Resumen: El blastoma pleuropulmonar (BPP) es el tumor pulmonar primario maligno pediátrico más común. Se asocia a variantes patogénicas de línea germinal del gen DICER1. La presentación antenatal es infrecuente y determina un desafío en el diagnóstico diferencial de malformación pulmonar congénita (MPC). Objetivo: comunicar un caso de presentación inhabitual de BPP asociado a síndrome DICER1 y describir la dificultad en diferenciarlo de MPC. Caso Clínico: Paciente masculino con diagnóstico antenatal de lesión pulmonar izquierda hipervascularizada, con desplazamiento medias- tínico y crecimiento progresivo, interpretada como MPC. Nació de 38 semanas y progresó con deterioro ventilatorio. La Tomograña Computada (TC) con contraste mostró una extensa masa quística multilocular con contenido aéreo con efecto de masa. Se realizó lobectomía superior izquierda abierta. La histología fue compatible con BPP tipo I, con bordes negativos y estudio genético para DICER1 positivo. Siete semanas post-resección se pesquisó imagen aérea en la parte superior del tórax izquierdo, requiriendo nueva resección tumoral y segmentectomía superior, con biopsia correspondiente a recidiva de BPP tipo 1 con bordes negativos. Recibió tratamiento adyuvante con quimioterapia, con seguimiento por 2 años, manteniéndose asintomático, sin nuevas recidivas, screening negativo para otras neoplasias asociadas a DICER1. Entre los antecedentes familiares, destacaba cáncer papilar de tiroides de la madre, quien resultó positiva para la mutación. Conclusión: el BPP es un cáncer poco frecuente, siendo difícil distinguirlo de MPC, especialmente en su presentación antenatal. Conocer su asociación al Síndrome DICER1 y hacer estudio genético son claves para detectar precozmente el BPP y buscar otros tumores asociados al síndrome.

Abstract: Pleuropulmonary blastoma (PPB) is the most common pediatric malignant primary lung tumor. It’s associated with the DICER1 gene pathogenic germline variants. Antenatal presentation is infrequent and poses a challenge in the differential diagnosis of congenital pulmonary airway malformation (CPAM). Objective: to report a case of unusual presentation of PPB associated with DICER1 syndrome and to describe the difficulty in differentiating it from CPAM. Clinical Case: Male patient with prenatal diagnosis of hypervascular left lung lesion, with mediastinal shift and progressive growth, initially interpreted as CPAM. He was born at 38 weeks, requiring transitory treatment with positive pressure due to ventilatory impairment. A CT scan with contrast showed a large multilocular cystic mass containing air causing mass effect, requiring open left upper lobectomy. Histology results were compatible with type I PPB, with negative margins, and positive genetic study for DICER1 syndrome. Seven weeks post-resection, an aerial image was detected in the upper left side of the chest, with progressive growth, requiring a new tumor resection and upper segmentectomy, with biopsy corresponding to recurrence of type I PPB with negative margins. He received adjuvant treatment with chemotherapy, with follow-up for 2 years, remaining asymptomatic, without recurrence, and with negative screening for other neoplasms associated with DICER1 syndrome. Among the family history, the mother had papillary thyroid cancer and tested positive for the mutation. Conclusion: PPB is a rare cancer, difficult to distinguish from CPAM, especially in its antenatal presentation. Nowing its association with DICER1 syndrome and performing a genetic study are key to the early detection of BPP and the search for other tumors associated with the syndrome.

RESUMO RACIONAL: A fundoplicatura de Nissen laparoscópica falha em controlar o refluxo gastroesofágico em quase 15% dos pacientes e a maioria deles deve ser reoperada devido aos sintomas. Diferentes técnicas cirúrgicas têm sido sugeridas. OBJETIVOS: Apresentar os resultados pós-operatórios de pacientes submetidos a 3 procedimentos diferentes: Reoperação e fundoplicatura de Nissen laparoscópica apenas (Grupo A), reoperação e fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal (Grupo B) ou reoperação e conversão para Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux (Grupo C). MÉTODOS: estudo prospectivo incluindo 77 pacientes submetidos inicialmente a fundoplicatura de Nissen laparoscópica que apresentaram recidiva do refluxo gastroesofágico após a operação. Eles foram avaliados antes e após a reoperação com questionário clínico e estudos funcionais específicos. Reestabelecida a anatomia da junção esôfago-gástrica, procedeu-se às referidas cirurgias. Nenhum paciente perdeu seguimento. RESULTADOS: Os sintomas persistentes foram observados com maior frequência nos pacientes dos Grupos A ou B, associados à estenose da fundoplicatura, fundoplicatura intratorácico ou fundoplicatura torcida. No Grupo C, os sintomas recorrentes associados a essa alteração anatômica foram observados com pouca frequência. Esfincter esofágico inferior incompetente foi confirmado em 57,7% dos pacientes pertencentes ao Grupo A em comparação com 17,2% após fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal, e 26% após a Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux. Nesse grupo, apesar do alto percentual de pacientes com esfincter esofágico inferior incompetente, 8,7% apresentaram refluxo ácido anormal após a cirurgia. CONCLUSÕES: As técnicas de Nissen ou Toupet combinados com a gastrectomia distal em Y de Roux são seguras e eficazes para o manejo da falha da fundoplicatura a Nissen. A técnica de Toupet é preferível para pacientes que sofrem principalmente com disfagia e dor.

