RESUMO Racional: Residência em Cirurgia Geral pode durar entre 2-6 anos, dependendo do país. Residência mais curta deve otimizar a exposição dos residentes às cirurgias. Sabe-se que o treinamento cirúrgico simulado encurta as curvas de aprendizado, mas a informação relacionada à como isso afeta a residência em relação à exposição clínica é escassa. Objetivo: Analisar o efeito da introdução de um programa de treinamento laparoscópico simulado validado em procedimentos abdominais realizados por residentes em um programa de Residência em Cirurgia Geral de três anos. Métodos: Um estudo de coorte não simultâneo foi desenhado. Quatro gerações (2012-2015) de cirurgiões graduados foram incluídos. Apenas os procedimentos abdominais em que os cirurgiões graduados foram o cirurgião principal foram descritos e analisados. O grupo controle foi de cirurgiões graduados de 2012 sem programa de treinamento laparoscópico simulado. Procedimentos cirúrgicos por ano de programa, técnica cirúrgica, intervenção de emergência ou eletiva e local do hospital (hospitais principais/comunitários) foram descritos. Resultados: Intervenções de 28 cirurgiões graduados foram analisadas (controle=5; programa de treinamento simulado=23). Os cirurgiões graduados realizaram média de 372 procedimentos abdominais, com maior número médio de procedimentos de médio a complexo no grupo de programa de treinamento simulado (48 vs. 30, p=0,02). Cirurgiões graduados treinados com programa de treinamento simulado realizaram número maior de procedimentos abdominais totais (384 vs. 319, p=0,04) e procedimentos laparoscópicos (183 vs. 148, p<0,05). Conclusões: A introdução do programa de treinamento laparoscópico simulado pode aumentar o número e a complexidade dos procedimentos totais e laparoscópicos na Residência em Cirurgia Geral de três anos.

ABSTRACT Background: A General Surgery Residency may last between 2-6 years, depending on the country. A shorter General Surgery Residency must optimize residents’ surgical exposure. Simulated surgical training is known to shorten the learning curves, but information related to how it affects a General Surgery Residency regarding clinical exposure is scarce. Aim: To analyze the effect of introducing a validated laparoscopic simulated training program in abdominal procedures performed by residents in a three-year General Surgery Residency program. Methods: A non-concurrent cohort study was designed. Four-generations (2012-2015) of graduated surgeons were included. Only abdominal procedures in which the graduated surgeons were the primary surgeon were described and analyzed. The control group was of graduated surgeons from 2012 without the laparoscopic simulated training program. Surgical procedures per program year, surgical technique, emergency/elective intervention and hospital-site (main/community hospitals) were described. Results: Interventions of 28 graduated surgeons were analyzed (control group=5; laparoscopic simulated training program=23). Graduated surgeons performed a mean of 372 abdominal procedures, with a higher mean number of medium-to-complex procedures in laparoscopic simulated training program group (48 vs. 30, p=0.02). Graduated surgeons trained with laparoscopic simulated training program performed a higher number of total abdominal procedures (384 vs. 319, p=0.04) and laparoscopic procedures (183 vs. 148, p<0.05). Conclusions: The introduction of laparoscopic simulated training program may increase the number and complexity of total and laparoscopic procedures in a three-year General Surgery Residency.

Ulcerative Colitis (UC) is a chronic inflammatory disease involving the colon, with alternating periods of remission and activity. Exacerbations can be severe and associated with complications and mortality. Diagnosis of severe UC is based on clinical, biochemical and endoscopic variables. Patients with severe UC must be hospitalized. First line therapy is the use of intravenous corticoids which achieve clinical remission in most patients. However, 25% of patients will be refractory to corticoids, situation that should be evaluated at the third day of therapy. In patients without response, cytomegalovirus infection must be quickly ruled out to escalate to second line therapy with biological drugs or cyclosporine. Total colectomy must not be delayed if there is no response to second line therapy, if there is a contraindication for second line therapies or there are complications such as: megacolon, perforation or massive bleeding. An active management with quick escalation on therapy allows to decrease the prolonged exposure to corticoids, reduce colectomy rates and its perioperative complications.

Background: In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. Aim: To report the results of our program in patients suffering intestinal failure. Patients and Methods: A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. Results: Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. Conclusions: Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.

Aim: To compare the surgical results of both groups: Simultaneous with the proctocolectomy (SRP) (group 1) or delayed after colectomy (DRP) (group 2). Material and methods: Retrospective study on 126 patients submitted to RP. All patients had a J-pouch, except 4 S. All of them protected with a loop ileostomy. The median time between colectomy and IPAA was 5 months (4-6 range). Clavien-Dindo II-V complications were registered. Results: 126 patients had IPAA. Age median 37 years (12-61 range); 72 (57%) women. SRP in 24 (19%) and DRP was performed in 102 (81%). Postoperative complications were recorded in 19 patients (13%). Wound infection and pelvic sepsis were observed in 4% each. Three patients needed early reoperation: two for hemoperitoneum and one for ischemic necrosis of the pouch. There was no post-operative mortality. No significant difference in 30 days postoperative complication rate was found between SRP and DRP. On long-term follow-up: Intestinal obstruction in 18 patients (14%), pouch-vaginal fistula (PVF) in 9 (12.5%) and chronic pouchitis in 8 (6.9%) were the most common complications. PVF was significantly more frequent on group 1. Conclusion: In this series, no significant difference was found in the early surgical results between group 1 and 2. In the long term, PVF was significantly more common in group 1.

Objetivo: Analizar las diferencias en los resultados quirúrgicos entre 2 grupos en colitis ulcerosa: proctocolectomía, reservorio ileal y anastomosis reservorio-anal (RIARA), simultáneo con la proctocolectomía (grupo 1) o diferido (grupo 2). Material y método: Estudio retrospectivo en 126 pacientes sometidos a RIARA. En todos los pacientes se confeccionó un RIARA en «J», excepto en 4 que se hizo en «S». Todos fueron protegidos con ileostomía. Complicaciones Clavien-Dindo II-V fueron registradas. Resultados: Pacientes con una mediana de edad de 37 años (12-61), 72 eran de género femenino (57%). Se practicó proctocolectomía y RIARA en 24 pacientes (19%) y proctectomía y RIARA en 102 (81%). Se observaron complicaciones postoperatorias en 19 pacientes (13%). Infección de la herida y sepsis pelviana, en 4% respectivamente, fueron las más frecuentes. Tres pacientes fueron reintervenidos: 2 por hemoperitoneo y uno por necrosis isquémica del reservorio. No hubo mortalidad postoperatoria. No se observó diferencia significativa en la morbilidad postoperatoria entre los grupos. Se observaron complicaciones a largo plazo en 48 pacientes (38%): obstrucción intestinal en 18 pacientes (14%), fístula reservorio-vaginal (FRV) en 9 (12,5%), y reservoritis crónica en 8 (6,9%) fueron las más frecuentes. Al comparar los 2 grupos, se observó mayor frecuencia de FRV en el grupo 1 (p = 0,02). Conclusión: En este estudio no se demostró diferencia en la morbilidad postoperatoria entre el grupo 1 y 2. En los resultados alejados hubo mayor frecuencia significativa de FRV en el grupo 1.

Background: Multiple clinical trials have demonstrated the benefits of adjuvant 5-fluorouracil-based chemotherapy for patients with resectable colon cancer (CC), especially in stage III. Aim: To describe the clinical characteristics of a cohort of CC patients treated at a single university hospital in Chile since 2002, and to investigate if chemotherapy had an effect on survival rates. Material and Methods: Review of a tumor registry of the hospital. Medical records of patients with CC treated between 2002 and 2012 were reviewed. Death certificates from the National Identification Service were used to determine mortality. Overall survival was described using the Kaplan-Meier method. A multivariate Cox proportional hazard regression model was also used. Results: A total of 370 patients were treated during the study period (202 in stage II and 168 in stage III). Adjuvant chemotherapy was administered to 22 and 70% of patients in stage II and III respectively. The median follow-up period was 4.6 years. The 5-year survival rate for stage II patients was 79% and there was no benefit observed with adjuvant chemotherapy. For stage III patients, the 5-year survival rate was 81% for patients who received adjuvant chemotherapy, compared to 56% for those who did not receive chemotherapy (hazard ratio (HR): 0.29; 95% confidence interval (CI): 0.15-0.56). The benefit of chemotherapy was found to persist after adjustment for other prognostic variables (HR: 0.47; 95% CI: 0.23-0.94).Conclusions: Patients with colon cancer in stage III who received adjuvant chemotherapy had a better overall survival.

