Abstract 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.

Resumen 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.

Abstract Esophageal cancer surgery is a challenge despite the advances in surgical techniques and perioperative care. It continues to have high rates of complications and mortality, even in large volume centers. This paperrevises the epidemiology, staging and therapeutic options for esophageal cancer, according to its stage andlocation. It also encompasses the digestive tract reconstruction options, according to our own experience andreports from abroad.

Resumen La cirugía del cáncer de esófago ha sido y sigue siendo un desafío pese a los avances en técnica quirúrgica y cuidados peri operatorios y a pesar de que las complicaciones postoperatorias y la morbimortalidad sigue siendo alta, aún en centros con alto volumen de procedimientos y más aún en centros no dedicados a laatención de estos pacientes. En este artículo se revisarán algunos aspectos epidemiológicos, las herramientasdiagnósticas actuales, su etapificación, y las opciones terapéuticas de acuerdo al estadío, sea en etapas precoces o avanzadas, la localización y tipo de tumor, opciones de reconstrucción del tránsito digestivo en base alo reportado en la literatura internacional, la experiencia nacional y en base a nuestros propios resultados enel Departamento de Cirugía del Hospital Clínico de la Universidad de Chile.

Background: Minimally invasive surgery reduced the incidence of postoperative complications. Many benign or malignant esophageal diseases can be treated with this technique. Aim: To report our experience with the technique in the treatment of esophageal tumors. Material and Methods: Analysis of a cohort of 85 patients with esophageal tumors aged 28 to 82 years (59 males). Sixty seven had esophageal cancer, 14 had leiomyomas or esophageal stromal tumors and four had duplication cysts. All were subjected to minimally invasive surgery. Short and long term results were recorded. Results: Forty three percent of patients with cancer had complications and 2.9% died. No complications were recorded among patients with stromal tumors or duplication cysts. Conclusions: Minimally invasive surgery is a feasible and safe therapeutic approach for patients with esophageal tumors.

Introducción: En las últimas dos décadas, la implementación de técnicas quirúrgicas mínimamente invasivas ha colaborado en la reducción de las complicaciones intra y postoperatorias. Un amplio espectro de enfermedades del esófago, benignas o malignas, pueden ser tratadas por medio de estas técnicas. Objetivo: Se presenta nuestra experiencia en el tratamiento quirúrgico de la patología tumoral esofágica y se hace una revisión de las indicaciones y resultados publicados en la literatura internacional. Material y Método: Se trata de 85 pacientes operados desde 1993 a la fecha, 67 corresponden a cáncer esofágico, 14 casos operados por leiomomas o tumores estromales esofágicos y 4 pacientes con quistes de duplicación. Todos fueron sometidos a cirugía mini invasiva de acuerdo a técnicas descritas previamente. Se analizan y discuten los resultados a corto y largo plazo y se discuten los resultados a la luz de los datos de la literatura internacional. Resultados: En los pacientes sometidos a esofagectomía por cáncer, las complicaciones ocurrieron en 43% y la mortalidad actual es de un 2,9%. En pacientes operados por tumores estromales o quistes de duplicación no hubo complicaciones postoperatorias ni mortalidad. En las otras patologías hubo mínima morbilidad y no hubo mortalidad, resultados que son comparables a la literatura consultada. Conclusión: Las técnicas de cirugía mínimamente invasiva diseñadas para el abordaje de los diversos tipos de patologías que afectan al esófago, resultan por lo general, altamente factibles de realizar, con buenos resultados en cuanto a complicaciones y mortalidad postoperatoria.

