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To describe the experience of the robotic approach for achalasia surgery in a tertiary center.Patients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed.45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211minutes. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered.In our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia.

Granular cell tumor is a very rare entity (0.03%) with controversial management, due to its low incidence and its usually benign behavior (98%). Its location in the digestive tract is unusual (3-11%), being the esophagus the most frequently affected organ, with about 400 published cases. However, the incidence in the cervical esophagus is anecdotal (20 published cases). We present a patient with an esophageal granular cell tumor that invaded trachea, thyroid and soft tissues, performing a block resection of the cervical esophagus, two tracheal rings, thyroid and prethyroid musculature. For digestive reconstruction, a free jejunum graft with microvascular anastomosis was made and tracheal reconstruction was performed using term-terminal anastomosis. The importance of the case is twofold: to contribute more casuistry, and to describe a highly complex surgical technique never indicated in this type of tumors, due to its rarely aggressive character.

Resumen Objetivo Analizar la morbimortalidad de la reconstruccion esofagica en un segundo tiempo en una unidad de cirugia esofagogastrica. Pacientes y metodo Desde enero de 2001 a octubre de 2006 se intervino a 20 pacientes a los que se realizo reconstruccion esofagica en un segundo tiempo con coloplastia o gastroplastia. Se ha analizado retrospectivamente la morbimortalidad de cada tecnica. Resultados Se intervino a 16 varones y 4 mujeres con una media de edad de 54,3 ± 17,5 anos. Los diagnosticos de la primera cirugia fueron: 7 por ingesta de causticos, 7 por sindrome de Boerhaave, 3 por perforacion iatrogenica, 1 por fistula traqueoesofagica, 1 por dehiscencia esofagoyeyunal y 1 por necrosis de la gastroplastia tras esofagectomia transhiatal. Se realizaron 14 (70%) coloplastias derechas, 4 (20%) coloplastias izquierdas y 2 (10%) gastroplastias con acondicionamiento gastrico. En 11 de los 20 pacientes se desestimo la gastroplastia por gastrectomia (8 casos) o cirugia gastrica previa (3 casos). Analizando la morbilidad destacan: derrame pleural (65%), insuficiencia respiratoria (45%), atelectasia (35%) y dehiscencia de anastomosis cervical (35%). Se reintervino a 5 pacientes: 3 por sepsis intraabdominal y 2 por hemoperitoneo. La mortalidad fue del 10% (2 casos). En el seguimiento posterior destaca 1 (5%) caso de estenosis de la anastomosis. Conclusiones La reconstruccion esofagica es una tecnica que en unidades especializadas presenta una mortalidad aceptable (10%) y una morbilidad no despreciable. La coloplastia es la tecnica mas utilizada en estos pacientes.

Resumen Introduccion El manejo del traumatismo abdominal cerrado ha variado mucho en los ultimos anos Material y metodos Estudiamos la aplicacion de un protocolo prospectivo a los pacientes con traumatismo abdominal cerrado durante un ano, con el objetivo de evaluar la utilidad del tratamiento no operatorio y su influencia en la morbimortalidad. Todos los pacientes atendidos siguiendo dicho protocolo fueron comparados con un grupo de pacientes previo Resultados Durante el periodo de estudio prospectivo, 65 pacientes fueron ingresados con traumatismo abdominal cerrado (grupo prospectivo [P]). Durante el periodo previo fueron atendidos 77 pacientes (grupo retrospectivo [R]). No hubo diferencias significativas entre ambos grupos en cuanto al sexo, la edad, la escala HIS (Haemodynamic Injury Scale) o el mecanismo de lesion. El 55% de los pacientes del grupo R fue intervenido, mientras que en el grupo P se intervino al 25% (p = 0,0005). Entre los pacientes con lesion esplenica, en el grupo R fue intervenido el 85%, mientras que en el grupo P solo el 50% (p = 0,03). Entre los pacientes con lesiones hepaticas fue intervenido el 70% en el periodo R y solo el 16% en el periodo P (p = 0,05). No hubo diferencias significativas entre los grupos R y P en la estancia hospitalaria, la estancia en UCI, la transfusion y la mortalidad hospitalaria Conclusiones La aplicacion de un protocolo de manejo de los pacientes con traumatismo abdominal cerrado permite el tratamiento no operatorio en la mayoria de los casos sin aumentar la morbimortalidad, la estancia hospitalaria o los requerimientos transfusionales, evitando la morbilidad ocasionada por la propia cirugia