A loop ileostomy with intraoperative anterograde colonic lavage has been described as an alternative to colectomy in the management of cases of Clostridium difficile infection refractory to medical treatment. We report a 69 years old diabetic women admitted with a septic shock. An abdominal CAT scan showed a pan-colitis that seemed to be infectious. A polymerase chain reaction was positive for Clostridium Difficile. Due to the failure to improve after full medical treatment, a derivative loop ileostomy and intra-operatory colonic lavage were performed, leaving a Foley catheter in the proximal colon. In the postoperative period, anterograde colonic instillations of Vancomycin flushes through the catheter were performed every 6 hours. Forty eight hours after surgery, the patient improved. A colonoscopy prior to discharge showed resolution of the pseudomembranous colitis.

Background: The neutrophil/lymphocyte ratio is an effective marker of inflammation ana can have prognostic value in surgical patients. Aim: To evaluate the effect of an increased neutrophil/lymphocyte ratio (NLR) on perioperative complications ana overall ana disease-free survival in patients undergoing elective resection for stage II colon cancer. Material and Methods: Data was obtained from clinical charts, preoperative blood results and hospital records of all patients undergoing an elective curative resection for colon cancer, between 2000 and 2007. Preoperative NLR was calculated. Follow-up was obtained from a prospectively maintained colorectal cancer database, clinical records and questionnaires. Uni and multivariable analysis were performed to identify associations, and survival analysis was performed using Kaplan-Meier curves. Results: One hundred twenty two patients with a mean age of69years (52% males), were evaluated. Median follow-up was 73 months, and overall survival for 1 and 5years was 95% and 68%, respectively. On a multivariable analysis after adjusting for age, sex, tumor depth invasion, use of adjuvant therapies and American Society of Anesthesiology preoperative risk score, an NLR > 5 was associated with an increased perioperative complication rate (odds ratio: 3,06, p = 0,033). Kaplan-Meier survival analysis showed a worse overall and disease-free survival for patients with NLR greater than five. Conclusions: A preoperative NLR of five or more is associated with greater perioperative morbidity and worse oncological outcomes in patients undergoing resection for elective stage II colon cancer.

Background: Colon perforation is an uncommon but feared complication of colonoscopy. The treatment is usually surgical but occasionally it does not require an operation. Aim: To report our experience in the diagnosis and management of colon perforation after colonoscopy. Material and methods: Retrospective review of the database of 11,720 colonoscopies. The medical records of those patients that had a perforation were reviewed. Results: Twelve perforations in patients aged 26 to 92 years (six women), were identified with a global perforation rate of 0.1%. Five occurred during diagnostic and seven during therapeutic procedures. All perforations were confirmed by a plain X ray or CT scan of the abdomen. Four patients, without signs of initial diffuse peritoneal irritation, were medically treated. One of these, finally required surgery. Among operated patients, a primary suture was done in five, a primary excision without colostomy in three and a Hartmann procedure due to a severe peritoneal contamination in one. No patient died. Conclusions: There is a higher risk of colon perforation during therapeutic colonoscopies. Selected cases may be safely treated without surgery

