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Introducción: Las fístulas aorto-entéricas (FAE) son una causa infrecuente de hemorragia digestiva. El pronóstico, generalmente ominoso, depende de una alta sospecha clínica y diagnóstico oportuno.Caso clínico: Reportamos el caso de una mujer de 66 años intervenida por un aneurisma sacular aórtico abdominal (AAA) yuxta-renal, con rotura contenida, fistulizado al duodeno. Presentó una hemorragia digestiva en el preoperatorio; sin embargo, el diagnóstico de la fístula se hizo en el intraoperatorio. La paciente fue sometida a reparación quirúrgica urgente con instalación de una prótesis aórtica bifemoral y resección duodenal. En el postoperatorio inmediato presentó una trombosis parcial de las ramas de la prótesis aórtica e isquemia de extremidades, siendo reintervenida exitosamente.Discusión: La FAE es una causa potencialmente fatal de hemorragia digestiva. El diagnóstico continúa siendo un desafío debido a su presentación inespecífica y siempre debiese ser considerado frente a una hemorragia digestiva sin causa aparente. Existen varias opciones para el enfrentamiento quirúrgico que deben ser analizadas caso a caso, sin retrasar la reparación de la fístula. Es preferible la resección duodenal ante la simple duodenorrafia.

This paper deals with quality from the perspective of structure, processes and indicators in surgery. In this specialty, there is a close relationship between effectiveness and quality. We review the definition and classification of surgical complications as an objective means of assessing quality. The great diversity of definitions and risk assessments of surgical complications hampered the comparisons of different surgical centers or the evaluation of a single center along time. We discuss the different factors associated with surgical risk and some of the predictive systems for complications and mortality. At the present time, standarized definitions and comparisons are carried out correcting for risk factors. Thus, indicators of mortality, complications, hospitalization length, postoperative quality of life and costs become comparable between different groups. The volume of procedures of a determinate center or surgeon as a quality indicator is emphasized.

La Sociedad de Cirujanos de Chile en concordancia con su misión, actualizó las propuestas en relación a la formación en la especialidad, trabajo que se había iniciado en el año 2008. Para este efecto se nombró una Comisión que fijó los delineamientos e invitó a sus pares a un taller de trabajo. Participaron 20 cirujanos, quienes se dividieron en grupos con un moderador y se discutieron las siguientes temáticas: caracterización del cirujano recién formado, características de los planes de formación, rol de la Sociedad de Cirujanos en la formación, impacto del desarrollo de las especialidades derivadas en la formación y en el desempeño del cirujano general, además de temas que surgieron de la discusión central. Cada grupo entregó las conclusiones de su análisis, las que fueron consolidadas en sucesivas sesiones de la Comisión. Sus resultados representan la base del presente informe.

Introducción: El Carcinoma Hepatocelular (HCC), tumor hepático primario más frecuente, se presenta en general en hígados cirróticos. Un porcentaje menor se desarrolla en pacientes sin cirrosis, en los cuales deben buscarse otras etiologías. Paciente y Método: Se presenta un caso clínico y las características anato-mopatológicas de una paciente con hepatocarcinoma e hígado no cirrótico tratada en nuestro centro. Mujer de 62 años, con historia de dolor abdominal y baja de peso. Estudio por imágenes revela masa hepática de aproximadamente 8 cm de diámetro mayor, en segmentos II, III y IV, sugerente de HCC. Resultados: Se realiza hepatectomía izquierda. Evoluciona de forma satisfactoria en el postoperatorio. La biopsia muestra un HCC moderada a pobremente diferenciado. El tejido no tumoral es normal, con gránulos intracitoplasmáticos Pas y Pas diastasa (+). Inmunohistoquímica identifica gránulos intracitoplasmáticos de antitripsina, con lo que se confirma la sospecha diagnóstica de déficit de α-1 antitripsina.

This paper deals with quality from the perspective of structure, processes and indicators in surgery. In this specialty, there is a close relationship between effectiveness and quality. We review the definition and classification of surgical complications as an objective means of assessing quality. The great diversity of definitions and risk assessments of surgical complications hampered the comparisons of different surgical centers or the evaluation of a single center along time. We discuss the different factors associated with surgical risk and some of the predictive systems for complications and mortality. At the present time, standarized definitions and comparisons are carried out correcting for risk factors. Thus, indicators of mortality, complications, hospitalization length, postoperative quality of life and costs become comparable between different groups. The volume of procedures of a determinate center or surgeon as a quality indicator is emphasized.

