Comparison of Outcomes between Obese and Nonobese Patients in Laparoscopic Adrenalectomy: A Cohort Study.

INTRODUCTION: Obesity is usually considered a risk factor for surgical complications. Laparoscopic adrenalectomy has replaced open adrenalectomy as the standard operation for adrenal tumors. OBJECTIVE: To compare the safety of laparoscopic adrenalectomy to treat adrenal tumors in obese versus nonobese patients. METHODS: This observational cohort study analyzed consecutive patients who underwent laparoscopic adrenalectomy with a lateral transperitoneal approach at a single center (2003-2020). Data and outcomes of obese (body mass index ≥30 kg/m2) and nonobese patients were compared. To analyze the association between operative time and other variables, we used simple and multivariate linear regression. RESULTS: N = 160 (90 obese/70 nonobese) patients underwent laparoscopic adrenalectomy. Cushing syndrome and pheochromocytoma were the most frequent indications. Obese patients were older (58 vs. 52 years, p < 0.001). A greater proportion of obese patients were ASA grade III + IV (71.1 vs. 48.6%, p = 0.004). Obesity was associated with a longer operative time (72.5 vs. 60 min, p < 0.001) and greater blood loss (40 vs. 20 mL, p = 0.022). There were no differences in conversion, morbidity, or hospital stay. After adjustment for confounding factors, operative time was positively correlated with BMI ≥30 kg/m2, learning curve, estimated blood loss, 2D laparoscopy, and specimen size. CONCLUSION: Lateral transperitoneal laparoscopic adrenalectomy is safe in patients with a BMI 30-35 kg/m2, so these patients also benefit from this minimally invasive surgery.

Cytoskeletal transgelin 2 contributes to gender-dependent adipose tissue expandability and immune function.

During adipogenesis, preadipocytes' cytoskeleton reorganizes in parallel with lipid accumulation. Failure to do so may impact the ability of adipose tissue (AT) to shift between lipid storage and mobilization. Here, we identify cytoskeletal transgelin 2 (TAGLN2) as a protein expressed in AT and associated with obesity and inflammation, being normalized upon weight loss. TAGLN2 was primarily found in the adipose stromovascular cell fraction, but inflammation, TGF-ß, and estradiol also prompted increased expression in human adipocytes. Tagln2 knockdown revealed a key functional role, being required for proliferation and differentiation of fat cells, whereas transgenic mice overexpressing Tagln2 using the adipocyte protein 2 promoter disclosed remarkable sex-dependent variations, in which females displayed "healthy" obesity and hypertrophied adipocytes but preserved insulin sensitivity, and males exhibited physiologic changes suggestive of defective AT expandability, including increased number of small adipocytes, activation of immune cells, mitochondrial dysfunction, and impaired metabolism together with decreased insulin sensitivity. The metabolic relevance and sexual dimorphism of TAGLN2 was also outlined by genetic variants that may modulate its expression and are associated with obesity and the risk of ischemic heart disease in men. Collectively, current findings highlight the contribution of cytoskeletal TAGLN2 to the obese phenotype in a gender-dependent manner.-Ortega, F. J., Moreno-Navarrete, J. M., Mercader, J. M., Gómez-Serrano, M., García-Santos, E., Latorre, J., Lluch, A., Sabater, M., Caballano-Infantes, E., Guzmán, R., Macías-González, M., Buxo, M., Gironés, J., Vilallonga, R., Naon, D., Botas, P., Delgado, E., Corella, D., Burcelin, R., Frühbeck, G., Ricart, W., Simó, R., Castrillon-Rodríguez, I., Tinahones, F. J., Bosch, F., Vidal-Puig, A., Malagón, M. M., Peral, B., Zorzano, A., Fernández-Real, J. M. Cytoskeletal transgelin 2 contributes to gender-dependent adipose tissue expandability and immune function.

Three-dimensional (3D) system versus two-dimensional (2D) system for laparoscopic resection of adrenal tumors: a case-control study.

