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Resumen Objetivo Describir la experiencia del abordaje robotico en la cirugia de la acalasia en un centro de tercer nivel. Material y metodos Se analizaron los pacientes con acalasia intervenidos mediante cirugia robotica entre mayo de 2010 y abril de 2019. Las variables a estudio se recogieron en una base de datos prospectiva y se realizo un analisis descriptivo. Resultados Se incluyeron 45 pacientes (55,6% varones) con edad media de 44 anos. El sintoma principal al diagnostico fue la disfagia. Diecinueve pacientes (42,2%) habian recibido tratamiento endoscopico previo a la cirugia, mayoritariamente dilatacion neumatica (84,2%). La tecnica quirurgica empleada fue la miotomia de Heller asociada a funduplicatura tipo Toupet, con un tiempo operatorio medio de 211 minutos. La estancia media fue 5 dias. Se produjeron 2 perforaciones postoperatorias (4,4%). La mortalidad peroperatoria fue del 0%. El seguimiento medio fue de 64 meses. A 3 y 5 anos se evidencio una importante disminucion del Eckardt score y el estudio manometrico mostro una disminucion de la presion del esfinter esofagico inferior en reposo media del 58% y del 70%, respectivamente, con persistencia de hipomotilidad del cuerpo esofagico. En dos pacientes (5,4%) se diagnostico reflujo gastroesofagico patologico y 4 (10,8%) presentaron recurrencia de los sintomas, requiriendo dilataciones neumaticas endoscopicas. En 2 casos las dilataciones no fueron efectivas por lo que se planteo la realizacion de una miotomia endoscopica. Conclusiones Segun nuestra experiencia, la cirugia robotica constituye un procedimiento seguro y efectivo para el tratamiento de la acalasia.

Resumen La cirugia minimamente invasiva permite el tratamiento de los tumores de la union esofagogastrica en condiciones de seguridad, reduciendo las complicaciones respiratorias y parietales y mejorando la recuperacion postoperatoria, manteniendo ademas los principios de la cirugia oncologica que permitan obtener unos resultados optimos de efectividad a largo plazo. Para ello, es necesario un volumen de actividad suficiente y avanzar en la curva de aprendizaje de forma tutelada, para poder garantizar una reseccion R0 y una linfadenectomia adecuada. La minima invasion no puede ser un objetivo en si misma. En caso de gastrectomia total, el riesgo de afectacion del margen proximal obliga a verificarlo mediante biopsia intraoperatoria, sin descartar la cirugia abierta de entrada. Por su parte, la esofagectomia minimamente invasiva se ha ido imponiendo progresivamente. Su principal dificultad, la anastomosis intratoracica, puede realizarse mediante una sutura laterolateral mecanica o manualmente asistida por robot, gracias a la vision tridimensional y a la versatilidad del instrumental.

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.

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.

Resumen Introduccion El tratamiento del cancer de esofago con pretension curativa requiere un planteamiento multidisciplinar. La terapia neoadyuvante, la radicalidad de la reseccion y la extension de la linfadenectomia pueden incrementar la morbimortalidad postoperatoria. El objetivo de este estudio es analizar los resultados del tratamiento quirurgico del cancer de esofago desde la creacion del Comite de Tumores Esofagogastricos. Metodos Estudio retrospectivo (de enero de 2005 a marzo de 2012) de todos los pacientes con cancer de esofago o de la union esofagogastrica a los que se les realizo una esofagectomia. Se analizaron el tipo de reseccion, las complicaciones postoperatorias, la mortalidad y la supervivencia. Resultados : A 100 pacientes de un total de 392 diagnosticados se les realizo una esofagectomia. En 74 casos se administro tratamiento neoadyuvante. Se realizaron 82 esofagectomias transtoracicas en 2 o 3 campos, 10 esofagectomias transhiatales y 8 coloplastias. En 98 pacientes la reseccion fue R0. Se diagnosticaron 9 dehiscencias anastomoticas intratoracicas y 6 cervicales. La morbilidad global fue del 42% y la mortalidad hospitalaria y a los 90 dias fue del 2%. La mediana de la estancia hospitalaria fue de 16 dias. La supervivencia actuarial al ano es del 82% y a los 5 anos, del 56%. Conclusiones El tratamiento quirurgico con intencion curativa de la neoplasia de esofago solo es posible en una cuarta parte de los pacientes diagnosticados. La elevada morbilidad se debe, sobre todo, a complicaciones toracicas.

Introduction 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. Methods 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. Results 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%. Conclusions 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.

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.

Esophageal cancer represents a high-risk group of patients. This study determines the association of artificial nutrition with morbidity, mortality, and survival and studies clinical situations that determine the choice between enteral (EN) and parenteral support (PN). This retrospective single-center study compared 2 periods: 1) treatment centered in surgical process with discretionary demand of support, and 2) elective therapeutic and nutritional interventions were systematized. Risks factors that determined use of PN and survival were included in 4 multivariate regression models: 2 logistic, 1 multinomial, and a survival Cox analysis. Significance determined with 95% confidence interval (CI) of 95%; inclusion criteria was P0.1. During an 11-yr period, 175 patients were studied. Artificial nutrition consisted of 45 jejunostomy EN, 28 PN, and 102 both. Risk factors that conditioned PN were first period (OR: 2.41; 95% CI: 1.13-5.14), stay in intensive care unit (ICU)3 days (OR: 1.70; 95% CI: 0.93-3.71), and surgical reintervention (OR: 3.83; 95% CI: 0.94-16.95). Risk factors associated with mortality were first period (OR: 22.7; 95% CI: 2.31-172.05), respiratory infection (OR: 11.23; 95% CI: 2.33-55.5) and coloplasty surgery (OR: 13.16; 95% CI: 2.11-83.33). Longer survival was associated with second period (OR: 2.36; 95% CI: 1.38-4.05) and lower neoplasm staging (OR: 1.43; 95% CI: 1.21-1.69). A multidisciplinary management that includes nutritional support of esophagectomized patients is 1 of the factors that improves survival. Protocol implies greater use of EN; PN remains an important nutritional therapy.

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.