ABSTRACT BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Abstract This article presents the results of empirical research that investigates the citizen's perspectives regarding the issue of death with dignity and the legitimacy of the implementation of measures to accompany this process. Through the implementation and analysis of seven discussion groups, carried out in the Metropolitan Region of Santiago de Chile, it can be concluded that there are high levels of consensus among the citizens supporting the need for implementation of external measures to end the life of patients who request it due to suffering related to terminal illnesses, and the need to have legal regulations that supports its application. All of this has been evaluated within the framework of a broad citizen assessment of personal autonomy and from the narration of experiences that reveal the great emotional and monetary burden involved in the process of caring for people with terminal illnesses.

Resumen El presente artículo expone los resultados de una investigación empírica que se ha adentrado en las experiencias y discursos ciudadanos respecto del tema de la muerte en dignidad, y de la legitimidad de la implementación de medidas de acompañamiento de este proceso. A través del análisis de lo obtenido en siete grupos de discusión, llevados a cabo en la Región Metropolitana de Santiago de Chile, se ha podido concluir la existencia de altos niveles de consenso en la ciudadanía, respecto de la legitimidad de implementar medidas externas para terminar con la vida de pacientes que lo soliciten debido al padecimiento de enfermedades terminales, y de la necesidad de contar con una normativa legal que respalde su aplicación. Todo esto en el marco de una amplia valoración ciudadana de la autonomía personal y desde la narración de experiencias que revelan los grandes costos emocionales y monetarios que implica el cuidado de personas con enfermedades terminales.

Resumo O presente artigo expõe os resultados de uma investigação empírica que adentrou as experiências e discursos cidadãos a respeito do tema da morte com dignidade e da legitimidade da implementação de medidas de acompanhamento deste processo. Através da análise do obtido em sete grupos de discussão, levados a cabo na Região Metropolitana de Santiago do Chile, se pode demonstrar a existência de altos níveis de consenso entre as pessoas no que diz respeito à legitimidade de implementar medidas externas para terminar com a vida de pacientes que as solicitem devido ao padecimento de enfermidades terminais e da necessidade de contar com uma normativa legal que respalde sua aplicação. Tudo isto no contexto de uma ampla valorização cidadã da autonomia pessoal e a partir da narrativa de experiências que revelam os grandes custos emocionais e econômicos implicados no cuidado de pessoas com enfermidades terminais.

RESUMO Racional: A identificação de fatores prognósticos do câncer de esôfago permitiu prever a evolução dos pacientes. Objetivo: Avaliar diferentes fatores prognósticos da sobrevida em longo prazo do câncer de esôfago e avaliar um novo fator prognóstico da sobrevida em longo prazo chamado índice linfoparietal (N+/T). Método: Estudo prospectivo do Hospital Clínico da Universidade do Chile, entre janeiro de 2004 e dezembro de 2013. Incluiu todas as operações de câncer de esôfago com intenção curativa e anastomose cervical. Os critérios de exclusão incluíram: câncer em estágio 4, ressecções R1, procedimentos paliativos e operações de emergência. Resultados: Cinquenta e oito pacientes foram incluídos, 62,1% eram homens, a idade média foi de 63,3 anos. Um total de 48,3% eram escamosos, 88% eram cânceres avançados, a colheita média de linfonodos foi de 17,1. A morbidade cirúrgica pós-operatória foi de 75%, com 17,2% de reoperações e 3,4% de mortalidade. A sobrevida global média foi de 41,3 meses, a sobrevida em três anos foi de 31%. A análise multivariada dos fatores prognósticos mostrou que variáveis significativas foram elevação pelo mediastinal anterior (p=0,01, OR: 6,7 [1,43-31,6]), fístula anastomótica (p=0,03, OR: 0,21 [0,05-0,87]), classificação N (p=0,02, OR: 3,8 [1,16-12,73]), estágio TNM (p=0,04, OR: 2,8 [1,01-9,26]) e índice linfoparietal (p=0,04, RR: 3,9 [1,01-15,17]. As curvas ROC do índice linfoparietal, classificação N e estádio TNM apresentam áreas abaixo da curva de 0,71, 0,63 e 0,64, respectivamente, com diferença estatística significativa (p=0,01). Conclusão: Os fatores prognósticos independentes de sobrevida em longo prazo no câncer de esôfago são a elevação mediastinal anterior, fístula anastomótica, classificação N, estágio TNM e índice linfoparietal. No câncer de esôfago, o novo índice linfoparietal é mais forte que o estágio TNM no prognóstico de sobrevida em longo prazo.