The Parochial Hospital of San Bernardo is an intermediate complexity hospital that functions in its original 115- year- old building. It is one of the oldest hospitals in the country. Driven by the local Catholic Church and despite multiple difficulties, the hospital has uninterruptedly served a progressively growing community, with medical care and spiritual support. In the last two decades, it also has incorporated teaching activities with Universidad de los Andes Medical School.

A través de la comunicación de la primera colecistectomía efectuada en Chile por el doctor Lucas Sierra Mendoza en 1899, se revisa el contexto quirúrgico de la época y se destacan las características de este distinguido cirujano. Con referencia a la experiencia inicial de Langenbuch, se expone la concepción etiopa-togénica de la enfermedad biliar litiásica y se recorre el camino de la colecistectomía en la centuria siguiente.

Se ha observado un aumento del número de mujeres que estudia medicina. No obstante, la incorporación de la mujer a la cirugía sigue siendo baja. En Chile no conocemos de información sobre este tema. Nuestro objetivo fue recopilar información que proporcionara cifras y tendencias en este sentido. Se obtuvo información de la Sociedad de Cirujanos de Chile (SCCh), del Capítulo Chileno del Colegio Americano de Cirujanos (CCh CAC), de la Comisión Nacional Autónoma de Especialidades Médicas (CONACEM) y de la Superintendencia de Salud de Chile (SS), hasta junio de 2011. La SCCh tiene 854 socios y 64 corresponden a mujeres (7,5%). El Capítulo Chileno del CAC tiene 162 miembros y 4 son mujeres (2,5%). Ante CONACEM se han certificado 1.070 cirujanos, de los cuales 80 son mujeres (7,5%). En el registro de la SS hay 1.177 cirujanos, 8,4% de sexo femenino. El año 1959 se incorporó la primera mujer a la SCCh. Desde ahí, el número ha sido progresivo, aumentando principalmente en las dos décadas recientes hasta alcanzar el 7,5% actual. No obstante este aumento, en todas las fuentes consultadas el porcentaje de mujeres en práctica quirúrgica es inferior al 10%. Pareciera ser que la mujer intenta realmente una mayor participación en el campo quirúrgico. Sin embargo, el "estilo de vida del cirujano", choca con una compatibilización mayor entre vida laboral y familiar. Creemos que hay espacio para investigaciones cualitativas en este campo, que reflejen mejor las motivaciones y dificultades de la mujer por acceder al mundo quirúrgico en nuestro medio.

The Parochial Hospital of San Bernardo is an intermediate complexity hospital that functions in its original 115- year- old building. It is one of the oldest hospitals in the country. Driven by the local Catholic Church and despite multiple difficulties, the hospital has uninterruptedly served a progressively growing community, with medical care and spiritual support. In the last two decades, it also has incorporated teaching activities with Universidad de los Andes Medical School.

Los condrosarcomas representan la tercera neoplasia osea maligna primaria. La ubicacion costal representa el 12%, siendo el tumor mas frecuente de las costillas. Se presenta con mayor frecuencia en la segunda y quinta decadas de la vida. Este tumor se clasifica histologicamente en grados 1, 2 y 3 en orden decreciente de diferenciacion. Para el grado 2, resecado oncologicamente, se observa una sobrevida a 10 anos del 64%; existiendo un 10% de riesgo de metastasis. La radioterapia tiene un escaso rol terapeutico y la quimioterapia no ha demostrado beneficios. Presentamos el caso de una mujer de 45 anos que consulto por un aumento de volumen sintomatico de la parrilla costal derecha, de tres meses de evolucion, cuya evaluacion a traves de tomografia axial y resonancia magnetica permitio delinear un tumor sarcomatoso de la pared con afectacion de costillas, musculos, diafragma, pleura, peritoneo e higado. Ademas se observaba escasa cantidad de liquido libre intraperitoneal. Fue resecado en block un condrosarcoma de 16,8 cm de eje mayor, grado 2, con compromiso de todos los planos de la pared, microfocos tumorales en capsula hepatica y celulas neoplasicas malignas en liquido peritoneal.

