Efficacy of amoxicillin/clavulanic acid after surgical drainage of perianal abscess in the prevention of the development of anal fistula (PERIQxA study): study protocol for a multicenter randomized, double-blind clinical trial.

BACKGROUND: Anorectal fistula, which is a relatively common pathology, is the chronic manifestation of the acute perirectal process that forms an anal abscess. The development of a fistula after incision and drainage of an anal abscess is seen in approximately 26-37%. Its treatment is a relevant topic, and the role of the use of antibiotic therapy in its prevention remains controversial, after the publication of several studies with contradictory results and several methodological limitations. Our hypothesis is that the combination of amoxicillin and clavulanic acid will reduce the incidence of anal fistula. METHOD: The aim of this study is to evaluate the efficacy of antibiotherapy after surgical drainage of perianal abscess in the development of perianal fistula. The PERIQxA study is a multicenter, randomized, double-blind controlled trial. The study has been designed to include 286 adult patients who will be randomly (1:1) assigned to either the experimental (amoxicillin/clavulanic acid 875/125 mg TDS for 7 days) or the control arm (placebo). The primary outcome measure is the percentage of patients that develop perianal fistula after surgery and during follow-up (6 months). DISCUSSION: This clinical trial is designed to evaluate the efficacy and safety of amoxicillin/clavulanic in the prevention of perianal fistula. The results of this study are expected to contribute to stablish the potential role of antibiotherapy in the therapeutics for anal abscess. TRIAL REGISTRATION: EudraCT Number: 2021-003376-14. Registered on November 26, 2021.

Non-antibiotic treatment of uncomplicated acute diverticulitis is applicable and safe in our environment. A prospective multicenter study.

INTRODUCTION: acute diverticulitis is one of the most frequent underlying causes behind individuals attending the Emergency Room with abdominal pain. The most widespread therapy for acute uncomplicated diverticulitis includes outpatient treatment with antibiotics; however, several publications indicate that patients can also be successfully treated without antibiotics. The results of the implementation of this more recent protocol in two hospitals in Madrid are presented. METHODS: an observational prospective study was performed. Participants were patients diagnosed with uncomplicated acute diverticulitis at two hospitals in Madrid, Hospital Universitario de Torrejón and Hospital Universitario Puerta de Hierro Majadahonda, between December 2018 and August 2021, treated on an outpatient basis without antibiotic therapy. The study group was compared with a control group, composed of patients diagnosed with uncomplicated acute diverticulitis and treated with outpatient antibiotic therapy at Hospital Universitario Puerta de Hierro between March 2015 and March 2018. RESULTS: three hundred and sixty-one patients were included, 182 in the study group and 179 in the control group. Diverticulitis was persistent in 19 patients (10.4 %) in the study group, who were not treated with antibiotics, and in five patients (2.8 %) in the control group, treated with outpatient antibiotic therapy (p = 0.004). Recurrences occurred in 23 patients (12.6 %) in the study group, and in 53 patients (29.6 %) in the control group (p < 0.0001). The analysis of the complications found no significant differences between both groups (p = 0.109). No urgent surgical intervention or mortality was recorded in the study group. CONCLUSIONS: in our environment, symptomatic non-antibiotic treatment of uncomplicated acute diverticulitis cases is safe, without showing a higher rate of complications. Although, there seems to be a worse initial symptom control.

Gastric inflammatory myofibroblastic tumor, a rare mesenchymal neoplasm: A case report.

BACKGROUND: The inflammatory myofibroblastic tumor (IMT) is a rare mesenquimal tumor of doubtful biological behaviour. It's characterised for affecting mainly children and young adults, although it can appear at any age, being the lungs the primary affected organ (in children it represents 20% of all primary pulmonary tumors). CASE SUMMARY: We present the case of a 45 year old woman, with a computed tomography (CT) finding of injury on the anterior surface of the fundus/gastric body and a solid perigastric injury of 12 mm in the ecoendoscopy. The case is presented in the tumor committee deciding to perform a laparoscopic wedge resection. The histological diagnosis was a IMT. The diagnosis is based on imaging tests like the abdominal CT, abdominal ecography and the ecoendoscopy but to confirm the diagnosis a pathological study is necessary. CONCLUSION: Due to the unpredictable nature of this tumor, surgical resection is the best therapeutic option.