Treatment of oesophageal cancer with curative intent requires a multidisciplinary approach. Neoadjuvant therapy, the radicality of resection and extension of lymphadenectomy have been associated with increased operative morbidity and mortality. The aim of this study was to assess the results of surgical treatment of oesophageal cancer since the presence of an interdisciplinary esophagogastric tumour board.Patients with cancer of the oesophagus and oesophagogastric junction who underwent oesophagectomy between January 2005 and March 2012 were included in this retrospective study. Data concerning type of resection, postoperative complications, mortality and survival were analysed.Of the 392 patients with a diagnosis of oesophageal cancer over the study period, 100 underwent oesophagectomy. Seventy-four patients received neoadjuvant treatment. Eighty-two patients underwent transthoracic resection while a transhiatal was used in 10 patients. Colon interposition was required in 8 cases. An R0 resection was achieved in 98 patients. Anastomotic leaks developed in 15 patients, 9 were intrathoracic and 6 were cervical. Postoperative morbidity occurred in 42% of patients, and intra-hospital and 90-day mortality was 2%. Median length of hospital stay was 16 days. The respective actuarial survival at 1 and 5 years were 82% and 56%.Surgical treatment with curative intention for oesophageal cancer is only possible in a quarter of patients diagnosed. The high morbidity rate was mainly due to intrathoracic complications.

Introduction Oesophageal reconstruction in a second time is a complex surgical operation which, in some cases, requires combining microvascular techniques to increase vascular flow to the conduit. «Supercharged» ileocoloplasty allows creation of a longer conduit that makes it possible to replace the entire oesophagus. We describe our initial experience with this technique for the total reconstruction of the oesophagus. Material and methods A retrospective review of the period from October 2007 to December 2009 identified 4 patients on whom a deferred oesophageal reconstruction was performed with a “supercharged” ileocoloplasty. The indications of this technique, morbidity and mortality, as well as functional results during follow up were evaluated. Results The indications of this technique were: previous failure of a left colon interposition (1), oesophageal disconnection due to a gastro-pleural fistula (1), total oesophagogastrectomy (1) and partial oesophagogastrectomy (1) due to the ingestion of caustic substances, respectively. Gastrointestinal complications were the most frequent. Two cervical fistulas were diagnosed which were resolved with an absolute diet, antibiotic therapy and enteral nutrition. There was no mortality. After a median follow up of 14.7 months, two patients were nourished exclusively by mouth, one by a mixed route (oral-enteral) and another exclusively by the enteral route due to an oesophageal stenosis 11 centimetres from the dental arch; this patient required dilations and is awaiting a jejunal graft. Conclusions “Supercharged” ileocoloplasty is a complex treatment option for the total reconstruction of the oesophagus when no other alternatives are available. Postoperative morbidity is significant but the functional results are good.