The attempts to colonize the Strait of Magellan soon followed the discovery of this route. PeDro Sarmiento de Gamboa, a Spanish sailor, established human settlements to fortify those lands and control the transit of vessels, especially those of English corsairs, which devastated Chilean and Peruvian coasts. During the summer of 1584, approximately 500 soldiers, artisans, priests, women and children established two villages called "Nombre de Jesús" and "Rey Don Felipe". From the beginning, these settlers had leadership and communication problems and difficulties to obtain food. After three winters only 17 to 18 people survived according to the testimony of one of the survivors, that was rescued by an English sailor named Cavendish, which renamed the village "Rey Don Felipe" as "Port Famine". When he observed the scenes of abandonment and death, he supposed that the settlers died due to lack of food. Other factors that facilitated the desolation were hypothermia, execution, anthropophagy and lesions caused by natives. There is also a possibility that intoxication by red tide (harmful algal bloom) could explain in part the finding of unburied corpses in the strait beaches.

The attempts to colonize the Strait of Magellan soon followed the discovery of this route. Pedro Sarmiento de Gamboa, a Spanish sailor, established human settlements to fortify those lands and control the transit of vessels, especially those of English cor-sairs, which devastated Chilean and Peruvian coasts. During the summer of 1584, approximately 500 soldiers, artisans, priests, women and children established two villages called “Nombre de Jesus” and “Rey Don Felipe”. From the beginning, these settlers had leadership and communication problems and difficulties to obtain food. After three winters only 17 to 18 people survived according to the testimony of one of the survivors, that was rescued by an English sailor named Cavendish, which rena-med the village “Rey Don Felipe” as “Port Famine”. When he observed the scenes of abandonment and death, he supposed that the settlers died due to lack of food. Other factors that facilitated the desolation were hypothermia, execution, anthropophagy and lesions caused by natives. There is also a possibility that intoxication by red tide (harmful algal bloom) could explain in part the finding of unburied corpses in the the strait beaches. (Rev Med Chile 2010; 138: 1456-1460).

The profile of the general surgeon has changed, aiming to incorporate new skills and to develop new specialties.To assess the quality of postgraduate General Surgery training programs given by Chilean universities, the satisfaction of students and their preferences after finishing the training period.A survey with multiple choice and Likert type questions was designed and applied to 77 surgery residents, corresponding to 59% of all residents of general surgery specialization programs of Chilean universities.Fifty five per cent of residents financed with their own resources the specialization program. Thirty nine percent disagreed partially or totally with the objectives and rotations of programs. The opportunity to perform surgical interventions and the support by teachers was well evaluated. However, 23% revealed teacher maltreatment. Fifty six percent performed research activities, 73% expected to continue training in a derived specialty and 69% was satisfied with the training program.Residents considered that the quality and dedication of professors and financing of programs are issues that must be improved. The opportunity to perform surgical interventions, obtaining a salary for their work and teacher support is considered of utmost importance.

Background: The profile of the general surgeon has changed, aiming to incorporate new skills and to develop new specialties. Aim: To assess the quality of postgraduate General Surgery training programs given by Chilean universities, the satisfaction of students and their preferences after finishing the training period. Material and methods: A survey with multiple choice and Likert type questions was designed and applied to 77 surgery residents, corresponding to 59% of all residents of general surgery specialization programs of Chilean universities. Results: Fifty five percent of residents financed with their own resources the specialization program. Thirty nine percent disagreed partially or totally with the objectives and rotations of programs. The opportunity to perform surgical interventions and the support by teachers was well evaluated. However, 23% revealed teacher maltreatment. Fifty six percent performed research activities, 73% expected to continue training in a derived specialty and 69% was satisfied with the training program. Conclusions: Residents considered that the quality and dedication of professors and financing of programs are issues that must be improved. The opportunity to perform surgical interventions, obtaining a salary for their work and teacher support are considered of utmost importance (Rev Med Chile 2009; 137: 940-5). (Key words: Education, medical, graduate; General surgery; Internship and Residency)

Gabriel Cano de Aponte was Governor of Chile since 1717 and until his death in 1733, being 68 years old. As a soldier, he was an experienced horse rider. The sequence of events that caused his death three months after an equestrian accident is unclear. A systematic clinical analysis of the latter is the main objective of this review. Historians have documented Cano de Aponte's "inclination for unbridled fun and equestrian exercises". During a holiday Cano de Aponte suffered a horse fall and subsequent crushing by the latter. It has been stated that a spinal lesion caused by the accident kept him bedridden for a period of three months, clear in reason and with intense pain, before his death. However, there is no evidence on historic data that conveys any typical sign associated with spinal injury following the accident. Therefore we suggest that Cano de Aponte suffered a complex pelvic ring fracture. The fact that he was prostrated, lucid, but suffered an intense pain best sustains the hypothesis of a pelvic fracture. After the initial period, one of the most common causes of death resulting from a pelvic fracture is deep venous thrombosis with secondary pulmonary thromboembolism. This must have been the sequence of events that most probably caused Cano de Aponte's death.