Update on the management of uncomplicated acute diverticulitis at our centre. Equally effective, more efficient. / Actualización del manejo de la diverticulitis aguda no complicada en nuestro centro. Igualmente efectivo, más eficiente.

GOALS: The current trend in the treatment of non-complicated diverticulitis is the outpatient management with antibiotic or even anti-inflammatory regimens in selected cases. We present a comparison of the results in our hospital with different protocols applied in 2016 and 2017. MATERIAL AND METHODS: All patients selected for this study were diagnosed with diverticulitis grade Ia of Hinchey's classification according to radiological findings on abdominal CT. We have analyzed two retrospective cohorts: 100 patients treated in 2016 according to the old protocol and 104 patients treated in 2017 with a new protocol. In 2016, the candidates for ambulatory treatment remained under observation for 24 hours before being discharged. The treatment consisted of 14 days of ciprofloxacin and metronidazole. In 2017, only patients with more acute symptoms were observed 24 hours and amoxicillin-clavulanic acid was prescribed for only 5 days. RESULTS: The persistence of the disease in 2016 was 6% and in 2017 was only 5.77% (p = 0.944). Recurrence during the first year was 13% in the first group, while in the second it was 5.7%, although this difference was not statistically significant. Likewise, a significant reduction in health costs was achieved. CONCLUSIONS: Outpatient treatment of acute uncomplicated diverticulitis with oral treatment seems to be a safe and effective therapeutic strategy in selected patients with low comorbidity.

Diverticulitis in immunodeficient patients: our experience in the management of high-risk patients.

INTRODUCTION: acute diverticulitis is a very prevalent disease. The need for a more aggressive management in immunodeficient patients has not been established. We present the results of our unit with immunodeficient patients diagnosed with acute diverticulitis and their follow-up. OBJECTIVES: to assess the possibility that a conservative management in this group is as valid as in the immunocompetent population. METHODS: a retrospective analysis study was performed in our hospital. Forty immunodeficient patients (transplant, corticoid treatment, dialysis, oncologic, HIV patients) diagnosed with acute diverticulitis were analyzed. The patients were managed with a surgical or non-surgical treatment according to their status on admission. The main analyzed items were the severity of the acute episode and the need for surgical treatment compared to the cause of immunodeficiency. Other studied variables included follow-up results and recurrences. RESULTS: thirty-two of the 40 patients studied received a non-surgical treatment during the acute episode, eight required emergency surgery (seven had a Hartmann procedure and one underwent a colon resection and anastomosis). Transplant patients and those between 40 and 50 years old proved to be higher risk groups. Three patients subsequently required elective surgery due to complications. Twenty-four patients had uneventful recoveries. CONCLUSIONS: the frequency of complicated acute diverticulitis is higher in immunodeficient patients than that of the general population. Non-surgical treatment seems to be as safe as in immunocompetent patients. Younger and transplanted patients were higher risk groups for severe acute diverticulitis that required a more aggressive management initially.

Serum levels of intact parathyroid hormone on the first day after total thyroidectomy as predictor of permanent hypoparathyroidism. / Uso del valor de la hormona paratiroidea intacta en el primer día postoperatorio tras tiroidectomía total como predictor de hipoparatiroidismo permanente.

BACKGROUND: Permanent hypoparathyroidism is the most common long-term complication after total thyroidectomy, causing significant morbidity and requiring long-term replacement therapy. Our study objective was to assess whether intact parathyroid hormone (iPTH) levels on the first day after total thyroidectomy are a good predictor of permanent hypoparathyroidism. PATIENTS AND METHODS: A retrospective observational study of all patients undergoing total thyroidectomy between January 2009 and December 2014. iPTH and calcium levels were measured the first day after surgery. Patients were followed up for at least one year after surgery. RESULTS: The study group consisted of 481 patients with a mean age of 53±14 years, 82% of them females. The most common reason for thyroidectomy was multinodular goiter (75%), followed by papillary thyroid cancer (15%). Transient hypocalcemia was the most common early complication after total thyroidectomy (49%), and permanent hypoparathyroidism was the most common long-term complication (6%). ROC curve analysis showed that iPTH level on the first postoperative day was a good predictor of permanent hypoparathyroidism (area under the curve 0.87; 95% CI: 0.84-0.91). Cut-off iPTH levels of 5pg/mL had 95% sensitivity, 77% specificity, 21.6% positive predictive value, and 99.6% negative predictive value. CONCLUSIONS: iPTH level on the first day after total thyroidectomy is a useful predictor of permanent hypoparathyroidism because of its high negative predictive value. Serum iPTH levels >5pg/mL virtually exclude presence of permanent hypoparathyroidism.

