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La resección quirúrgica con márgenes negativos de las metástasis hepáticas de cáncer colorectal, representa la única opción de tratamiento con potencial curativo, sin embargo, el 85% de estos pacientes son considerados irresecables a la evaluación inicial, ya sea por número, tamaño y localización de las metástasis o por un remanente hepático futuro insuficiente. ALPPS es una técnica quirúrgica compleja, que permite en dos tiempos operatorios, la resección de extensas porciones de parénquima hepático tras un periodo de incremento volumétrico del remanente, que alcanza el 80% en un periodo de 9 días, lo que supera ampliamente a otras técnicas como la embolización/ligadura portal preoperatoria. Pese a cuestionamientos iniciales relativos a la morbimortalidad asociada, la significativa ganancia de masa hepatocelular lograda con ALPPS, ha permitido el tratamiento exitoso de pacientes con alta carga tumoral metastásica hepática, tensionando principios fundamentales clásicamente considerados para la realización de hepatectomías mayores en forma segura. El objetivo de este trabajo es presentar la experiencia inicial con la aplicación de la técnica de ALPPS llevado al extremo de dejar un remanente hepático constituido por un único segmento.
R0 resection of colorectal liver metastases is the main curative treatment option; however, 85% of patients are considered initially unresectable, either due to number, size and location of metastases or insufficient future liver remnant. ALPPS is a complex surgical technique, which allows, in two operative times, the resection of extensive portions of liver parenchyma after a period of volumetric remnant increase, which reaches 80% in 9 days, far exceeding other techniques as well as preoperative portal embolization / ligation. Despite initial doubts regarding the associated morbidity and mortality, the significant gain in hepatocellular mass achieved with ALPPS has allowed the successful treatment of patients with high hepatic metastatic tumor burden, questioning fundamental principles classically considered for safely performing major hepatectomies. The aim of this article is to show the initial experience with the ALPPS technique application taken to the extreme of leaving a liver remnant made up of a single segment.
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Resumen Introducción El uso del sistema de visión 3D en cirugía laparoscópica puede significar una mejor performance de los procedimientos quirúrgicos de mayor complejidad. Objetivo Reportar las indicaciones, los resultados y la valoración de un grupo de cirujanos de diferentes especialidades en el uso de visión 3D. Materiales y Método: Se analizan las indicaciones quirúrgicas y los resultados subjetivos y objetivos del uso del sistema óptico 3D (n = 155 pacientes) en cirugía laparoscópica compleja. Para evaluación subjetiva se aplicó a una encuesta de percepción cualitativa a los cirujanos participantes tipo Likert. Para la evaluación objetiva, se registran los tiempos quirúrgicos empleados en los diferentes procedimientos efectuados y las complicaciones postoperatorias y se comparan con los pacientes operados con sistema 2D (n = 783 pacientes) en el mismo periodo. Resultados el 70,6% concuerda tener mejor imagen con la técnica 3D, el 64,7% de los cirujanos refieren que se puede reducir el tiempo operatorio, el 58,8% considera que se puede reducir el error quirúrgico, el 92% y 100% respectivamente afirman que el confort del cirujano es mejor con el uso de óptica 3D y que esta técnica es recomendable para los procedimientos complejos. El tiempo operatorio se redujo en algunos procedimientos, especialmente urológicos. No se encontró diferencias sustanciales al comparar los resultados con el uso de sistema 3D versus 2D en cuanto a complicaciones postoperatorias. En la 3D no se encontró mortalidad postoperatoria, probablemente por el menor número de pacientes de ese grupo. Conclusión La laparoscopia 3D posee una buena valoración por los cirujanos que la emplearon, principalmente en calidad de imagen, reducción del tiempo operatorio y confort del cirujano en comparación con la laparoscopía 2D convencional. No se encontró diferencias sustanciales al comparar los resultados con el uso de sistema 3D versus 2D en cuanto a tiempo operatorio ni complicaciones postoperatorias.