ABSTRACT Background: The identification of prognostic factors of esophageal cancer has allowed to predict the evolution of patients. Aim: Assess different prognostic factors of long-term survival of esophageal cancer and evaluate a new prognostic factor of long-term survival called lymphoparietal index (N+/T). Method: Prospective study of the Universidad de Chile Clinical Hospital, between January 2004 and December 2013. Included all esophageal cancer surgeries with curative intent and cervical anastomosis. Exclusion criteria included: stage 4 cancers, R1 resections, palliative procedures and emergency surgeries. Results: Fifty-eight patients were included, 62.1% were men, the average age was 63.3 years. A total of 48.3% were squamous, 88% were advanced cancers, the average lymph node harvest was 17.1. Post-operative surgical morbidity was 75%, with a 17.2% of reoperations and 3.4% of mortality. The average overall survival was 41.3 months, the 3-year survival was 31%. Multivariate analysis of the prognostic factors showed that significant variables were anterior mediastinal ascent (p=0.01, OR: 6.7 [1.43-31.6]), anastomotic fistula (p=0.03, OR: 0.21 [0.05-0.87]), N classification (p=0.02, OR: 3.8 [1.16-12.73]), TNM stage (p=0.04, OR: 2.8 [1.01-9.26]), and lymphoparietal index (p=0.04, RR: 3.9 [1.01-15.17]. The ROC curves of lymphoparietal index, N classification and TNM stage have areas under the curve of 0.71, 0.63 and 0.64 respectively, with significant statistical difference (p=0.01). Conclusion: The independent prognostic factors of long-term survival in esophageal cancer are anterior mediastinal ascent, anastomotic fistula, N classification, TNM stage and lymphoparietal index. In esophageal cancer the new lymphoparietal index is stronger than TNM stage in long-term survival prognosis.

La localización en el duodeno es la más compleja para el tratamiento de los tumores del estroma gastrointestinal (Gastrointestinal Stromal Tumors, GIST). Los GIST duodenales son relativamente infrecuentes, con una prevalencia de 5 % a 7 % de todos los tratados quirúrgicamente. La mayoría de las publicaciones sobre GIST duodenales son reportes de caso o series de casos. Consecuentemente, las manifestaciones clínicas, el diagnóstico radiológico, el tratamiento quirúrgico y los factores pronósticos, constituyen materia de controversia. En el presente artículo se revisa, principalmente, el tratamiento quirúrgico de los GIST duodenales, tratando de establecer las opciones quirúrgicas de acuerdo con su localización. La mayoría de los artículos sobre GIST duodenales mencionan que, a diferencia de otros tumores localizados en el aparato gastrointestinal, el procedimiento óptimo para el tratamiento del GIST duodenal no se encuentra bien caracterizado en la literatura científica. Sin embargo, la revisión de las publicaciones sobre el tema demuestra que el abordaje quirúrgico descrito por diferentes autores es bastante estándar. Todos toman en cuenta la localización del GIST en el duodeno y sus relaciones anatómicas, para decidir entre la resección local o la pancreatoduodenectomía. Utilizando este conocimiento de sentido común, se proponen opciones quirúrgicas para GIST duodenales basadas en su localización en el duodeno.

Duodenal gastrointestinal stromal tumors (GIST) constitute the most challenging location for the treatment of this intestinal tract neoplasm. Duodenal GIST are relatively uncommon tumors, and their prevalence is very low, accounting for 5% to 7% or less of all surgically resected GISTs. Most published reports on duodenal GIST are case reports or case series. Consequently, the clinical manifestations, radiologic diagnosis, appropriate surgical treatment, and prognostic factors constitute a subject of current controversy. This review mainly addresses the surgical management of duodenal GISTs trying to establish and define surgical options according to GISTs location within the duodenum. Most articles concerning duodenal GISTs state that unlike tumors involving other sites of the gastrointestinal tract, the optimal procedure for duodenal GISTs has not been well characterized. However, when carefully reviewing the published literature on the subject, it was found that surgical approaches to duodenal GISTs are fairly standard among different authors. All take into account the location of GIST in the duodenum and its anatomic relationships to decide whether local resection or Whipple operation should be performed. Based upon this common sense knowledge, defined surgical options for duodenal GISTs according to their localization within the duodenal frame are proposed.

Background: Peer methodology (PM) is an adaptation of the privileged access interviewer methodology and is used for prevalence studies. PM estimates higher drug consumption frequencies among school and college students than self reports, since it minimizes underreporting. Aim: To assess drug abuse among students using PM. Material and methods: A random sample of 234 school students of middle and low-middle socioeconomic status, aged 9 to 14 years (53% women) were interviewed using PM about drug consumption. Results: The frequency of licit drug consumption during the last year was 29% and 15% during the last month (current consumption). The consumption of tobacco and alcohol was 20% and 18% respectively during the last year. The figures for the last month were 11% and 8% respectively. The beginning age for smoking and alcohol consumption were 11.1 ±1.5 and 11.3± 1.8 years respectively. The frequency of illicit drug consumption was 3.5%. Illicit drug users began licit drug consumption at earlier ages their non user peers. Conclusions: There is a high frequency of illicit drug consumption among school age children.