RACIONAL: O tratamento cirúrgico do câncer de esôfago está associado com alta morbidade e mortalidade. Os acessos transtorácicos abertos ou os transmediastinais são considerados procedimentos invasivos e têm sido associados à altas taxas de complicações e de mortalidade operatória. Desta forma, a operação do esôfago minimamente invasiva tem sido sugerida como alternativa aos procedimentos clássicos, porque iria produzir melhora no desempenho pós-operatório a longo prazo. OBJETIVO: Avaliar a sobrevida, mortalidade e morbidade da esofagectomia por câncer de esôfago submetidos às técnicas minimamente invasivas e compará-los com os resultados publicados na literatura internacional. MÉTODO: Estudo observacional, prospectivo. Entre 2003 e 2012, 69 pacientes foram submetidos à esofagectomia minimamente invasiva devido ao câncer. Foram analisadas morbidade e mortalidade pós-operatória de acordo com a classificação Clavien-Dindo. A taxa de sobrevivência foi analisada pelo método de Kaplan-Meier. O número de nódulos linfáticos obtidos durante a dissecção do nódulo linfático foi analisado como um índice da qualidade da técnica cirúrgica. RESULTADOS: 63,7% dos pacientes tiveram complicações menores (tipo I-II Clavien Dindo), enquanto nove (13%) necessitaram de re-exploração cirúrgica. A complicação pós-operatória mais comum correspondeu a deiscência da anastomose cervical observada em 44 (63,7%) pacientes, mas sem suas repercussões clínicas, apenas dois deles necessitaram de reoperação. A taxa de mortalidade foi de 4,34%, e reoperação foi necessária em nove (13%) casos. O tempo médio de sobrevivência foi de 22,59±25,38 meses, com a probabilidade de uma taxa de sobrevida em três anos estimada em 30%. O número de linfonodos ressecados foi 17,17±9,62. CONCLUSÃO: As técnicas minimamente invasivas têm menor morbidade e mortalidade, satisfatório número de linfonodos ressecados e resultados a longo prazo semelhantes após operação aberta, em termos de qualidade de vida e sobrevida.

BACKGROUND: Surgical treatment of esophageal cancer is associated to a high morbidity and mortality rate. The open transthoracic or transhiatal esophagectomy are considerably invasive procedures and have been associated to high rates of complications and operative mortality. In this way, minimally invasive esophageal surgery has been suggested as an alternative to the classic procedures because would produce improvement in clinical longterm postoperative outcomes. AIM: To assess survival, mortality and morbidity results of esophagectomy due to esophageal cancer submitted to minimally invasive techniques and compare them to results published in international literature. METHOD: An observational, prospective study. Between 2003 and 2012, 69 patients were submitted to a minimally invasive esophagectomy due to cancer. It was recorded postoperative morbidity and mortality according to the Clavien-Dindo classification. The survival rate was analyzed with the Kaplan-Meier method. The number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique, was analysed. RESULTS: 63.7% of patients had minor complications (type I-II Clavien Dindo), while nine (13%) required surgical re-exploration. The most common postoperative complication corresponded to leak of the cervical anastomosis seen in 44 (63.7%) patients but without clinical repercusion, only two of them required reoperation. The mortality rate was 4.34%, and reoperation was necessary in nine (13%) cases. The average survival time was 22.59±25.38 months, with the probability of a 3-year survival rate estimated at 30%. The number of resected lymph nodes was 17.17±9.62. CONCLUSION: Minimally invasive techniques have lower morbidity and mortality rate, very satisfactory lymphnodes resection and similar long term outcomes in term of quality of life and survival compared to results observed after open surgery.

Background: Minimally invasive surgical techniques are increasingly used for the treatment of benign esophageal diseases. Aim: To report the results of minimally invasive surgical techniques among patients with benign esophageal diseases. Material and Methods: Four hundred eighty three patients aged 37 to 81 years (184 males), were studied. Of these, 278 had a Barret esophagus, 125 had a hiatal hernia, 75 had achalasia and five had esophageal diverticula. All patients were studied using standard protocols, operated using minimally invasive techniques and followed, registering postoperative complications and recurrence of symptoms. Results: Among patients with esophageal reflux, 85% had successful results on the long term. Among patients with hiatal hernia and subjected to laparoscopic surgery, 12% had complications and 12% had recurrence of symptoms which increased to 17% if a mesh was not used. The recurrence rate among patients with achalasia is less than 5%. There was no recurrence among patients with esophageal diverticula. Conclusions: Minimally invasive surgery for esophageal diseases has good success rates, with a lower incidence of complications than open surgery.

Introducción: En este artículo se presenta la experiencia de nuestro grupo de trabajo de los resultados obtenidos en el tratamiento quirúrgico con técnicas mínimamente invasivas en patología esofágica benigna. Material y Método: Se analizan los resultados en pacientes sometidos a cirugía antirreflujo por enfermedad por reflujo gastroesofágico, esófago de Barrett, tratamiento de las hernias hiatales, acalasia esofágica y diver-tículos esofágicos. Resultados: Los resultados obtenidos por nuestro grupo son comparables a los que señala la literatura internacional, con mínima morbilidad y sin mortalidad. En pacientes con reflujo gastroesofágico, los resultados a largo plazo presentan una tasa de éxito en el 85% de los casos. En pacientes con hernia hiatal operados por vía laparoscópica las complicaciones son cercanas al 12% y la recurrencia es de un 12% en promedio, pero se eleva al 17% cuando no se usa malla. En Acalasia por otro lado, la tasa de recurrencia es menor a un 5%. Los pacientes operados por divertículos esofágicos no presentan recidiva. Conclusiones: Las técnicas de cirugía mínimamente invasiva diseñadas para el abordaje de los diversos tipos de patologías que afectan al esófago, resultan por lo general, altamente factibles de realizar por cuanto reproducen los resultados de la cirugía abierta pero con menor tasa de complicaciones.