To analyze the morbidity and mortality of second time esophageal reconstruction in an Esophagogastric Unit.Second time esophageal reconstruction surgery with coloplasty and gastroplasty was performed on 20 patients, from January 2001 to October 2006. The morbidity and mortality of each technique has been analyzed retrospectively.The mean age of the 16 males and 4 women operated on was 54.3 +/- 17.5 years. The diagnoses at the first surgery were: 7 caustic ingestions, 7 Boerhaave syndrome, 3 iatrogenic perforations, 1 tracheal-esophageal fistula, 1 esophageal-jejunal dehiscence and 1 necrosis of the gastroplasty after transhiatal oesophagectomy. There were 14 (70%) right coloplasties, 4 (20%) left coloplasties and 2 (10%) gastroplasties with gastric conditioning. In 11 of the 20 patients gastroplasty was ruled out due to gastrectomy (8 cases) or previous gastric surgery (3 cases). It was noted on analyzing the morbidity: pleural effusion (65%), respiratory failure (45%), atelectasis (35%) and cervical anastomosis dehiscence (35%). Five patients were re-intervened: 3 due to intra-abdominal sepsis and 2 due to hemoperitoneum. Mortality was 10% (2 cases). In subsequent follow up there was 5% (1 case) of stenosis of the anastomosis.Esophageal reconstruction technique which in specialist units has an acceptable mortality rate (10%) and an insignificant morbidity. Coloplasty was the technique most used on these patients.

The patient is a 52-year-old male diagnosed with adenocarcinoma of the distal esophagus in Barrett’s esophagus, cT3N+M0. He was treated with neoadjuvant radiotherapy and chemotherapy as well as esophagectomy with three-field lymph node dissection following the McKeown technique. Thirty days after being discharged from the hospital, he was diagnosed with a left laterocervical mass. Ultrasound demonstrated a vascular tumor formation. Further study with CT angiography (Fig. 1) revealed a partially thrombotic pseudoaneurysm of the left transverse cervical artery. Selective embolization was performed (Fig. 2), which provided satisfactory improvement. Although pseudoaneurysm of the transverse cervical artery is an uncommon complication, it should be considered after cervical lymph node dissection. c i r e s p . 2 0 1 4 ; 9 2 ( 4 ) : e 1 5

En referencia a la carta al director del Dr. Escrig, queriamos hacer algunos comentarios. En primer lugar, hay que destacar el hecho de que, tal como describimos en nuestro trabajo, el principal objetivo de la aplicacion del protocolo de actuacion en el tratamiento de los traumatismos abdominales cerrados no es incidir en la mortalidad, que al ser pacientes en su mayor parte afectados de traumatismo en otros organos (TCE, etc.), depende de muchos aspectos, sino sobre todo permitir la aplicacion de un tratamiento no operatorio con la mayor seguridad posible, hecho que creemos queda demostrado en el trabajo publicado. Tal como se describe, el protocolo se basa en la utilizacion de diferentes metodos diagnosticos y terapeuticos (arteriografia) que, en un elevado porcentaje de casos, permiten evitar el tratamiento quirurgico, y en muchos casos de laparotomias exploradoras. Asi pues, el estudio descrito permite afirmar que es posible la aplicacion de un protocolo de estudio y manejo del traumatismo abdominal cerrado que permita incrementar la aplicabilidad de un tratamiento no operatorio con seguridad y eficacia, incluso en centros con mucho menor numero de casos que los grandes centros traumatologicos, donde clasicamente se habian descrito protocolos similares. Por otra parte, es precisamente con un numero de casos limitado (que refleja la incidencia habitual en nuestro medio) que queriamos comprobar la aplicabilidad del protocolo descrito, para que podamos concluir que es aplicable en la mayor parte de centros y no solo en grandes centros traumatologicos. Sin embargo, querriamos agradecer la aportacion del Dr. Escrig, pues, tal como el refiere, la metodologia de las pruebas de hipotesis estan lastradas por el tamano muestral, y, ademas, solo permite tomar decisiones dicotomicas sobre las hipotesis. Por ello, el enfoque bayesiano es una alternativa muy atractiva para un mejor analisis de los datos. De todas maneras, en caso de realizar el analisis por este procedimiento, este deberia realizarse respecto a todos los datos analizados, o los de mayor relevancia, como el porcentaje de intervencion o el numero de laparotomias exploradoras.