PURPOSE: Laparoscopy is the standard technique for resecting adrenal tumors worldwide. The main drawbacks of conventional 2D laparoscopy are limited depth perception and tactile feedback. Currently available high-quality 3D laparoscopy systems might improve surgical outcomes for adrenalectomy. We compare the safety and efficacy of 3D versus 2D laparoscopy in the treatment of adrenal tumors. METHODS: This case-control study analyzed prospectively collected data from patients with benign or malignant adrenal tumors treated laparoscopically at a single academic medical center between April 2003 and March 2020. We collected demographic, diagnostic, preoperative, and operative variables, and used multiple linear and logistic regression to analyze differences in various short-term outcomes between the two approaches while adjusting for potential confounders. RESULTS: We included 150 patients: 128 with benign tumors and 22 with malignant tumors; 95 treated with 3D laparoscopy (case group); and 55 with 2D laparoscopy (control group). After adjustment for patient, surgical, and tumor characteristics, a 2D vision was associated with a longer operative time (ß = 0.26, p = 0.002) and greater blood loss (ß = 0.20, p = 0.047). There was no significant difference in rates of conversion to open surgery (odds ratio [OR] = 1.47 (95% CI 0.90-22.31); p = 0.549) or complications (3.6% vs. 2.1%; p = 0.624). CONCLUSIONS: With experienced surgeons, laparoscopic adrenalectomy was safer and more feasible with the 3D system than with the 2D system, resulting in less operative blood loss and shorter operative time with no differences in rates of conversion to open surgery or postoperative complications. For adrenal tumors, 3D laparoscopy offers advantages over 2D laparoscopy.

Decreased TLR3 in Hyperplastic Adipose Tissue, Blood and Inflamed Adipocytes is Related to Metabolic Inflammation.

BACKGROUND/AIMS: Obesity is characterized by the immune activation that eventually dampens insulin sensitivity and changes metabolism. This study explores the impact of different inflammatory/ anti-inflammatory paradigms on the expression of toll-like receptors (TLR) found in adipocyte cultures, adipose tissue, and blood. METHODS: We evaluated by real time PCR the impact of acute surgery stress in vivo (adipose tissue) and macrophages (MCM) in vitro (adipocytes). Weight loss was chosen as an anti-inflammatory model, so TLR were analyzed in fat samples collected before and after bariatric surgery-induced weight loss. Associations with inflammatory and metabolic parameters were analyzed in non-obese and obese subjects, in parallel with gene expression measures taken in blood and isolated adipocytes/ stromal-vascular cells (SVC). Treatments with an agonist of TLR3 were conducted in human adipocyte cultures under normal conditions and upon conditions that simulated the chronic low-grade inflammatory state of obesity. RESULTS: Surgery stress raised TLR1 and TLR8 in subcutaneous (SAT), and TLR2 in SAT and visceral (VAT) adipose tissue, while decreasing VAT TLR3 and TLR4. MCM led to increased TLR2 and diminished TLR3, TLR4, and TLR5 expressions in human adipocytes. The anti-inflammatory impact of weight loss was concomitant with decreased TLR1, TLR3, and TLR8 in SAT. Cross-sectional associations confirmed increased V/ SAT TLR1 and TLR8, and decreased TLR3 in obese patients, as compared with non-obese subjects. As expected, TLR were predominant in SVC and adipocyte precursor cells, even though expression of all of them but TLR8 (very low levels) was also found in ex vivo isolated and in vitro differentiated adipocytes. Among SVC, CD14+ macrophages showed increased TLR1, TLR2, and TLR7, but decreased TLR3 mRNA. The opposite patterns shown for TLR2 and TLR3 in V/ SAT, SVC, and inflamed adipocytes were observed in blood as well, being TLR3 more likely linked to lymphocyte instead of neutrophil counts. On the other hand, decreased TLR3 in adipocytes challenged with MCM dampened lipogenesis and the inflammatory response to Poly(I:C). CONCLUSION: Functional variations in the expression of TLR found in blood and hypertrophied fat depots, namely decreased TLR3 in lymphocytes and inflamed adipocytes, are linked to metabolic inflammation.

Polysaccharides and phenolics of miscanthus belowground cell walls and their influence on polyethylene composites.

Belowground materials from two miscanthus species were ground into fragments for preparing polyethylene composites. Both species show a lot of similarities in terms of polysaccharides, lignin and cell wall-linked p-coumaric and ferulic acids contents. The structures of polysaccharides and of lignins are markedly different in the miscanthus belowground and aboveground biomass. The non-cellulosic fraction of the samples comprises a high level of xylose, with the arabinose to xylose ratio about twice as high as that observed for analogous stem samples, suggesting that belowground arabinoxylans are more substituted than stem ones. The mechanical properties of the belowground miscanthus-polyethylene composites correlate with several of their compositional traits, with similar trends as for plant stem-polyethylene composites with positive correlations for lignin and p-coumaric acid contents and negative correlations for most non-cellulosic sugars.