Review of duodenal perforations after endoscopic retrograde cholangiopancreatography in Hospital Puerta de Hierro from 1999 to 2014.

INTRODUCTION: endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard in biliary and pancreatic pathology. Although the procedure has a significant morbidity and mortality rate. Algorithms are needed for the management and treatment of the associated complications. OBJECTIVE: to review the post-ERCP perforations treated in the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The results were evaluated according to the types of perforation and treatment. METHODS AND RESULTS: this is a descriptive and observational study of all post-ERCP perforations reported and treated by the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The following data were collected: indication for the test and findings, type of perforation, time and method of diagnosis, time to surgery and the technique used; the subsequent complications as well as the evolution and time of admission were registered. Results were evaluated according to the type of perforation (Stapfer classification) and the treatment performed. Thirty-six perforations were reported (21 type I, eight type II, two type III and five type IV), with an associated incidence of less than 1%. The diagnosis was immediate (in the first 24 hours) in 67% of cases; type I was the most frequent: 28 of 36 patients (77.7%) required surgery. The majority underwent a cholecystectomy followed by suture, intraoperative cholangiography, bile duct exploration and drainage whenever possible. Four patients died with type I perforations; two were intervened and two were managed conservatively. The most frequent complication was a collection/fistula which occurred in 21.42% of patients who underwent surgery. CONCLUSIONS: periduodenal perforations secondary to ERCP treatment should be oriented according to the clinical and radiological findings. In our experience, type I perforations require immediate surgical intervention, whereas type II and III perforations can be managed conservatively in some cases when there are no complications such as associated abdominal collections, peritoneal irritation and/or sepsis. Type IV perforations respond to conservative management.

[Primary, non-metastatic gastrointestinal stromal tumour surgery: results of the GRISK study]. / Cirugía de los tumores del estroma gastrointestinal primarios no metastásicos. Resultados del estudio GRISK.

INTRODUCTION AND OBJECTIVES: Radical surgery is the standard treatment for localised gastrointestinal stromal tumours (GIST). A series of primary GIST, their treatment and pre-established risk of recurrence after their follow-up is evaluated. MATERIAL AND METHODS: A retrospective, descriptive and multicentre study was conducted on primary, non-metastatic GIST operated on between June 2007 and December 2008. The variables of greater relevance were analysed, including, location, size, mitotic index, and NHI and AFIP recurrence prognostic criteria, and their correlation with the disease-free survival (DFS) of the patients. RESULTS: The series included 141 patients with a mean age of 65 years. The most frequent GIST location was in the stomach (70.8%) and small intestine (22.9%), and with a mean tumour size of 6.7 cm (0.5-35 cm). The surgery was R0 in 97.2% of cases (laparoscopic approach, 21.5%). The distribution according to NHI/Flescher criteria was, high (31.95%), and intermediate (26.4%), and according to AFIP/Miettinen criteria it was, high (22.9%) and intermediate (12.5%). After a mean follow-up of 20.3 months, there was a 7.1% (10 cases) recurrence, with only 2 cases belonging to the group with a «low risk¼ using the NHI and AFIP prognostic criteria. The DFS at one year was 95.5% and 91.5% at 2 years. CONCLUSIONS: The series showed a high DFS and a good correlation with both the Flescher and the Miettinen criteria. However, the risk of recurrence varied according to the AFIP criteria (intermediate/high, 58.3%), or the AFIP criteria (intermediate/high, 35.4%) which included the tumour location. For this reason, we consider these latter criteria as the most adequate for assessing the prognostic risk of GIST recurrence.