Introduction The use of the 3D vision system in laparoscopic surgery can mean better performance in more complex surgical procedures. Aim Report the indications, results and assessment of a group of surgeons of different specialties in the use of 3D vision. Materials and Method Surgical indications and subjective and objective results of the use of 3D optical system in patients (n = 155) submitted to complex laparoscopic surgery are analyzed. Subjective evaluation based on a survey of qualitative perception (Likert) was applied to the participating surgeons. For objective evaluation, the operatory times and postoperative complications were recorded and compared with the results observed with the use of the 2D system (783 patients) in the same period. Results 70.6% agree to have a better image with the 3D technique, 64.7% of surgeons report that the operative time can be reduced, 58.8% consider that it can be reduced the surgical error, 92% and 100% respectively considered that the comfort of the surgeon is better with the use of 3D optics and that this technique is recommended for complex procedures. No substantial differences were found when comparing the results with the use of 3D versus 2D system by the same surgical teams in terms of operative times and postoperative complications. In 3D, postoperative mortality was probably not found due to the lower number of patients in this group. Conclusion 3D laparoscopy has a good evaluation by the surgeons who used it, mainly in image quality, reduction of operative time and comfort of the surgeon compared to conventional 2D laparoscopy. No substantial differences were found when comparing the results with the use of 3D versus 2D system in terms of operative times or postoperative complications.
Assuntos
Humanos , Laparoscopia/métodos , Imageamento Tridimensional/métodos , Chile , Inquéritos e Questionários , Laparoscopia/estatística & dados numéricos , Imageamento Tridimensional/instrumentação , Cirurgia Assistida por Computador/métodos , Pesquisa Comparativa da Efetividade , Duração da CirurgiaRESUMO
Reef-building corals maintain a symbiotic relationship with dinoflagellate algae of the genus Symbiodinium, and this symbiosis is vital for the survival of the coral holobiont. Symbiodinium community composition within the coral host has been shown to influence a coral's ability to resist and recover from stress. A multitude of stressors including ocean warming, ocean acidification, and eutrophication have been linked to global scale decline in coral health and cover in recent decades. Three distinct thermal regimes (highTP, modTP, and lowTP) following an inshore-offshore gradient of declining average temperatures and thermal variation were identified on the Belize Mesoamerican Barrier Reef System (MBRS). Quantitative metabarcoding of the ITS-2 locus was employed to investigate differences and similarities in Symbiodinium genetic diversity of the Caribbean corals Siderastrea siderea, S. radians, and Pseudodiploria strigosa between the three thermal regimes. A total of ten Symbiodinium lineages were identified across the three coral host species. S. siderea was associated with distinct Symbiodinium communities; however, Symbiodinium communities of its congener, S. radians and P. strigosa, were more similar to one another. Thermal regime played a role in defining Symbiodinium communities in S. siderea but not S. radians or P. strigosa. Against expectations, Symbiodinium trenchii, a symbiont known to confer thermal tolerance, was dominant only in S. siderea at one sampled offshore site and was rare inshore, suggesting that coral thermal tolerance in more thermally variable inshore habitats is achieved through alternative mechanisms. Overall, thermal parameters alone were likely not the only primary drivers of Symbiodinium community composition, suggesting that environmental variables unrelated to temperature (i.e., light availability or nutrients) may play key roles in structuring coral-algal communities in Belize and that the relative importance of these environmental variables may vary by coral host species.
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Antozoários/parasitologia , Dinoflagellida/classificação , Dinoflagellida/fisiologia , Especificidade de Hospedeiro , Animais , Antozoários/genética , Belize , DNA/análise , Dinoflagellida/genética , Monitoramento Ambiental , Variação Genética , Temperatura Alta , Oceanos e Mares , Filogenia , Simbiose/fisiologia , Temperatura , TermotolerânciaRESUMO
The authors regret that acknowledgment for Dr. Adrian Marchetti was omitted from the manuscript. The correct acknowledgment is written below.
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The term Choledocholithiasis refers to the presence of biliary stones in the extrahepatic bile ducts, which are found in 5 to 10% of patients undergoing cholecystectomy for gallstones. Nowadays, with the adoption of the laparoscopic cholecystectomy(LC) as a standard, multiple minimally invasive treatment options for bile duct stones are feasible, with no consensus to date on the procedure of choice. The two stage endoscopic techniques involve the use of Endoscopic Retrograde Cholangiopancreatography(ERCP) before or after performing a LC, which has the main advantage of separating the bile duct procedure from the LC. However, the need for two separate anesthesia times, the possibility of blank or failed ERCP, and the chance for calculi migration between procedures increase the length of hospital stay and associated costs. The single stage procedures include the Laparoscopic Bile Duct Exploration (LBDE), and more recently, the performance of a laparoscopy guided intraoperative ERCP(Rendez Vous). The LBDE, when performed by an experienced surgical team, is an effective and safe technique. Nonetheless, it is considered a technically demanding procedure, whose results cannot be extrapolated to the general surgical community. Recently, the Rendez Vous has become a treatment alternative that simplifies both the surgical and the endoscopic procedures, decreases morbidity, and requires a single anesthesia time. On the downside, Rendez Vous technique involves complex operating room (OR) logistics, requiring both a trained surgical and endoscopic team at the same time. (AU)
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Coledocolitíase/terapia , Coledocolitíase/cirurgia , Coledocolitíase/fisiopatologia , ColecistolitíaseRESUMO
Background: Advanced gallbladder cancer has a high mortality. Therefore, this tumor should be diagnosed and treated in early stages. Aim: To analyze the survival rates of patients with an early gallbladder cancer. Material and Methods: Retrospective analysis of medical records of patients with early gallbladder cancer diagnosed until 2003. From that date, all patients with gastrointestinal cancer were registered in a prospective record. Patients with early gallbladder cancer defined as Tis (Carcinoma in situ), T1A (Tumor invades lamina propia) and T1B (Tumor invades muscular layer), were included in this analysis. Results: Eighty patients aged 31 to 87 years (74 percent women) were analyzed. The diagnosis was made during surgery in two patients and during the pathological study in the rest. All 24 patients with Tis tumors were alive after 96 months of follow up. Only one of 16 patients with T1A tumors died of unknown causes. Among the 40 patients with T1B tumors, 24 were re-operated and survival was over 90 percent. Conclusions: This group of patients with early gallbladder cancer had a five years survival over 90 percent. In patients with muscle involvement does not seem necessary to extend the surgery.
Introducción: Dada la elevada mortalidad del cáncer vesicular en etapas avanzadas, lo ideal es diagnosticarlo y tratarlo en una etapa temprana de la enfermedad. Objetivo: Analizar la sobrevida de pacientes con carcinoma temprano de la vesícula biliar y el impacto de una eventual re-operación. Material y Método: Se incluyen en el estudio 80 pacientes con cáncer temprano, siendo la mayoría (65 pacientes) parte de un estudio prospectivo desde mayo de 2004 hasta febrero de 2013. Fueron divididos en 3 grupos: a) carcinoma in situ T1s; b) carcinoma mucoso T1a; c) carcinoma muscular I1b. Seguimiento en el 100 por ciento de los casos. Resultados: El diagnóstico de carcinoma temprano se hizo en 2 pacientes durante la cirugía, en el resto fue un hallazgo del estudio histo-patológico. Los 24 pacientes con carcinoma in situ estaban vivos a los 96 meses de seguimiento. De los 16 pacientes con carcinoma mucoso, sólo 1 (6 por ciento) falleció sin conocerse la causa. Entre los 40 pacientes con cáncer muscular, hubo 24 que no se reoperaron y 16 reoperados. Los resultados anatomo patológicos fueron similares y la sobrevida de ambos grupos fue superior al 90 por ciento. Conclusión: En pacientes con carcinoma de la vesícula biliar in situ y hasta la mucosa, la colecistectomía logra sobrevida mayor del 95 por ciento a largo plazo. En pacientes con carcinoma muscular, ésta se acompaña de una sobrevida mayor a 90 por ciento a 5 años y no parece justificarse ampliar la cirugía.