The first laparoscopic surgery for colorectal cancer was reported fifteen years ago. After a long period, the evidence seems to support this technique as a safety treatment for oncologic cases and for some authors there is no doubt that better result can be obtained. At our institution, a protocol in laparoscopic colorectal surgery was started in 1998, the main aim was to progress in oncologic cases according to complexity and advances in the learning curve. The aim of this paper is to analize early results and the safety of oncologic resection in patients who underwent laparoscopic surgery for colorectal cancer. Material and Method: This is a prospective study which include all patients operated on for colorectal cancer by laparoscopy between 1998 and 2004. Results: During this period, 131 patients underwent laparoscopic colorectal surgery and colorectal cancer was the indication for surgery in 32 patients (24%). The mean age was 64 year old (r: 26-88) and 47% of patients were female. The tumor location was rectum in 9 patients and colon in 23 patients (rigth 6, left 7 and sigmoid 10). The tumor resection was performed with curative intent in 29 patients. The surgical technique was sigmoid resection in 10 patients, left hemicolectomy in 7, right hemicolectomy in 6, low anterior resection in 4, abdominoperineal resection in 3 and restorative proctocolectomy with J pouch in two cases. Four patients were converted to open surgery (12%) due to anatomic dificulty. One or more complications were observed in 8 patients (25%) and one patient died after surgery. The mean number of lymph nodes retrieved was 23 (r: 4-86) and a positive histopathologic margin was not observed at any patient. According to TNM clasification, stage I, II, III and IV was observed in 31%, 28% 28% and 13% of patients respectively. The median time of passing flatus, solid oral feeding and hospital stay was 2 days, 3 days and 5 days respectively. All patients have been followed up (mean time 16.4 months) and no tumor trocar implants have been observed. No tumor progression have been observed in any stage I or II patients. Conclusion: Working under a protocol allows to obtain satisfactory surgical results. Considering results obtained from the surgical specimens and a short follow-up, looks like colorectal cancer can be treated by laparoscopy whitout compromising the oncologic standard observed after open surgery

Han pasado 15 años desde la primera publicación de una cirugía laparoscópica por cáncer colorrectal (CLCC) y finalmente parece ser que la evidencia la apoya, e incluso para algunos autores es indiscutible que se obtendrían mejores resultados. En nuestra institución, el año 1998 se dio inicio a un protocolo en cirugía laparoscópica de colon, para abordar los casos oncológicos en forma progresiva y de acuerdo al avance en la curva de aprendizaje. El objetivo de este trabajo es analizar los resultados inmediatos y la seguridad de la resección oncológica en pacientes sometidos a una CLCC. Material y Método: Este es un trabajo prospectivo que incluye a todos los pacientes operados por cáncer colorrectal en el marco de un protocolo de desarrollo de la cirugía laparoscópica. Resultados: Entre septiembre de 1998 y agosto de 2004 se efectuaron 131 cirugías laparoscópicas colorrectales; en 32 (24%) de ellos el motivo de la intervención fue un cáncer colorrectal. La edad promedio fue 64 años (i: 26-88) y el 47% correspondió al sexo femenino. El tumor se encontraba localizado en el recto en 9 pacientes y en los 23 restantes en el colon (derecho 6, izquierdo 7 y sigmoides 10). La resección del tumor fue realizada con intención curativa en 29 pacientes. Las operaciones practicadas fueron: resección de colon sigmoides en 10 pacientes, hemicolectomía izquierda en 7, hemicolectomía derecha en 6, resección anterior baja en 4, resección abdóminoperineal en 3 y proctocolectomía más reservorio ileal en 2 pacientes. En 4 pacientes fue necesario convertir a cirugía convencional (12%) por dificultad anatómica. Una o más complicaciones se observaron en 8 pacientes (morbilidad de 25%) y un paciente fallece en la serie. El promedio de ganglios recuperados en la pieza operatoria fue 23 (4-86) y en ningún paciente se observó un margen microscópico positivo. De acuerdo a la etapificación TNM, los pacientes fueron clasificados como etapa I, II, III y IV el 31%, 28%, 28% y 13% respectivamente. La mediana del restablecimiento del tránsito a gases, realimentación con sólidos y estadía hospitalaria fue 2 días, 3 días y 5 días. Todos los pacientes han acudidos a controles postoperatorios regulares (promedio de seguimiento 16.4 meses) sin observar implantes en sitios de trocares en ninguno de ellos. No se ha observado progresión tumoral en ninguno de los pacientes etapa I y II. Conclusión: El trabajo en el marco de un protocolo permite obtener resultados seguros y similares a los publicados después de cirugía convencional. Considerando los resultados en las piezas operatorias y un seguimiento a corto plazo, se sugiere que la CLCC mantiene los criterios de seguridad oncológica de la cirugía convencional