Evaluation of photocrosslinked Lutrol hydrogel for tissue printing applications.

Application of hydrogels in tissue engineering and innovative strategies such as organ printing, which is based on layered 3D deposition of cell-laden hydrogels, requires design of novel hydrogel matrices. Hydrogel demands for 3D printing include: 1) preservation of the printed shape after the deposition; 2) maintaining cell viability and cell function and 3) easy handling of the printed construct. In this study we analyze the applicability of a novel, photosensitive hydrogel (Lutrol) for printing of 3D structured bone grafts. We benefit from the fast temperature-responsive gelation ability of thermosensitive Lutrol-F127, ensuring organized 3D extrusion, and the additional stability provided by covalent photocrosslinking allows handling of the printed scaffolds. We studied the cytotoxicity of the hydrogel and osteogenic differentiation of embedded osteogenic progenitor cells. After photopolymerization of the modified Lutrol hydrogel, cells remain viable for up to three weeks and retain the ability to differentiate. Encapsulation of cells does not compromise the mechanical properties of the formed gels and multilayered porous Lutrol structures were successfully printed.

Gastric perforations from abdominal trauma.

BACKGROUND: Gastric rupture due to abdominal trauma is rare (0.02-1.7%); it is usually caused by traffic accidents. Delayed diagnosis, abdominal contamination and associated lesions cause morbidity and mortality. PATIENTS AND METHODS: Retrospective review of 2,083 patients with abdominal traumatism treated at our center over 20 years. We reviewed recent ingestion of a meal, etiology, time to surgery, site, Stomach Injury Scale, abdominal contamination, treatment, associated injuries, complications and mortality. RESULTS: Gastric perforation occurred in 25 patients (1.2%), median age 35 years. Stomachs were distended from recent meals in 16 (64%). The commonest causes were traffic accidents (n = 13) and blunt weapon injury (n = 7). The median time to surgery was 1 h. Gastric lesions occurred predominantly in the anterior wall (n = 12) followed by the greater curvature (n = 7). Type II lesions repaired with simple suturing were the most usual. Abdominal contamination occurred in all cases. Associated lesions were present in 22 patients; the most commonly affected intra-abdominal organ was the liver, and the lungs were the most affected extra-abdominal organ. The morbidity rate was 60% (n = 15) and the mortality rate 4% (n = 1). CONCLUSION: Early diagnosis and surgical treatment are important for reducing the morbidity and mortality in these patients.

Heme Biosynthetic Pathway is Functionally Linked to Adipogenesis via Mitochondrial Respiratory Activity.

OBJECTIVE: To investigate key enzymes of heme biosynthesis in human adipocytes and adipose tissue (AT). METHODS: Heme biosynthesis-related gene expression (ALAS1, ALAD, HMBS) was investigated in whole AT from humans (n = 178 and n = 75) and rats according to obesity status and during adipogenesis of human preadipocytes. The effects of aminotriazole (an ALAD inhibitor) and of ALAD knockdown were also studied. RESULTS: Consistent heme biosynthesis-related gene expression was detected in both subcutaneous AT (SAT) and visceral AT (VAT) and was significantly increased in SAT. ALAS1, ALAD, and HMBS mRNAs were positively associated with adipogenic gene expression in human AT and significantly decreased in subjects with obesity. These results were replicated in an independent cohort. Both SAT and VAT heme levels were positively correlated with ALAS1, ALAD, and HMBS mRNAs. ALAD and HMBS were mainly expressed in adipocytes and increased during differentiation of human adipocytes in parallel to adipogenic genes. In rats, high-fat diet-induced weight gain resulted in decreased Alad and Hmbs mRNAs in a similar way to what was observed with Adipoq. Aminotriazole administration or ALAD knockdown attenuated adipogenesis in parallel with decreased glucose uptake and impaired mitochondrial respiratory function during human adipocyte differentiation. CONCLUSIONS: Current data suggest a possible role of heme biosynthesis in human adipogenesis.

Video-assisted surgery in gastric cancer.

INTRODUCTION: The present study presents the initial results of the use of video-assisted surgery in the curative intent treatment of gastric cancer in a specialised unit of esophago-gastric pathology. METHODS: Since December 2002 we have substituted laparotomy for video-assisted surgery for the surgical treatment of gastric cancer. We report our initial experience in 28 patients. In 20 we performed a total gastrectomy with Roux Y esophago-jejunum reconstruction. In another 8 cases we performed subtotal gastrectomy with Roux Y reconstruction. The anastomoses in total gastrectomy were performed with laparoscopy with the EEA head descending via the endo-esophageal route. The resected piece is extracted via minimum laparotomy. The associated complete lympadenectomy D2 was performed in the tumours of the gastric antrum and D1 plus the lymph node groups 7, 8, 9 and proximal 11 at the second level in the gastric body and fundus. RESULTS: The mean duration of intervention was 222 minutes and the mean blood loss was 185 ml. Mortality was 3.7% and morbidity was 19%. There was a reduction in post-operative analgesia requirements and the mean hospital stay was 11 days. CONCLUSIONS: Gastric resection and related lympadenectomy can be performed using video-assisted surgery in a manner that is as safe as conventional surgery and, further, has considerable advantages. The greater complexity requires that the surgical team is better trained in the use of the laparoscopy technique. In the few studies on the theme, there appears to be no oncological inconveniences associated with the technique.

Cell survival and proliferation after encapsulation in a chemically modified Pluronic(R) F127 hydrogel.

Pluronic® F127 is a biocompatible, injectable, and thermoresponsive polymer with promising biomedical applications. In this study, a chemically modified form, i.e., Pluronic ALA-L with tailored degradation rate, was tested as an encapsulation vehicle for osteoblastic cells. UV cross-linking of the modified polymer results in a stable hydrogel with a slower degradation rate. Toxicological screening showed no adverse effects of the modified Pluronic ALA-L on the cell viability. Moreover, high viability of embedded cells in the cross-linked Pluronic ALA-L was observed with life/death fluorescent staining during a 7-day-culture period. Cells were also cultured on macroporous, cross-linked gelatin microbeads, called CultiSpher-S® carriers, and encapsulated into the modified cross-linked hydrogel. Also, in this situation, good cell proliferation and migration could be observed in vitro. Preliminary in vivo tests have shown the formation of new bone starting from the injected pre-loaded CultiSpher-S® carriers.

Multiple Hürthle cell adenomas in a patient with thyroid hormone resistance.

BACKGROUND: Thyroid hormone resistance (RTH) is a rare cause of thyroid dysfunction. High TSH levels, as described in RTH syndrome, are known to be associated with an increased risk of developing thyroid nodules with subsequent growth and malignancy. PATIENT FINDINGS: In 2006, a 29-year-old Caucasian man presented with a palpable mass in the neck. Increased free thyroxine and triiodothyronine levels were found in the context of unsuppressed TSH levels, despite no signs or symptoms of hyperthyroidism. Ultrasonography revealed a multinodular and enlarged goitre, and fine-needle aspiration cytology revealed suspicious features of malignancy. After excluding pituitary tumour and levothyroxine (l-T4) treatment, the patient was diagnosed with generalized RTH. Screening for all the known mutations in thyroid hormone receptor-ß (TR ß (THRB)) was negative. Thyroidectomy disclosed five Hürthle adenomas and three hyperplasic nodules. Euthyroidism was achieved after surgery with 6.1 µg/kg per day of l-T4. CONCLUSION: RTH may be a risk factor that predisposes to the development of multiple Hürthle cell adenomas. To our knowledge, this is the first case of multiple Hürthle cell adenomas in a patient with RTH. LEARNING POINTS: High TSH levels, as described in RTH syndrome, are known to be associated with an increased risk of developing thyroid nodules, with subsequent growth and malignancy.The exact role of TR ß mutants in thyroid carcinogenesis is still undefined.We report the first case of multiple Hürthle cell adenomas associated with RTH.

Evaluation of bone regeneration with an injectable, in situ polymerizable Pluronic F127 hydrogel derivative combined with autologous mesenchymal stem cells in a goat tibia defect model.

In situ forming bone substitute materials are attractive candidates for filling irregularly shaped defects. In this study, a chemically modified form of the Pluronic F127 hydrogel was used. Similar to the parent form, this derivative underwent a sol-gel transition in the body and additional radical curing resulted in a stable three-dimensional network gel with a controllable degradation rate. An extra cell source of autologous bone marrow-derived mesenchymal stem cells was mixed with the hydrogel to increase the ossification process, when implanted in noncritical size unicortical tibia defects. These cells were cultured and predifferentiated on two types of cell carrier systems, that is, gelatin CultiSpher-S microcarriers and hydroxyapatite tubular carriers. Radiographic and histological evaluation revealed that bone regeneration was comparable in the defects with the bone substitute compositions and the untreated control defects at 2 and 4 weeks postimplantation and that newly formed bone originated from the cells on the CultiSpher-S carriers. This resulted, 6 and 8 weeks postimplantation, in faster bone repair in the defects filled with the hydrogel plus CultiSpher-S carriers in comparison to the control defects. Surprisingly, there was no formation of new bone originating from the hydroxyapatite carriers. The hydrogel by itself seemed to stimulate the natural repair process.

SOI optical microring resonator with poly(ethylene glycol) polymer brush for label-free biosensor applications.

Label-free monitoring of biomolecular interactions has become of key importance for the emerging proteomics field. Monitoring real time interaction kinetics and high throughput screening of complex samples is of major importance for a variety of applications. We previously reported the use of Silicon-on-Insulator photonics microring resonators for cheap disposable biosensors on chip. Silicon photonics is a platform for micro- and nanoscale integrated devices that can be fabricated at extremely low cost, with standard CMOS processing facilities. Incorporation of a hydrophilic heterobifunctional polymer coating on the silicon chips largely improved the system's response to non-specific binding. We report the chemical coating procedure, the chemical surface characterization and optical measurements for both specific and non-specific interactions. Two heterobifunctional polymer coatings were investigated, alpha-sulfanyl-omega-carboxy-poly(ethylene glycol) and monoprotected diamino-poly(ethylene glycol). Homogenous coatings with thicknesses of 2.3 and 2.5 nm were obtained, corresponding to a surface loading of 99 pm/cm(2) carboxy- and 97 pm/cm(2) aminogroups, respectively. The polymer coated sensor with covalently bound biotin receptor molecules showed very low response to Bovine Serum Albumin (BSA) up to 1 mg/ml in contrast to a high response to avidin with much lower concentrations (2, 10, 87.5 and 175 microg/ml). By extrapolation the detection limit is about 10 ng/ml or 0.37 fg avidin mass. Comparison with the values reported for standard silanization confirms the polymer coating does not deteriorate the system's limit of detection. This makes the optical biosensor chip suitable to be integrated in a microflow system for commercial label-free biosensors and for lab-on-a-chip applications.

Evaluation of an injectable, photopolymerizable, and three-dimensional scaffold based on methacrylate-endcapped poly(D,L-lactide-co-epsilon-caprolactone) combined with autologous mesenchymal stem cells in a goat tibial unicortical defect model.

An in situ crosslinkable, biodegradable, methacrylate-endcapped poly(D,L-lactide-co-epsilon-caprolactone) in which crosslinkage is achieved by photoinitiators was developed for bone tissue regeneration. Different combinations of the polymer with bone marrow-derived mesenchymal stem cells (BMSCs) and alpha-tricalcium phosphate (alpha-TCP) were tested in a unicortical tibial defect model in eight goats. The polymers were randomly applied in one of three defects (6.0 mm diameter) using a fourth unfilled defect as control. Biocompatibility and bone-healing characteristics were evaluated by serial radiographies, histology, histomorphometry, and immunohistochemistry. The results demonstrated cell survival and proliferation in the polymer-substituted bone defects. The addition of alpha-TCP was associated with less expansion and growth of the BMSCs than other polymer composites.

[Risk factors for acute abdominal wall dehiscence after laparotomy in adults]. / Factores de riesgo de dehiscencia aguda de la pared abdominal tras laparotomía en adultos.

INTRODUCTION: Total evisceration consists of protrusion of the abdominal viscera due to dehiscence of all the planes of the abdominal wall after laparotomy. The greater the number of risk factors, the greater the probability of evisceration. PATIENTS AND METHOD: We performed a retrospective study of patients with evisceration treated in the previous 9 years. RESULTS: Among 12,622 patients who underwent laparotomy, 57 eviscerations were detected (45 men, 12 women; mean age 70 years). The diagnosis was peritonitis in 26 patients and intestinal occlusion in 19. Emergency surgery was performed in 48 patients. Reintervention was performed in 12 patients. Postoperative complications were found in all patients, especially wound infection and paralytic ileus. The main clinical finding was staining of the dressing. Laboratory investigations revealed leukocytosis, hypoproteinemia, and anemia. Surgical repair consisted of simple closure and/or retention sutures; mesh was associated in 6 patients. Subsequent morbidity was 77%. Twenty-six patients required admission to the intensive care unit. The mean length of hospital stay was 28.5 days. The were 41 recoveries (72%) and 16 deaths (28%). Review of 18 parameters involved in evisceration showed that 80% (45 patients) presented 9 or more risk factors. CONCLUSIONS: Evisceration is a serious occurrence that produces high morbidity and mortality. The most frequent risk factors in our series were age greater than 65 years, hemodynamic instability, increased intra-abdominal pressure, emergency surgery, infection of the wound or abdominal wall, hypoproteinemia and anemia. Because these risk factors can be predicted, when several are grouped together, reinforcement should be used when closing the abdominal wall.

Video-assisted surgery in gastric cancer

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Introduction. The present study presents the initialresults of the use of video-assisted surgery in thecurative intent treatment of gastric cancer in a specialisedunit of esophago-gastric pathology.Methods. Since December 2002 we have substitutedlaparotomy for video-assisted surgery for the surgicaltreatment of gastric cancer. We report our initialexperience in 28 patients. In 20 we performed a totalgastrectomy with Roux Y esophago-jejunum reconstruction.In another 8 cases we performed subtotalgastrectomy with Roux Y reconstruction. Theanastomoses in total gastrectomy were performedwith laparoscopy with the EEA head descendingvia the endo-esophageal route. The resected piece isextracted via minimum laparotomy. The associatedcomplete lympadenectomy D2 was performed inthe tumours of the gastric antrum and D1 plus thelymph node groups 7, 8, 9 and proximal 11 at thesecond level in the gastric body and fundus.Results. The mean duration of intervention was 222minutes and the mean blood loss was 185 ml. Mortalitywas 3.7% and morbidity was 19%. There was areduction in post-operative analgesia requirementsand the mean hospital stay was 11 days.Conclusions. Gastric resection and related lympadenectomycan be performed using video-assistedsurgery in a manner that is as safe as conventionalsurgery and, further, has considerable advantages.The greater complexity requires that the surgicalteam is better trained in the use of the laparoscopytechnique. In the few studies on the theme, thereappears to be no oncological inconveniences associatedwith the technique

Factores de riesgo de dehiscencia aguda de la pared abdominal tras laparotomía en adultos / Risk factors for acute abdominal wall dehiscence after laparotomy in adults

Introducción. La evisceración total es la salida de vísceras abdominales por una dehiscencia de todos los planos de la pared, tras una laparotomía. Cuanto mayores son los factores de riesgo más elevada es la probabilidad de sufrir evisceración. Pacientes y método. Estudio retrospectivo de los pacientes con evisceración tratados en los últimos 9 años. Resultados. En 12.622 pacientes laparotomizados se detectaron 57 evisceraciones (45 varones y 12 mujeres; edad media 70 años). El diagnóstico fue de peritonitis en 26 casos y de oclusión intestinal en 19. La cirugía fue urgente en 48 pacientes. Fue preciso reintervenir en 12 pacientes. En todos se detectaron complicaciones postoperatorias, entre las que destacaba la infección de la herida y el íleo paralítico. En la clínica predominó el manchado del apósito. La analítica mostró leucocitosis, hipoproteinemia y anemia. Se repararon mediante cierre simple y/o puntos totales y en 6 casos se asociaron mallas. La morbilidad posterior fue del 77%. En 26 pacientes fue preciso aplicar cuidados intensivos. La estancia media fue de 28,5 días. Hubo 41 curaciones (72%) y 16 muertes (28%). Tras revisar 18 parámetros implicados en la evisceración, 45 pacientes (80%) presentaban 9 o más factores de riesgo. Conclusiones. La evisceración es una enfermedad muy grave, con una elevada morbimortalidad. Los factores de riesgo más frecuentes, en nuestra serie, fueron: edad > 65 años, inestabilidad hemodinámica, aumento de la presión intraabdominal, cirugía urgente, infección de la herida o de la pared, hipoproteine- mia y anemia. Dado que estos factores de riesgo son predecibles, ante la suma de varias de estas causas deberíamos añadir medidas de refuerzo al cierre de la pared abdominal (AU)

