Metaplastic carcinoma of the breast with squamous differentiation: prognostic factors and multidisciplinary treatment.

BACKGROUND: The objective of this study was to analyze the characteristics of patients diagnosed with metaplastic carcinoma of the breast with squamous differentiation and to identify the particular clinical and histological characteristics that need to be taken into account in this type of tumors. CASE PRESENTATION: Retrospective observational study of two patients managed at our hospital between 2014 and 2020 (15 months mean follow-up), plus all cases published in the last 7 years (8 patients). Thus, a total of 10 cases were analyzed, all with less than 2 years mean global survival. Studied variables were: age, medical background, tumor size, axillary involvement, radiological characteristics, surgical approach, complementary treatments, histologic characteristics, and progression of the disease. In 50% of cases, the disease appeared as a palpable mass of rapid growth, associated with axillary infiltration; 80% of the tumors were triple negative; 30% of them progressed to distant metastatic disease in 30%. CONCLUSIONS: This unusual carcinoma requires a complex multidisciplinary treatment. Its prognosis is unfavorable due to its high local aggressiveness, with rapid progression and appearance of metastatic disease. The predominance of different histological components may determine the response to medical treatments.

Superior mesenteric vein aneurysm.

A 41-year-old female patient was under study for abdominal pain located in the epigastrium and mesogastrium with no other associated symptoms. There was no record of previous episodes of pancreatitis and she denied abdominal trauma and laboratory tests were normal. A computed tomography (CT) scan was performed.

Adenocarcinoma of the small intestine in Crohn's disease.

The first case of small-bowel carcinoma (SBC) associated with Crohn's disease (CD) was described by Ginzburg in 1956. Since then, only 220 cases have been published in the literature.

Surgery and considerations for the repair of Petersen's space hernia after mini gastric bypass.

This paper reports a case of Petersen's space hernia after mini gastric bypass. This is an anecdotal post-operative complication in the mini gastric bypass technique, with an estimated rate of 1/5000 cases. Similar cases described in the literature were treated by the surgical hernia reduction and the closure of the mesenteric defect. Our patient had a unique management, performing a conversion to Roux-en-Y gastric bypass with dissection of the biliopancreatic limb at the anastomosis and creation of a variable foot-point anastomosis with excellent mid-term post-operative results. This should provide better long-term results as compared to simple mesenteric closure, avoiding the complications of mini gastric bypass technique.

Adult gastric duplication: an unknown condition within the spectrum of gastric submucosal lesions.

BACKGROUND: Gastric duplication is an uncommon condition in adults representing only 4-8% of all gastrointestinal duplications. It develops as a cystic growth within the thick gastric wall that is surrounded by a layer of smooth muscle and lined with gastric mucosa. It is usually asymptomatic but may present with nonspecific abdominal symptoms as well as cyst-related complications such as gastrointestinal (GI) bleeding, ulceration and even pancreatitis. They are difficult to distinguish from other gastric submucosal lesions and may also mimic a gastrointestinal tumor (GIST) or mucinous cyst of the pancreas. Endoscopic ultrasound (EUS) is the most widely used diagnostic procedure and histology provides a definitive diagnosis. CASE REPORT: We report the case of a 36-year-old female patient with a history of a "contained" perforated gastric ulcer that was managed conservatively. The patient was diagnosed with a gastric GIST which prompted a laparoscopic subtotal gastrectomy and Roux-en-Y reconstruction with a good postoperative outcome. DISCUSSION: The definitive histological diagnosis was gastric duplication. Thus, the previous diagnosis of a "contained" perforated gastric ulcer was in fact a complication of the gastric duplication itself.

General surgery training in Spain: core curriculum and specific areas of training.

The royal decree RD 639/2014 has been published, regulating among others, the core curriculum, and specific areas of training (SAT). It is of great interest for the specialty of General and Digestive Surgery (GS and DS). The aim is to expose and clarify the main provisions and reflect on their implications for the practical application of the core curriculum and SAT in the specialty of General and Digestive Surgery, to promote initiatives and regulations. This RD will be a milestone in our specialty that will test the strength of the specialty, if it does not finally culminate in its degradation against the emergence of new surgical specialties. A new stage begins in which the Spanish Association of Surgeons should be involved to define the conceptual basis of GS and DS in the XXI century, and the creation of new SAT to continue to maintain the "essence of our specialty".

Left-sided appendicitis: diagnosis and minimally invasive treatment.

Intestinal malrotation and situs inversus can have important repercussions if acute abdominal pain develops. Intraabdominal structures can have inverted position and thus may easily mislead the surgeon during physical examination. Fortunately, radiological exams have improved the preoperative diagnosis of these patients. However, in difficult cases when an underlying surgical disease is suspected, laparoscopy remains the gold standard in order to diagnose and treat if possible the suspected disorder. We present a case of acute left-side appendicitis in a child with unknown congenital intestinal malrotation. In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain.

Bariatric Surgery: An Opportunity to Improve Quality of Life and Healthy Habits.

Bariatric surgery therapy (BST) is an effective treatment for obesity; however, little is known about its impacts on health-related quality of life (HRQoL) and related factors. This study aimed to evaluate changes in HRQoL and its relationship with weight loss, depression status, physical activity (PA), and nutritional habits after BST. Data were obtained before and 18 months postprocedure from 56 obese patients who underwent BST. We administered four questionnaires: Short Form-36 health survey for HRQoL, 14-item MedDiet adherence questionnaire, Rapid Assessment of PA (RAPA) questionnaire, and Beck's Depression Inventory-II. Multivariable linear regression analysis was used to identify factors associated with improvement in HRQoL. After the surgery, MedDiet adherence and HRQoL improved significantly, especially in the physical component. No changes in PA were found. Patients without previous depression have better mental quality of life, and patients who lost more than 25% of %TBWL have better results in physical and mental quality of life. In the multivariable analysis, we found that %TBWL and initial PCS (inversely) were related to the improvement in PCS and initial MCS (inversely) with the MCS change. In conclusion, BST is an effective intervention for obesity, resulting in significant weight loss and improvements in HRQoL and nutritional habits.

Effect of bariatric surgery in the body burden of persistent and non-persistent pollutants: longitudinal study in a cohort of morbidly obese patients.

Introduction: Obesity is a pathological state that involves the dysregulation of different metabolic pathways and adipose tissue cells, constituting a risk factor for the development of other diseases. Bariatric surgery is the most effective treatment. The study of the behavior of pollutants in situations of extreme weight loss can provide biomonitoring information and tools to manage diseases of environmental etiology. Aim: To determine the prevalence of serum persistent and non-persistent pollutants in obese patients subjected to bariatric surgery and analyze the impact of sociodemographic variables on these changes. Methods: GC-MS/MS and UHPLC-MS/MS were utilized to determine the detection rates and concentrations of 353 compounds, including persistent organic pollutants (POPs), pesticides, pharmaceuticals, and rodenticide, in serum samples of 59 obese patients before and after undergoing bariatric surgery. Results: Detection rates of p,p'-DDE, HCB, ß-HCH, naphthalene, phenanthrene and PCB congeners 138, 153 and 180 significantly increased due to surgery-induced weight loss. Serum levels of p,p'-DDE, PCB-138, PCB-153 and PCB-180 also increased after surgery. Correlations between naphthalene levels, weight loss, variation of total lipids and time after surgery were found. Additionally, correlations were observed between concentrations of PCB-138 and weight loss, and between phenanthrene levels and reduction of total lipids. No statistically significant differences were observed for other groups of contaminants, pharmaceuticals and other chemicals included in the quantification methods. Conclusions: Increment of POPs was observed after bariatric surgery. Serum concentrations of POPs after surgery were influenced by adiposity-related variables. Although biomonitoring studies show a decreasing tendency of exposure, rapid weight loss leads to an increase of circulating POPs. Further research on the interplay between adipose tissue, POPs and peripheral organs is required.

Hypercalcemia associated with adenosquamous pancreatic carcinoma: a reason to initiate palliative treatment.

BACKGROUND: hypercalcemia in patients with diagnosed carcinoma has predominantly a humoral basis mediated by parathyroid hormone-related protein (PTH-rP). Among the reported cases, hypercalcemia associated with the majority of abdominal malignancies indicates an advanced stage of disease. CASE REPORT: we present a case of a 78-year-old patient with an adenosquamous pancreatic carcinoma associated with humoral hypercalcemia mediated by PTH-rP. CONCLUSION: in this case, demonstration of unexpectantly rapid increase in calcium serum correlated with aggressive tumor growth led us to raise the hypothesis that PTH-rP could be a mediator of invasion and dissemination secreted by some tumors, and probably indicates the appropriate time to initiate palliative treatment.

Axillary management in patients with breast cancer and positive axilla at diagnosis. Experience in a Spanish university hospital with a 5-year follow-up.