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Humanos , Masculino , Adulto , Feminino , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Neoplasias da Vesícula Biliar/cirurgia , Neoplasias da Vesícula Biliar/mortalidade , Diagnóstico Precoce , Seguimentos , Neoplasias da Vesícula Biliar/patologia , Estudos Prospectivos , Reoperação , Análise de SobrevidaRESUMO
Introduction: The benefits of liver metastasis excision in gastric cancer are not clearly demonstrated. Aim: To communicate preliminary experience concerning excision of hepatic metastasis and simultaneously performing gastrectomy in patients with gastric cancer. Material and Methods: In a prospective study, 3 of 397 patients treated for gastric cancer that met certain criteria, underwent hepatic metastasis excision. Results: Three patients with gastric cancer and liver metastases. A 58 years old male in whom one liver metastasis was excised and two were treated with radiofrequency ablation, who is alive after 40 months of follow up. A 26 years old female subjected to the excision of one liver metastasis. Eight months later, the lesion relapsed and a right hepatectomy was carried out. The patient died after 19 months of follow up. A 56 years old female subjected to the excision of one liver metastasis, who died 9 months later...
Introducción: En pacientes con cáncer gástrico y metástasis hepáticas sincrónicas, la posibilidad de tener sólo 1 a 3 metástasis es cerca de 2 por ciento, ya que, en la inmensa mayoría, corresponde a una enfermedad sistémica. Objetivos: Comunicar una experiencia preliminar que se refiere a realizar metastasectomía hepática simultánea a la gastrectomía en pacientes con cáncer gástrico. Material y Método: En estudio prospectivo, 3 de 397 pacientes tratados por cáncer gástrico que cumplían algunos criterios, fueron sometidos además a metatasectomía hepática. Resultados: Se incluye a 3 pacientes, 2 con sólo metástasis hepáticas y 1 paciente con metástasis hepáticas y peritoneales, en los que se realizó metastasectomía. La evolución postoperatoria en los 3 fue sin incidentes. En 2 pacientes la metástasis era única y en otro se realizó además radiofrecuencia de 3 pequeñas metástasis, siendo el único paciente vivo a 40 meses; los otros fallecen a los 19 y 9 meses...
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Humanos , Masculino , Adulto , Feminino , Pessoa de Meia-Idade , Neoplasias Gástricas/patologia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/secundário , Evolução Clínica , Metastasectomia , Neoplasias Gástricas/cirurgia , Estudos Prospectivos , Taxa de SobrevidaRESUMO
Accurate methods to measure autophagic activity in vivo in neurons are not available, and most of the studies are based on correlative and static measurements of autophagy markers, leading to conflicting interpretations. Autophagy is an essential homeostatic process involved in the degradation of diverse cellular components including organelles and protein aggregates. Autophagy impairment is emerging as a relevant factor driving neurodegeneration in many diseases. Moreover, strategies to modulate autophagy have been shown to provide protection against neurodegeneration. Here we describe a novel and simple strategy to express an autophagy flux reporter in the nervous system of adult animals by the intraventricular delivery of adeno-associated viruses (AAV) into newborn mice. Using this approach we efficiently expressed a monomeric tandem mCherry-GFP-LC3 construct in neurons of the peripheral and central nervous system, allowing the measurement of autophagy activity in pharmacological and disease settings.
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Autofagia/fisiologia , Sistema Nervoso/metabolismo , Animais , Linhagem Celular , Dependovirus/metabolismo , Vetores Genéticos/metabolismo , Humanos , Camundongos , Microscopia Eletrônica , Proteínas Associadas aos Microtúbulos/metabolismo , Sistema Nervoso/ultraestrutura , Nervo Isquiático/metabolismo , Nervo Isquiático/ultraestrutura , Medula Espinal/metabolismo , Medula Espinal/ultraestruturaRESUMO
Background: Laparoscopic cholecystectomy is nowadays the standard surgical treatment for cholelithiasis. Aim: To determine surgical mortality of laparoscopic cholecystectomy as compared with the open procedure. Material and Methods: Review of medical records of all patients subjected to open or laparosco-pic surgery in a surgical service of a clinical hospital, in a period of 20 years. Results: The records of 26.441 patients were reviewed. The figures for overall, open and laparoscopic surgery mortality were 0.16, 0.39 and 0.07 percent respectively. Only two of the 43 deceased patients, died as a direct complication of the surgical procedure. In the rest, the causes of mortality were underlying severe medical conditions. Conclusions: La-paroscopic cholecystectomy has a very low mortality that depends mostly on underlying medical conditions and advanced age.