Introduction. Total evisceration consists of protrusion of the abdominal viscera due to dehiscence of all the planes of the abdominal wall after laparotomy. The greater the number of risk factors, the greater the probability of evisceration. Patients and method. We performed a retrospective study of patients with evisceration treated in the previous 9 years. Results. Among 12,622 patients who underwent laparotomy, 57 eviscerations were detected (45 men, 12 women; mean age 70 years). The diagnosis was peritonitis in 26 patients and intestinal occlusion in 19. Emergency surgery was performed in 48 patients. Reintervention was performed in 12 patients. Postoperative complications were found in all patients, especially wound infection and paralytic ileus. The main clinical finding was staining of the dressing. Laboratory investigations revealed leukocytosis, hypoproteinemia, and anemia. Surgical repair consisted of simple closure and/or retention sutures; mesh was associated in 6 patients. Subsequent morbidity was 77%. Twenty-six patients required admission to the intensive care unit. The mean length of hospital stay was 28.5 days. The were 41 recoveries (72%) and 16 deaths (28%). Review of 18 parameters involved in evisceration showed that 80% (45 patients) presented 9 or more risk factors. Conclusions. Evisceration is a serious occurrence that produces high morbidity and mortality. The most frequent risk factors in our series were age greater than 65 years, hemodynamic instability, increased in-tra-abdominal pressure, emergency surgery, infection of the wound or abdominal wall, hypoproteinemia and anemia. Because these risk factors can be predicted, when several are grouped together, reinforcement should be used when closing the abdominal wall (AU)

Tratamiento adyuvante y neoadyuvante del cáncer de esófago. Evolución y estado actual / Adjuvant and neoadjuvant therapy of esophageal cancer. Development and current situation

El tratamiento adyuvante y neoadyuvante del cáncer de esófago es un tema que sigue siendo controvertido. Los ensayos realizados en las últimas 2 décadas han permitido aclarar algunos conceptos y marcar las futuras líneas de trabajo e investigación. Mientras el tratamiento adyuvante va perdiendo fuerza, el neoadyuvante demuestra ser prometedor. A falta de los resultados de los ensayos en curso, se ha demostrado efectivo en el control local de la enfermedad, en la disminución de las recidivas y, en algún caso, en la supervivencia postoperatoria. Se efectúa una revisión de los principales trabajos hasta la actualidad y se marcan las líneas de trabajo en un futuro inmediato (AU)

Cirugía laparoscópica en el cáncer gástrico / Laparoscopic surgery in gastric cancer

Introducción. Aportamos nuestra experiencia en el tratamiento del cáncer gástrico mediante cirugía laparoscópica. Pacientes y método. Entre enero de 2003 y de 2004 hemos sustituido, en casos seleccionados, la laparotomía por la laparoscopia en la cirugía del cáncer gástrico. Aportamos nuestra experiencia con 8 pacientes de un total de 23 gastrectomías realizadas. En 6 hemos efectuado una gastrectomía total con reconstrucción esofagoyeyunal en "Y" de Roux a la que hemos asociado una pequeña laparotomía transversa subxifoidea para extraer la pieza y realizar la anastomosis esofagoyeyunal. En otros 2 casos hemos realizado una gastrectomía subtotal con reconstrucción en "Y" de Roux. La pequeña laparotomía transversa sólo se utiliza aquí para extraer la pieza. La linfadenectomía es la misma que en cirugía abierta: D2 completa en los tumores de tercio inferior y D1 más los grupos ganglionares 7, 8 y 9 del segundo nivel en los de cuerpo y fondo gástrico. Resultados. Los resultados aún son poco valorables debido al reducido número de pacientes operados. La mortalidad fue nula y la morbilidad del 12 por ciento. La duración media de las intervenciones fue de 230 min. Se redujeron los requerimientos de analgesia postoperatoria y la estancia hospitalaria media se situó en 8,3 días. Se reconvirtió a cirugía abierta a otros 3 pacientes. Conclusiones. La resección gástrica y la linfadenectomía asociada pueden realizarse perfectamente por laparoscopia de manera segura. Su mayor complejidad exige una mejor preparación en la técnica laparoscópica. En los escasos trabajos sobre el tema no se aprecian inconvenientes oncológicos para su realización (magnitud de la resección, linfadenectomía, recidivas) (AU)