Los medicos sabemos muy bien que a unexamen no se le puede exigir que mida mas deaquello que para lo que fue creado. Con esaobservacion nos podemos situar frente al Exa-men Medico Nacional (EMN), valorarlo y dimen-sionar su aporte en la educacion medica actual.A comienzos del 2000, las facultades demedicina que constituian ASOFAMECH da-ban paulatino desarrollo a la implementacion deun examen final comun, para ser rendido portodos los egresados de la carrera de medicina.Fue disenado como un examen que midieraconocimientos y destrezas intelectuales, en basea 180 preguntas que abarcasen las areas demedicina interna y especialidades derivadas,pediatria, cirugia, obstetricia y ginecologia, sa-lud publica, psiquiatria y en menor proporcionespecialidades como oftalmologia, dermatolo-gia y otorrinolaringologia. Todas las preguntasdebian ser aportadas por las facultades asocia-das y evaluadas por sus representantes, para suvalidacion desde el punto de vista tecnico encuanto a su confeccion y del contenido, deacuerdo a su atingencia. En diciembre de 2007el EMN fue rendido por casi novecientos medi-cos recien titulados, provenientes de trece fa-cultades de medicina, que constituyen practica-mente la mitad de las facultades que estan enfuncionamiento en la actualidad.El EMN surgio como una necesidad de te-ner una observacion objetiva de los conoci-mientos teoricos de los egresados, al momentode la titulacion profesional. No puede ni debeconstituirse como una prueba que valide el ejer-cicio profesional, colocando un rendimiento mi-nimo en conocimientos teoricos como unicacondicion para poder ejercer la profesion en elpais. Por un lado, fue la respuesta frente a laaparicion de variadas escuelas de medicina,con orientaciones diferentes en cuanto a susenfasis y perfiles de egreso, de modo de pro-pender a que los conocimientos mas propios eirrenunciables de la carrera fuesen entregadosuniformemente y por tanto mensurables en cadamedico; y por otro se planteo como una medidatendiente a asegurar la calidad de la educacionmedica. De esa forma, el EMN es tambien unelemento que permite dar confianza ante laopinion publica, puesto que se trasforma en lamedida con la que los egresados de una escuelade medicina cumple con los objetivos acorda-dos al momento de definirse un perfil. Hastaaqui las cosas, es bastante claro lo esperabledel EMN y el desarrollo que ha tenido mereceuna entusiasta mirada.Sin embargo, en la formacion medica entranen escena otros elementos que una pruebacomo el EMN, al menos como esta estructuradaactualmente, no considera. En primer lugar es-tan las habilidades practicas que en mayor omenor medida son deseables al momento detitularse, y que ese novel medico podra desa

Ivan IV “The Terrible” was the first Tsar of all Russias and wascrowned in 1547. He extended Russian territories and opened the route to Siberia in successfulcampaigns against Tartars. He increased his personal power to the point of generating anautocracy that isolated him progressively from the council of Boyars. He had a complexpersonality and his acts were impregnated by a profound religiousness, episodes of rage, moodchanges and a sense of “personal fate”. All these traits configure the controversial “temporal lobepersonality”. The possible association between these personality traits and the eventual epilepsythat Ivan IV could suffer, is discussed. This association is called “temporal lobe syndrome”.Considering the mood changes, with severe irritability and episodes of control loss alternated withfeelings of guilt, sadness and isolation, another possibility is that the Tsar had an affective bipolardisorder or, less probably, a personality disorder (Rev Med Chile 2006; 134: 1465-69).(

Splenic artery aneurysms are rare and occur predominantly in women. Most of them are asymptomatic until rupture. We report a previously healthy 73 year-old woman who presented with non specific symptoms: dyspepsia and constipation. Laboratory tests were normal. Subsequent examinations (ultrasound and CT) showed a large aneurysm of the splenic artery without any sign of rupture. Endovascular treatment remained successfully performed using coil embolization. During a 12-months follow-up period, the patient was asymptomatic and no evidences of complications or splenic infarction were observed on CT scans