Background: Minimally invasive surgery has the advantage of a lower rate of complications and can be used for benign esophageal diseases. Aim: To report a single surgeon experience with laparoscopic surgery for benign esophageal diseases. Material and Methods: Prospective analysis of 421 patients (160 males) with benign esophageal disease, who were subjected to laparoscopic surgery by a single surgeon. Immediate mortality, surgical complications and long term results in terms of symptoms recurrence, were analyzed. Results: The underlying diagnoses of the operated patients were Barrett's esophagus or esophagitis in 257, hiatal hernia in 91, achalasia in 68 and esophageal diverticula in five. Surgery obtained successful results in 90% of patients with Barrett's esophagus. Among patients with hiatal hernia, there was a 12% rate of complications and a 30% recurrence, when a mesh was not used. Among patients with achalasia the recurrence rate was less than 5%. Conclusions: Laparoscopic surgery has a fair success rate in benign esophageal diseases, with a lower rate of complications.

The pedicle transverse rectus abdominus myocutaneous flap (TRAM) is widely used for breast reconstruction, however is not exempt from complications. Between 2004 and 2010 the authors performed breast reconstruction after total mastectomy in 52 patients with pedicled TRAM flaps. Purpose: To describe the demography, outcomes and complications in patients operated for breast cancer and reconstructed with TRAM flap. To assess the influence of smoking, the laterality and timing of reconstruction. Material and Method: Retrospective, observational and comparative. We reviewed the medical records of 52 patients operated by the authors between 2004 and 2010. Four cases were excluded due to incomplete data. Results: In the 48 patients studied were 50 TRAM flaps. The most frequent comorbidity was smoking (27%). Regarding the timing of reconstruction, 74% (37) was performed immediately post-mastectomy and 26% (13) was deferred. Was used by 78% (39) ipsilateral TRAM, 18% (9) contralateral and 4% (2) bilateral. Only minor complications were observed and the cosmetic result evaluated by the surgeon's satisfaction was very good or excellent in 62% (31). Smoking, timing of reconstruction and laterality did not affect in complications or cosmetic outcome (p > 0.05). Conclusions: The pedicled TRAM flap is an excellent alternative for reconstruction in breast cancer patients. It is not exempt from complications, with a tendency to get better cosmetic results in the non-smoker group.

El colgajo de recto abdominal con isla transversal de piel infraumbilical (TRAM) pediculado es ampliamente utilizado para la reconstrucción mamaria, sin embargo, no está exento de complicaciones. Entre los años 2004 y 2010 los autores realizaron reconstrucción mamaria post-mastectomía total en 52 pacientes con colgajos TRAM pediculados. Objetivo: Describir la demografía, resultados y complicaciones de las pacientes operadas por cáncer de mama y reconstruidas con colgajo TRAM. Evaluar la influencia del tabaquismo, la lateralidad y el momento de la reconstrucción en dichos resultados. Material y Método: Diseño retrospectivo, observacional y comparativo. Se revisaron las historias clínicas de las 52 pacientes operadas por los autores entre los años 2004-2010. Se excluyeron 4 casos por datos incompletos. Resultados: En las 48 pacientes estudiadas se realizaron 50 colgajos TRAM. La comorbilidad más frecuente fue el tabaquismo (27%). La reconstrucción se realizó en un 74% (37) de manera inmediata postmastectomía y en un 26% (13) fue diferido. Se utilizó en un 78% (39) TRAM ipsilateral, 18% (9) contralateral y 4% (2) bilateral. Sólo se observaron complicaciones menores; el resultado estético evaluado por la satisfacción del cirujano fue muy bueno o excelente en un 62% (31). El tabaquismo, momento de la reconstrucción y la lateralidad no influyeron en las complicaciones ni en el resultado estético (p > 0,05). Conclusiones: El colgajo TRAM pediculado es una excelente alternativa de reconstrucción en pacientes mastectomizadas. No está exento de complicaciones, con una tendencia a obtener mejores resultados estéticos en el grupo no fumador.