endpoints included leak rate, morbidity, mortality, hospital stay, and endoscopically identified anastomotic strictures requiring dilatation. Results : 68 patients (40 men, 59%) were evaluated, 37 with manual anastomosis and 31 with mechanical anastomosis with similar demographic characteristics. Anastomotic leaks occurred in 13 patients (19.1%), with no difference found between manual and mechanical anastomosis (18.9 vs. 19.3%; p=0.93). Overall morbidity (61%), in-hospital mortality (3%) and length of hospital stay (median 12 days) were not affected by anastomotic technique. Follow-up endoscopic evaluation was available in all patients and anastomotic stricture associated or not with leak was detected in 18 patients (22%), in cases of stricture without leak is more frequent with manual than mechanical anastomosis technique (21.6 vs 6.4%; p=0.07) with longer duration of surgical procedure in case of manual anastomosis (p=0.05). Conclusions : Our non-randomized study suggests that the manual anastomosis technique results in a shorter surgical time and a lower stricture rate than mechanical anastomosis in cervical esophagogastric reconstruction after transhiatal esophagectomy, with a similar rate of leakage, hospital stay and morbidity and mortality.

Linfografía y embolización del conducto torácico como tratamiento del quilotórax tras esofagectomía por cáncer de esófago / Lymphography and embolization of the thoracic duct as a treatment for chylothorax after esophagectomy for esophageal cancer

Introducción: El quilotórax es una complicación poco frecuente en las esofagectomías pero que se asocia a un aumento de la mortalidad posquirúrgica. Se han descrito diversos factores que pueden incrementar su aparición y el tratamiento del mismo es controvertido, siendo la linfografía con embolización percutánea del conducto torácico uno de los usados por varios grupos. Material y método: Estudio retrospectivo de los pacientes a los que se les realizó una esofagectomía por cáncer de esófago o de la unión esofagogástrica a Siewert I/II entre enero del 2010 y abril del 2019, y desarrollaron un quilotórax como complicación. Se analizan datos epidemiológicos, el tipo de cirugía, la morbilidad y el tratamiento. Resultados: Se realizaron 274 esofagectomías por cáncer en el período comprendido. Trece pacientes (4,7%) fueron diagnosticados de quilotórax en el postoperatorio; 3 se resolvieron con tratamiento conservador. En los 10 pacientes restantes se realizó linfografía con punción de la cisterna de Pécquet y embolización del conducto torácico, con resolución del quilotórax en 9. Un paciente (10%) presentó una fístula biliar después del procedimiento. Conclusiones: La linfografía con punción de la cisterna de Pécquet y embolización del conducto torácico es una técnica con baja morbilidad y buenos resultados en la resolución del quilotórax postesofagectomía. (AU)

Introduction: Chylothorax is a rare complication in esophagectomies that is associated with increased postoperative mortality. Several factors have been described that may favor its appearance. Its treatment is controversial, and lymphography with percutaneous embolization of the thoracic duct is used by several groups. Material and method: Our retrospective study included patients who underwent esophagectomy for cancer of the esophagus or the esophagogastric junction (Siewert I/II) between January 2010 and April 2019 and developed chylothorax as a complication. Epidemiological data, type of surgery, morbidity and treatment were analyzed. Results: 274 cancer-related esophagectomies were performed in the study period. Thirteen patients (4.7%) were diagnosed with chylothorax in the postoperative period; 3 were resolved with conservative treatment. In the remaining 10 patients, lymphography was performed with aspiration of the cisterna chyli and thoracic duct embolization, which resolved the chylothorax in 9. One patient (10%) presented a biliary fístula after the procedure. Conclusions: Lymphography with aspiration of the cisterna chyli and thoracic duct embolization is a technique with low morbidity that provides good results for the resolution of chylothorax after esophagectomy. (AU)

Lymphography and embolization of the thoracic duct as a treatment for chylothorax after esophagectomy for esophageal cancer. / Linfografía y embolización del conducto torácico como tratamiento del quilotórax tras esofagectomía por cáncer de esófago.

INTRODUCTION: Chylothorax is a rare complication in esophagectomies that is associated with increased postoperative mortality. Several factors have been described that may favor its appearance. Its treatment is controversial, and lymphography with percutaneous embolization of the thoracic duct is used by several groups. MATERIAL AND METHOD: Our retrospective study included patients who underwent esophagectomy for cancer of the esophagus or the esophagogastric junction (Siewert I/II) between January 2010 and April 2019 and developed chylothorax as a complication. Epidemiological data, type of surgery, morbidity and treatment were analyzed. RESULTS: 274 cancer-related esophagectomies were performed in the study period. Thirteen patients (4.7%) were diagnosed with chylothorax in the postoperative period; 3 were resolved with conservative treatment. In the remaining 10 patients, lymphography was performed with aspiration of the cisterna chyli and thoracic duct embolization, which resolved the chylothorax in 9. One patient (10%) presented a biliary fístula after the procedure. CONCLUSIONS: Lymphography with aspiration of the cisterna chyli and thoracic duct embolization is a technique with low morbidity that provides good results for the resolution of chylothorax after esophagectomy.