[Primary orbital squamous cell carcinoma]. / Carcinoma escamoso primario de órbita.

Primary orbital squamous cell carcinoma is a rare entity. There is little published literature. We report a case of primary squamous cell carcinoma of the orbital soft tissues. Surgical resection offered the best treatment for the patient. Complete resection of the lesion was achieved. The patient received adjuvant radiotherapy due to the proximity of the lesion to the surgical margins. Surgical treatment is feasible and should be considered as part of the surgeon's arsenal. However, therapeutic decisions must be made on a case-by-case basis.

[Giant adrenal myelolipoma. Right laparoscopic adrenalectomy]. / Mielolipoma adrenal gigante. Adrenalectomía derecha laparoscópica.

Adrenal myelolipoma is a rare, benign, non-functioning tumor. It is composed by fat and hematopoietic tissues. We present the case of a 33-year-old woman with diagnosis of a 14 cm diameter non-functioning right adrenal incidentaloma, with imaging features suggestive of myelolipoma. Based on the benign nature of the tumor, laparoscopic resection was performed. Histopathology showed a myelolipoma, weighting 444 grams. The patient evolved with an uneventful postoperative period. Laparoscopic adrenalectomy for a giant myelolipoma was feasible and successful.

[Melanoma behavior according to age]. / Comportamiento del melanoma según la edad.

In recent years the incidence of melanoma in elderly patients has increased with an unfavorable oncologic outcome due not only to immune deterioration but also to greater aggressiveness of the tumor. The aim of this study was to evaluate the behavior of cutaneous melanoma in relation to age. A consecutive series of cases with melanoma operated in a reference center in the period 2001-2013 was included. The sample was divided into two groups according to the age. Group 1 (G1): under 65 years and Group 2 (G2): over 65 years. Histopathological variables and oncologic outcomes were compared between the two groups. Three hundred and eighty eight patients were operated. They belonged to G1 241 (62%) and to G2 147 (38%). Both groups were homogeneous with respect to the histological type of melanoma. Group 2 had thicker melanomas (Breslow > 4 mm 19% vs. 7%, p < 0.005) and higher rates of ulceration (37% vs. 20%, p: 0.007) and distant metastases (stage IV 11% vs. 3%, p 0.01). There was no difference between groups regarding nodal involvement. With a mean follow up of 45 (6-98) months throughout the series, recurrence of disease was higher in group 2 (26% vs. 17%, p: 0.03), but the specific mortality showed no significant difference (9.5% vs. 5.3%, p: 0.12). In conclusion, cutaneous melanoma in patients over 65 years is more aggressive with higher rates of local recurrence and distant metastases.

Solitary fibrous tumor of the parapharyngeal space: report of 2 cases and a literature review.

The solitary fibrous tumor (SFT) is usually described as a lesion arising from the pleura. Rarely, it has been described in the parapharyngeal space (PS). This study aims to report two cases of SFT in the PS and to perform a literature review on this topic. Two patients undergoing surgical resection of a SFT in the PS, were reported. A literature review on SFT of the PS, was also performed. Two patients were analyzed. