Perforation in the peritoneal cavity during transanal endoscopic microsurgery for rectal tumors: a real surgical complication with a challenging prognosis?

BACKGROUND: Perforation in the peritoneal cavity during transanal endoscopic microsurgery represents a major challenge. It is usually treated by primary suture, though some authors propose laparoscopic repair with or without ostomy. It is unclear whether perforation increases the risk of tumor dissemination. AIM: The purpose of the study is to assess the safety of primary suture of peritoneal perforation and the long-term risk of dissemination, also, to determine risk factors for perforation and to propose a predictive model for lesions with risk of perforation. METHOD: This is an observational study with prospective data collection at Parc Taulí University Hospital, Sabadell, of patients undergoing transanal surgery with perforation into the peritoneal cavity from June 2004 to September 2017. The main variable is postoperative morbidity and mortality. The long-term follow-up of local recurrence and peritoneal tumor dissemination is described, and a quantitative predictive model for peritoneal cavity perforation is proposed. RESULTS: Forty-five patients out of 686 (6.6%) presented perforation into the peritoneal cavity. Ten patients (22.2%) in the perforation group had morbidity, a rate similar to the non-perforated group. There was no peritoneal dissemination in patients with adenoma or with carcinoma treated with curative intent. In the quantitative predictive model, risk factors for perforation were proximal edge of tumor > 14 cm from anal verge (6 points), size ≥ 6 cm (2), age ≥ 85 years (4), anterior quadrant (3) , and sex (2). Total scores of ≥ 6 points predicted perforation. CONCLUSIONS: Primary suture after peritoneal cavity perforation during transanal surgery is safe and does not increase the risk of recurrence or peritoneal dissemination. Our predictive model provides guidance regarding the risk of perforation and the need to suture the defect after transanal surgery resection.

Chronic pancreatitis. Some important historical aspects. / Pancreatitis crónica. Algunos aspectos históricos relevantes.

Since ancient times the increase of size and hardness sometimes presented by the abdominal structure known as the pancreas has attracted attention. Portal was the first to describe the clinical signs of chronic pancreatitis in 1803. In 1815, Fleischman speculated about the potential role of excessive alcohol consumption. Comfort coined the term "chronic relapsing pancreatitis" in 1946 and described hereditary pancreatitis 6 years later. Zuidema defined tropical pancreatitis in 1959 and 2 years later Sarles described another form of pancreatitis to which Yoshida gave the name autoimmune pancreatitis in 1995. Groove pancreatitis was described by Potet in 1970. Obstructive pancreatitis was defined in 1984 and Ammann identified idiopathic pancreatitis 3 years later. This article gives a historical account of the pioneers who developed the knowledge of how to assess the characteristics that allowed the different forms of chronic pancreatitis to be defined.

Historical review of our knowledge of acute pancreatitis. / Revisión histórica de algunos conocimientos sobre pancreatitis aguda.

Acute pancreatitis is one of most common causes of consultation due to abdominal pain in medical emergency units and it requires hospital admission. Although the majority of cases are mild and patients tend to recover quickly, a small percentage of cases is severe, with mortality in the region of 5-10%. This historical review considers how our understanding of this disease has changed since it was first described in 1579 thanks to the contributions of renowned experts such as Nicolaes Tulp, Reginald Fitz, Nicholas Senn and many others who, through their expertise and dedication, have improved the survival of patients with this disease.

American vs. European Trauma Centers: A Comparison of Preventable Deaths. / Comparación de la mortalidad evitable de un trauma center americano vs. un centro de referencia europeo.

INTRODUCTION: The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths. METHODS: Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy. RESULTS: The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P=.06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was 'knowledge-based' (44%). In contrast, at the SRC center the most common errors were 'rule-based' (58%) (P<.001). CONCLUSIONS: The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and 'ruled-based' errors have been found in the Spanish center.

[Pancreatic neuroendocrine tumours. What do we know of their history?]. / Tumores neuroendocrinos pancreáticos. ¿Qué conocemos de su historia?