Background: Nearly 10% of emergency consultations are due to acute abdominal pain. In people over 65 years old, it can have atypical presentations, that retard the correct diagnosis and worsens prognosis. Aim: To study the causes, evolution and prognosis of acute abdomen in the elderly. Material and methods: Prospective study of 45 patients aged more than 65 years old (mean age ± SD, 75.7±7.7, 51% men) and 221 patients of less than 65 years old (mean age ± SD, 36.7±14.0, 48% men), consulting for acute abdomen in the emergency room. Results: Sixty six percent of elderly patients had concomitant diseases, that were multiple in 63%. In this age group, the causes accounting for 71% of acute abdominal pain were bilio-pancreatic diseases (31.1%), intestinal adhesive obstruction (17.7%), complicated abdominal wall hernia (13.7%), and complications of peptic ulcer disease (8.9%). Sixty four percent required surgical treatment and, in almost 50% the surgical risk was classified in ASA III or IV, according to the American Society of Anesthesiology. Thirty one percent had postoperative complications. Compared with their younger counterparts, elderly patients required significantly (p

Herod the Great was the founder of a dynasty that reigned on Judea for several generations. His birth date is estimated on year 73 AC and died at 70 years old. Descriptions of the final disease of Herod were obtained from the classical chronicles of Flavius Josephus, "The Jewish war" and "Jewish Antiquities". A medical explanation for his death is attempted. A parasitism caused by Schistosoma haematobium is suggested as the etiology for chronic renal failure (edema, halitosis and orthopnea) and a "gangrene of genitalia that engendered worms" in the words of Josephus. This would be explained by the formation of genital and urinary fistulae, observed in such disease. The asseveration that Herod was "attacked by black bilis" is also discussed, based on the concepts of the Hippocratic medicine of that time (Rev Méd Chile 2003; 131: 569-72).

Caroli disease is a cystic congenital malformation of the intrahepatic biliary tract, frequently associated with lithiasis. Commonly, cystic dilatations are bilateral and infrequently they affect only one hepatic lobule or segment. We report six patients with localized Caroli disease, three in the right and three in the left hepatic lobule, that were subjected to a hepatic resection. There were no postoperative complications or mortality. After 28 months of follow up, patients are asymptomatic and with normal hepatic function and ultrasonography. The importance of diagnosing localized Caroli disease, in which hepatic resection can be curative, is emphasized (Rev Med Chile 2003; 131: 183-9)

Cleopatra VII, one of the last Egyptian sovereigns of the ptolomeic dynasty, is envisioned as a mythic figure, surrounded by intrigues and mystery. Her mysterious death was caused, according to history, by a snake bite. This article shows some instances of great Cleopatra's life and the state of the art on snake venoms. Even at the present time, snake bites are a public health problem in Asia, Africa, Central and South America, causing more than 25000 deaths every year. Most snake venoms have a protein structure and cause neurotoxic and hemolytic effects, altering coagulation and fibrinolysis. The mortality due to snake bites fluctuates between 1 and 22%. Specific treatment includes the use of specific antiserums with highly purified components (Rev Med Chile 2001; 129: 1222-26).

We report two males and one female, aged 71, 81 and 73 years old respectively, previously operated of a renal cell carcinoma. During the follow up of the 71 years old male, the CAT scan showed three lesions in the pancreas. Also, the CAT scan in the female showed one lesion in the tail of the pancreas. The 81 years old male was admitted to the emergency room due to a upper gastrointestinal bleeding. Endoscopy showed a proliferating lesion in the second portion of the duodenum whose biopsy showed a clear cell carcinoma. The CAT scan showed also a tumoral mass in the head of the pancreas. All three patients were subjected to surgical resection of the tumors without postoperative complications or mortality (Rev Med Chile 2001; 129: 86-90).

We report a 26 years old male that suffered a motorcycle accident resulting in a traumatic aortic rupture and splenic laceration. He was subjected to a surgical repair of the aortic lesion under complete heparinization. The splenic rupture was non operatively managed successfully. (Rev Méd Chile 2000; 128: 529-32)

We report a 23 years old male admitted to the hospital after a fall from a great altitude with severe trauma. During the second week of hospitalization he presented a severe nosebleed that did not respond to conventional tamponade. A selective angiography was performed and the branches of the internal maxillary artery were embolized in two occasions, stopping the bleeding. The patient was discharged from the hospital after 71 days of hospitalization.