Introducción: La colecistectomía laparoscópica se ha convertido en el gold standard de la cirugía biliar y se emplea masivamente en todo Chile. Objetivos: Determinar la mortalidad operatoria en 4 períodos de 5 años de la colecistectomía laparoscópica comparada con la colecistectomía tradicional. Material y Método: Se incluyó a todos los pacientes sometidos a colecistectomía, ya sea laparotómica o laparoscópica, entre enero de 1991 y diciembre de 2010 (20 años). Se analizó las causas de mortalidad, el grupo etario en que ocurrió y el tipo de abordaje quirúrgico. Resultados: Se operaron un total de 26.441 pacientes, con un promedio de 1.322 operados por año. La mortalidad global de la colecistectomía laparotómica fue de 0,39 por ciento y de la laparoscópica de 0,07 por ciento, con un promedio general de 0,16 por ciento. Las principales causas de mortalidad fueron patologías médica severas. Sólo 2 pacientes de los 43 fallecidos (5 por ciento) tuvieron una complicación directamente derivada de la cirugía como causa de la mortalidad. Conclusiones: La colecistectomía laparoscópica es una operación de muy baja mortalidad (7 de 10.000 operados). Esta complicación se presenta principalmente en pacientes con grave patología biliar, de edad avanzada y con múltiples complicaciones médicas.
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Humanos , Adulto , Pessoa de Meia-Idade , Colecistectomia/mortalidade , Doenças Biliares/cirurgia , Fatores Etários , Causas de Morte , Chile , Colecistectomia Laparoscópica/mortalidade , Colelitíase/mortalidade , Doenças Biliares/mortalidade , Estudos RetrospectivosRESUMO
Background: Surgery for gastric cancer may have high rates of complications and mortality. Aim: To analyze operative mortality of total and subtotal gastrectomy in the period 2004-2010. Material and Methods: Prospective study 345 patients with gastric cancer, mean age 62 years, 64 percent males, subjected to a total or subtotal R0, R1 or R2 gastrectomy. All patients were assessed in the postoperative period and all complications were recorded. Results: Total and subtotal gastrectomies were performed in 224 and 69 patients respectively. Postoperative complications consisted in anastomotic leaks, duodenal stump leaks, hemoperitoneum, pulmonary infections and intestinal obstruction. Mortality of total gastrectomy R1 or R2 was 2.1 percent whereas palliative gastrectomy, to improve quality of life, had 15 percent mortality. Subtotal gastrectomy had 1.4 percent mortality. Conclusions: There has been a reduction in operative mortality of gastrectomy for gastric cancer, however the rate of complications has not changed.
Objetivos: Analizar la morbilidad y mortalidad operatoria de la gastrectomía total y subtotal en el período 2004-2010 y compararlo con las cifras publicadas en los últimos 40 años. Material y Método: El presente estudio prospectivo incluye a los pacientes sometidos a gastrectomía total o subtotal R0 R1 o R2 entre mayo de 2004 y diciembre de 2010. Se evaluaron la morbilidad y la mortalidad postoperatoria. Resultados: La gastrectomía total se realizó en 244 pacientes y la subtotal en 69 pacientes. La morbilidad postoperatoria correspondió a filtración de la anastomosis, filtración del muñón duodenal, hemoperitoneo, infecciones pulmonares y obstrucción intestinal. La mortalidad de la gastrectomía total R0 o R1 fue de 2,1 por ciento, mientras que la gastrectomía de aseo tuvo un 15 por ciento de mortalidad. La gastrectomía subtotal presentó una mortalidad de 1,4 por ciento. Conclusiones: Como consecuencia de todos los adelantos técnicos y materiales en la cirugía del cáncer gástrico, que significó una baja muy importante en la mortalidad operatoria, las complicaciones postoperatorias no han variado estos últimos 40 años.
