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.

Cutaneous necrosis is a rare but serious complication, among patients treated with warfarin or acenocumarol derivatives. We report a 71 years old female with a history of deep venous thrombosis, receiving acenocumarol for three months. The treatment was discontinued, but had to be restarted, due to a new episode of thrombosis. Three days after restarting acenocumarol, the patient consulted for ecchymosis and pain of the right foot. At physical examination, there was distal cyanosis and absence of distal pulses. The patient was subjected to an embolectomy with the suspicion of an acute arterial occlusion, but no emboli were found. Due to the possibility of a cutaneous necrosis caused by Acenocumarol, the medication is discontinued. The cutaneous lesions progressed and eight days after the failed embolectomy, a gangrene of the right foot was diagnosed. The patient did not accept amputation dying fourteen days after the first intervention.

A propósito un caso registrado, se resume la historia clínica y se revisa la literatura, dada la escasa frecuencia de esta complicación derivada del tratamiento por anticoagulantes orales. La necrosis cutánea es un evento adverso raro, pero serio, de la anticoagulación con derivados de acenocumarol o warfarina. Se comunicó por primera vez en 1943. La incidencia de la necrosis cutánea inducida por anticoagulantes orales es de 0,01 al 0,1% de los pacientes tratados. El número de casos publicados en el mundo es de aproximadamente 300, y menos de 100 en lengua inglesa en las últimas tres décadas. Este trabajo reporta el caso de una paciente que presenta necrosis cutánea en hombro izquierdo y pierna derecha.

We report a 27 years old woman presenting with hematochezia. An upper endoscopy and colonoscopy did not reveal the bleeding site. Due to persistence of bleeding, the patient was operated, finding a fibrinous secretion surrounding bowel loops and a hyper vascularized concentric papular lesion. The involved bowel loop was excised. The pathological study of the surgical piece revealed intestinal tuberculosis. The patient started treatment for extra pulmonary tuberculosis.

Reportamos el caso de una paciente de 27 años con tuberculosis extrapulmonar gastrointestinal que se manifestó clínicamente como una hemorragia digestiva baja masiva exanguinante requiriendo cirugía de urgencia, donde se realizó laparotomía exploradora con entero y colonoscopia intraoperatoria localizando lesión a nivel de intestino delgado, resecando segmento comprometido con anastomosis primaria, evolución satisfactoria sin complicaciones postoperatorias.