Starting with Paul Langerhans, who first described pancreatic islets in 1869, this article reviews the various protagonists who, in the last century and a half, have contributed to the discovery of the main hormones originating in the pancreas, the analytical methods for their measurement, the imaging techniques for identifying tumoural location, and the various pancreatic neoplasms.

[Historical compilation of cystic fibrosis]. / Recopilación histórica de la fibrosis quística.

Cystic fibrosis is the most common life-shortening recessively inherited disorder in the Caucasian population. The genetic mutation that most frequently provokes cystic fibrosis (ΔF508) appeared at least 53,000years ago. For many centuries, the disease was thought to be related to witchcraft and the "evil eye" and it was only in 1938 that Dorothy H. Andersen characterized this disorder and suspected its genetic origin. The present article reviews the pathological discoveries and diagnostic and therapeutic advances made in the last 75 years. The review ends with some considerations for the future.

Rhodamine B removal with activated carbons obtained from lignocellulosic waste.

By-products from the wax production process from carnauba palm (leaves), from the extraction of oil from macauba seeds (endocarp) and from pine nut production (shell) have been assessed for activated carbon production, using H3PO4 or CaCl2 for their chemical activation. The resulting activated charcoals have been thoroughly characterized by elemental and thermal analysis, X-ray diffraction, infrared spectroscopy, electron scanning microscopy and N2 adsorption behavior. Subsequently, their adsorption capacity for the removal of rhodamine B (RhB) from aqueous solutions has been evaluated by studying different parameters: contact time, pH, adsorbent dose, initial dye concentration and solution temperature. The adsorption of RhB followed Freundlich's model in all cases. Kinetic studies indicate that the pseudo-second order model can be used for describing the dynamics of the adsorption process. Thermodynamic parameters have also been evaluated, indicating its endothermic and spontaneous nature. Finally, a preliminary analysis of the impact of cellulose content in the carbon precursor materials has been conducted, by using a mixture of native cellulose with one of the lignocellulosic materials.

[Discoveries and techniques that have contributed to improving the treatment of pancreatic diseases]. / Descubrimientos y técnicas que han contribuido a mejorar el tratamiento de las enfermedades pancreáticas.

Due to its retroperitoneal location, the pancreas has historically been a mysterious organ that is difficult to examine and which complicates treatment. The discovery of anesthesia and asepsis in the mid-19th century allowed laparotomic diagnosis, which was previously only possible at autopsy. The expectations of surgery were improved by the detection of blood groups, vitamin K synthesis, and the development of intensive care units. In addition, high levels of presurgical diagnosis and an unquestionable improvement of its results were enabled by advances in laboratory methods (serum quantification of amylase and lipase, tumoral markers, genetics, and techniques for measuring exocrine pancreatic function), imaging and endoscopic modalities, and fine tuning of surgical techniques. In this article, we review the history of the main milestones that have allowed progress in all these aspects.

Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability.

INTRODUCTION: The main cause of mortality in trauma patients with pelvic fractures is hypovolemic shock. We analyzed the association between the source of bleeding, mechanism of action and type of fracture. METHODS: Prospective descriptive study involving trauma patients older than 16 years old, admitted to the intensive care unit or dead before admission, with pelvic fractures and hemodynamic instability. Hemodynamic instability was defined as SBP <90 and/or HR> 100 beats/min. Pelvic fracture was defined by the Tile classification. RESULTS: A total of 157 of 1088 trauma patients had pelvic fracture. We included 63 patients, all hemodynamically unstable. A total of 85% of pelvic fractures after falls from great heights bled from the fracture itself, compared to only 44% of victims of impact (hit). A total of 65% of patients with stable pelvic fracture bled from associated lesions; 70% of patients with unstable fracture bled from the fracture itself. There is an interaction between the mechanism of action and type of fracture. The probability of pelvic bleeding is higher in the precipitated patient (> 80%) regardless of the type of fracture. Bleeding from associated injuries is greater in impact victims, doubling when the fracture is stable (91%). CONCLUSIONS: Mechanism of action is a key to determine the source of bleeding in patients with pelvic fracture. After falls patients bleed from the fracture itself, while patients with an impact (hit) can bleed both from the fracture and associated injuries, depending on the type of fracture.

Autoimmune pancreatitis type-1 associated with intraduct papillary mucinous neoplasm: report of two cases.

Chronic pancreatitis lesions usually embrace both intraduct papillary mucinous neoplasm (IPMN) and pancreatic ductal adenocarcinoma (PDAC). Patients at genetically-determined high risk of PDAC often harbor IPMN and/or chronic pancreatitis, suggesting IPMN, chronic pancreatitis and PDAC may share pathogenetic mechanisms. Chronic autoimmune pancreatitis (AIP) may also herald PDAC. Concurrent IPMN and AIP have been reported in few patients. Here we describe two patients with IPMN who developed type-1 AIP fulfilling the Honolulu and Boston diagnostic criteria. AIP diffusively affected the whole pancreas, as well as peripancreatic lymph nodes and the gallbladder. Previous pancreatic resection of focal IPMN did not show features of AIP. One of the patients carried a CFTR class-I mutation. Of notice, serum IgG4 levels gradually decreased to normal values after IPMN excision. Common risk factors to IPMN and AIP may facilitate its coincidental generation.

Impact of ATLS training on preventable and potentially preventable deaths.

BACKGROUND: Multiple trauma continues to have a high incidence worldwide. Trauma is the leading cause of death among people between the ages of 10 and 40. The Advanced Trauma Life Support (ATLS) is the most widely accepted method for the initial control and treatment of multiple trauma patients. It is based on the following hypothesis: The application of the ATLS program may reduce preventable or potentially preventable deaths in trauma patients. MATERIALS AND METHODS: The present article reports a retrospective study based on the records of prospectively evaluated trauma patients between January 2007 and December 2012. Trauma patients over the age of 18 admitted to the critical care unit or patients who died before hospital admission were included. A multidisciplinary committee looked for errors in the management of each patient and classified deaths into preventable, potentially preventable, or nonpreventable. We recorded the number of specialists at our center who had received training in the ATLS program. RESULTS: A total of 898 trauma patients were registered. The mean injury severity score was 21 (SD 15), and the mortality rate was 10.7 % (96 cases). There were 14 cases (14.6 %) of preventable or potentially preventable death. The main errors were delay in initiating suitable treatment and performing a computed tomography scan in cases of hemodynamic instability, followed by initiation of incorrect treatment or omission of an essential procedure. As the number of ATLS-trained professionals increases, the rates of potentially preventable or preventable death fall. CONCLUSIONS: Well-founded protocols such as the ATLS can help provide the preparation health professionals need. In our hospital environment, ATLS training has helped to reduce preventable or potentially preventable mortality among trauma patients.

[A brief history of the anatomy and physiology of a mysterious and hidden gland called the pancreas]. / Breve historia de la anatomía y fisiología de una recóndita y enigmática glándula llamada páncreas.

Because of its retrogastric location and appearance, which is similar to mesenteric fat, for centuries the pancreas has been a mysterious, hidden organ that has received little attention. However, its importance was intuited and described by Herophilus, Ruphos of Ephesus and Galen. This gland began to appearin distinct medical treatises from the 16th century. There are two important scientists in the history of the pancreas. The fist, Johann Georg Wirsung, described the main pancreatic duct in 1642, a date considered by many to be the start of Pancreatology. The second, Claude Bernard, described pancreatic exocrine function between 1849 and 1856 and is considered the father of pancreatic physiology. Besides these two outstanding figures, there is a constellation of personalities who contributed to improving knowledge of this enigmatic gland with the results of their studies. The aim of this article is to call attention to some of the most notable findings that have enhanced knowledge of this gland over the years.

Evaluation of vascular changes in cavernous arteries by penile doppler ultrasound in patients undergoing laparoscopic radical prostatectomy.

Patients undergoing radical prostatectomy for prostate cancer may experience erectile dysfunction (ED). Age of patients, experience of the surgeons and existence of ED before surgery are factors related to its appearance. The objective of the study was to assess the hemodynamic changes produced in the cavernous arteries in patients undergoing laparoscopic radical prostatectomy (LRP) measured with penile Doppler ultrasound (PDUS). A prospective database of 83 patients undergoing LRP was analysed. PDUS were performed at baseline and twelve months after surgery. International Index of Erectile Function (IIEF) and Erectile Hardness Score (EHS) questionnaires were also evaluated. A 12-month decrease in all hemodynamic parameters of both cavernous arteries was found except for the end diastolic velocity (EDV) on the left cavernous artery. Only changes between baseline and twelve-months mean values of the diameter (0.725 vs. 0.67 mm; p= 0.033) and peak systolic velocity (PSV) of the right cavernous artery (32.6 vs. 27.22 cm/s; p = 0.004) presented significant variations. The rest of the parameters were close to statistical significance, except for EDV of the right cavernous artery (p = 0.887). The erectile function domain of the IIEF showed a significant decrease (median at baseline: 26 vs. post-surgery: 7; p < 0.0001) as well as the EHS test (grade I at baseline: 2.4% vs. 12-months: 31.3%; p < 0.0001). Our study supports the idea that LRP produces local vascular injuries. A decrease in the PSV and in the diameter of both cavernous arteries was observed with PDUS and it may explain the vascular origin of ED.

Seasonal and sex-related variations in serum steroid hormone levels in wild and farmed brown trout Salmo trutta L. in the north-west of Spain.

Serum steroid profiles were investigated in order to evaluate the potential use of circulating sex steroid levels as a tool for sex identification in brown trout. Changes in the serum concentrations of testosterone (T), progesterone (P), 17-ß-estradiol (E2), and cortisol (F) in wild and farmed mature female and male brown trout, Salmo trutta L., were measured in each season (January, May, July, and October) in six rivers and four hatcheries located in the north-west of Spain. Serum cortisol levels in farmed brown trout were significantly higher and showed a seasonal pattern opposite to that found in wild trout. Because levels of the hormones under study can be affected by disruptive factors such as exposure to phytoestrogens (which alters the hypothalamic-pituitary-gonadal axis) and infection with Saprolegnia parasitica (which alters the hypothalamic-pituitary-adrenal axis), both factors are taken into account.

[Recommendations of the Spanish Pancreatic Club on the diagnosis and treatment of chronic pancreatitis: part 2 (treatment)]. / Recomendaciones del Club Español Pancreático para el diagnóstico y tratamiento de la pancreatitis crónica: parte 2 (tratamiento).

Chronic pancreatitis (CP) is a complex disease with a wide spectrum of clinical manifestations ranging from asymptomatic disease to disabling forms or serious complications. The management of CP frequently differs among geographical areas and even among centers. These differences are due to the scarcity of high-quality studies and clinical practice guidelines that focus on the diagnosis and treatment of this disease. The aim of the Spanish Pancreatic Club was to create evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts in this disease. These experts were selected on the basis of their clinical and research experience in CP. A list of questions was drawn up and each question was then reviewed by two panelists. These questions were then used to produce a draft, which was discussed in a face-to-face meeting with all the participants. Levels of evidence were based on the classification of the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus process, recommendations were established for the management of pain, pseudocysts, biliary and duodenal stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

[Recommendations of the Spanish Pancreatic Club on the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis)]. / Recomendaciones del Club Español Pancreático para el diagnóstico y tratamiento de la pancreatitis crónica: parte 1 (diagnóstico).

Chronic pancreatitis (CP) is a relatively uncommon, complex and highly heterogeneous disease. There is no clear pattern applicable to the initial stages of CP, which hampers its early diagnosis. Some of the complications of CP, especially chronic pain, can be difficult to manage. There is wide variation in the diagnosis and treatment of CP and its complications among centers and health professionals. The Spanish Pancreatic Club has developed a consensus document on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts in this disease. A list of questions was drawn up. Each question was reviewed by two experts. These questions were then used to produce a draft, which was discussed in a face-to-face meeting with all the participants. The first part of the consensus document focusses on the diagnosis of CP and its complications.