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Humanos , Masculino , Adulto , Feminino , Pessoa de Meia-Idade , Gastrectomia/métodos , Gastrectomia/mortalidade , Neoplasias Gástricas/cirurgia , Neoplasias Gástricas/mortalidade , Complicações Pós-Operatórias/epidemiologia , Tempo de Internação , Estadiamento de Neoplasias , Neoplasias Gástricas/epidemiologia , Estudos Prospectivos , ReoperaçãoRESUMO
The management of patients with advanced gastric carcinoma who are candidates to surgical resection, implies the use of additional adyuvant or neo-adyuvant treatments. The present article reviews briefly the results of different treatments. The best results up to now have been obtained with the use of quemotherapy plus radiotherapy after surgical resection (Mac Donald´sprotocol) or with the use of preop and postoperative quemotherapy (Cunningham´s protocol). Patients candidates to such treatments correspond to cases with resected gastric cancer, with tumoral infiltration up to the serosa to extra serosa infiltration and those who have 1 or more metastatic lymph nodes. There are several new treatment protocol, which must be evaluated by prospective and randomized studies.
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Humanos , Neoplasias Gástricas/cirurgia , Neoplasias Gástricas/tratamento farmacológico , Neoplasias Gástricas/radioterapiaRESUMO
El cáncer de recto localmente avanzado sigue presentando el desafío de la recidiva local. La radioquimioterapia preoperatoria ha demostrado disminución del tamaño tumoral y a veces desaparición de éste, sumada a menor recidiva local. Nuestro objetivo fue evaluar el uso de radioquimioterapia preoperatoria para pacientes con cáncer de recto localmente avanzados en nuestro medio. Se estableció un protocolo prospectivo para pacientes con cáncer de recto etapas II y III. Se administró FU 600 mg/m² la 1ª y 5ª semanas y 300 mg/m² la 2ª, 3ª y 4ª semanas, asociada a radioterapia de 4.500 cGy por 5 semanas. Después de 6 semanas se realizó la cirugía resectiva, completándose en el postoperatorio 6 ciclos de 5FU con Leucovorina. Entre abril de 1999 y agosto de 2001 se trataron 20 pacientes. Complicaciones graves de la radioquimioterapia ocurrieron en dos pacientes (10 por ciento). NO hubo complicaciones intraoperatorias, las postoperatorias ocurrieron en 7 casos y falleció un paciente por una bronconeumonía. En el estudio histológico de la pieza operatoria se comprobó desaparición del tumor en tres pacientes (15,7 por cientos). En una mediana de seguimiento de 15 meses no se ha detectado recidiva local
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Humanos , Masculino , Adulto , Feminino , Pessoa de Meia-Idade , Adenocarcinoma , Cuidados Pré-Operatórios , Neoplasias Retais , Adenocarcinoma , Broncopneumonia/etiologia , Quimioterapia Adjuvante , Leucovorina , Complicações Pós-Operatórias , Estudos Prospectivos , Neoplasias RetaisRESUMO
Background: a-glucosidase is found in human seminal plasma as an acid form, located in accessory glands, and as a neutral form secreted almost exclusively by the epididymis. Quantification of a-glucosidase activity is a marker of the secretory function of the epididymis and indemnity of the sperm transport pathway Aim: To obtain reference values for a-glucosidase in normal samples of seminal plasma, to evaluate its behavior in serial samples and to determine the effect of proteolytic enzymes. Material and methods: Fifty donors, with normal semen analysis according to the criteria of the World Health Organization, were evaluated. For the study with alpha-quimotrypsin, 0.1 to 10 mg/ml of the enzyme was added to the seminal plasma from a group of donors. a-glucosidase was also measured in semen obtained from nine patients at different time intervals. Results: Normal a-glucosidase values ranged from 14.52 to 25.69 µU/ml. Concentrations up to 10 mg/ml of alpha-quimotrypsin (10 times of that usually used in the liquefaction of the semen) did not alter the quantification of a-glucosidase. Serial determinations revealed oscillations in their magnitude, which stayed in each patient's characteristic range. However a subgroup presented a marked reduction of the activity of a-glucosidase as the abstinence diminished (40 percent). Conclusions: Evaluation of a-glucosidase in seminal plasma gives reliable information of the secretor state of the epididymis and especially replaces invasive methods used to evaluate the indemnity of the spermatic transport from the epididymis to the anterior urethra