Background: Axillary lymph node dissection (ALND) was the standard in breast cancer with axillary involvement until recently. Along with the number of metastatic nodes, axillary positivity was considered a main prognostic factor and scientific evidence shows that the administration of radiotherapy on ganglion areas decreases the risk of recurrence even in positive axilla. The objective of this study was to evaluate the axillary treatment in patients with positive axilla at diagnosis, the evolution of them over time, and to assess patient's follow-up with the aim of avoiding the morbidity associated with axillary dissection. Methods: A retrospective observational study of breast cancer patients diagnosed between 2010 and 2017 was performed. In total, 1,100 patients were studied, out of which 168 were women with clinically and histologically positive axilla at diagnosis. Seventy-six percent received primary chemotherapy and subsequent treatment with sentinel node biopsy, axillary dissection, or both. Patients with positive sentinel lymph node biopsy received either radiotherapy or lymphadenectomy depending on the year time they were diagnosed. Results: For 60 patients out of 168, neoadjuvant chemotherapy resulted in a complete pathological axillary response. Axillary recurrence was registered for six patients. No recurrence was detected in the biopsy group associated with radiotherapy. These results support the benefit of lymph node radiotherapy for patients with positive sentinel node biopsy after receiving primary chemotherapy. Conclusion: Sentinel node biopsy provides useful and reliable information about cancer staging and might prevent lymphadenectomy, leading to a decrease in morbidity. Pathological response to systemic treatment came out as the most important predictive factor of disease-free survival of breast cancer.

[Staged oesophageal reconstruction for benign disease]. / Reconstrucción diferida del esófago tras su interrupción para el tratamiento de una patología benigna.

OBJECTIVES: To assess morbidity, mortality and quality of life after oesophageal reconstruction in patients with oesophageal exclusion for benign diseases. PATIENTS AND METHODS: From 2002 to 2011, 20 of 24 patients with esophageal exclusion due to benign disease underwent a delayed reconstruction. We analyzed morbidity, mortality and health-related quality of life using the SF-36 questionnaire, before and after reconstruction. RESULTS: Twenty patients were operated (16 men and 4 women) with an average age of 54.5 ± 10.5 years. Main causes of oesophageal disconnection were: 10 cases of caustics ingestion, 3 iatrogenic perforations, 4 anastomotic leaks and 3 cases with Boerhaave syndrome. Fourteen (60%) coloplasties and 6 (25%) gastric interpositions were performed with an average time of 212,2 ± 23.5 days after oesophageal exclusion. Pulmonary complications were the most common postoperative complications (55% patients) and according to the modified Clavien classification were divided into: grade 1 (10%), grade 2 (15%), grade 3a (40%), grade 3b (10%), and grade 4a (10%). The 30-day mortality (grade 5) of the series was 10%. Quality of life after reconstruction improved significantly in all analyzed domains of the SF-36 questionnaire. CONCLUSIONS: Deferred oesophageal reconstruction is associated with a high morbidity and a mortality rate of 10%. After reconstruction, the quality of life improved in all the parameters evaluated.

[Laparoscopic biliopancreatic diversion: a surgical technique in our learning curve]. / Derivación biliopancreática laparoscópica: técnica quirúrgica en nuestra curva de aprendizaje.

BACKGROUND: We present our initial experience with the laparoscopic BPD technique for super-obese patients. Recommended tips on the technique are summarized. METHODS: A total of 35 super-obese patients were submitted to BPD by laparoscopy in November 2009 and June 2010 for the treatment of morbid obesity. RESULTS: All operations were performed by laparoscopy with no need to convert to laparotomy. No mayor complications and mortality related to surgery were observed. CONCLUSION: The Scopinaro technique can be safely performed in super-obese patients by surgeons with special dedication for bariatric surgery and advanced skills in intracorporeal suturing and knot-tying.

Prehabilitation for Bariatric Surgery: A Randomized, Controlled Trial Protocol and Pilot Study.

Bariatric surgery is the most efficacious treatment for obesity, though it is not free from complications. Preoperative conditioning has proved beneficial in various clinical contexts, but the evidence is scarce on the role of prehabilitation in bariatric surgery. We describe the protocol and pilot study of a randomized (ratio 1:1), parallel, controlled trial assessing the effect of a physical conditioning and respiratory muscle training programme, added to a standard 8-week group intervention based on therapeutical education and cognitive-behavioural therapy, in patients awaiting bariatric surgery. The primary outcome is preoperative weight-loss. Secondary outcomes include associated comorbidity, eating behaviour, physical activity, quality of life, and short-term postoperative complications. A pilot sample of 15 participants has been randomized to the intervention or control groups and their baseline features and results are described. Only 5 patients completed the group programme and returned for assessment. Measures to improve adherence will be implemented and once the COVID-19 pandemic allows, the clinical trial will start. This is the first randomized, clinical trial assessing the effect of physical and respiratory prehabilitation, added to standard group education and cognitive-behavioural intervention in obese patients on the waiting list for bariatric surgery. Clinical Trial Registration: NCT0404636.