A Coating Based on Bioactive Compounds from Streptomyces spp. and Chitosan Oligomers to Control Botrytis cinerea Preserves the Quality and Improves the Shelf Life of Table Grapes.

Botrytis cinerea is the most harmful postharvest disease of table grapes. Among the strategies that can be envisaged for its control, the use of coatings based on natural products is particularly promising. The study presented herein focuses on the assessment of the antagonistic capacity of two Streptomyces species and their culture filtrates against B. cinerea. Firstly, the secondary metabolites were characterized by gas chromatography-mass spectrometry, with N1-(4-hydroxybutyl)-N3-methylguanidine acetate and 2R,3S-9-[1,3,4-trihydroxy-2-butoxymethyl]guanine acetate as the main compounds produced by S. lavendofoliae DSM 40217; and cyclo(leucyloprolyl) and cyclo(phenylalanylprolyl) as the most abundant chemical species for S. rochei DSM 41729. Subsequently, the capacity of S. lavendofoliae DSM 40217 and S. rochei DSM 41729 to inhibit the growth of the pathogen was tested in dual culture plate assays, finding 85-90% inhibition. In agar dilution tests, their culture filtrates resulted in effective concentration values (EC90) in the 246-3013 µg·mL-1 range. Upon the formation of conjugate complexes with chitosan oligomers (COS) to improve solubility and bioavailability, a synergistic behavior was observed, resulting in lower EC90 values, ranging from 201 to 953 µg·mL-1. Ex situ tests carried out on 'Timpson' and 'Red Globe' table grapes using the conjugate complexes as coatings were found to maintain the turgor of the grapes and delay the appearance of the pathogen by 10-15 days at concentrations in the 750-1000 µg·mL-1 range. Hence, the conjugate complexes of COS and the selected Streptomyces spp. culture filtrates may be put forward as promising protection treatments for the sustainable control of gray mold.

CA 19-9 in pancreatic cancer: retrospective evaluation of patients with suspicion of pancreatic cancer.

CA 19.9 serum levels were prospectively determined in 573 patients admitted to hospital for suspicion of pancreatic cancer. The final diagnosis was 77 patients with no malignancy, 389 patients with pancreatic cancer, 37 neuroendocrine pancreatic cancer, 28 cholangiocarcinomas, 4 gallbladder cancer, 27 ampullary carcinomas, and 11 periampullary carcinomas. CA 19.9 was determined using a commercial assay from Roche Diagnostics, and 37 U/ml was considered as the upper limit of normality. Abnormal CA 19.9 serum levels were found in 27%, 81.5%, 85.7%, 59.3%, 63.6%, and 18.9% of patients with benign diseases, pancreatic cancer, cholangiocarcinomas, and ampullary, periampullary, or neuroendocrine tumors. Significantly higher concentrations of CA 19.9 were found in patients with than in those without malignancy or with neuroendocrine tumors. CA 19.9 serum levels were higher in pancreatic cancer or cholangiocarcinoma than in other malignancies (p < 0.0001). CA 19.9 serum levels were also correlated with tumor stage, treatment (significantly lower concentrations in resectable tumors), and tumor location (the highest in those located in the body, the lowest in those in the tail or uncinate) and site of metastases (highest in liver metastases). A trend to higher CA 19.9 serum concentrations was found in patients with jaundice, but only with statistical significance in the early stages. Using 50 or 100 U/ml in patients with jaundice, CA 19.9 was useful as an aid in the diagnosis of pancreatic cancer (sensitivity 77.9%, specificity 95.9%) as well as tumor resectability in pancreatic cancer with different cutoffs according to tumor location and bilirubin serum levels with specificities ranging from 90% to 100%. CA 19.9 is the tumor marker of choice in pancreatic adenocarcinomas, with a clear relationship with tumor location, stage, and resectability.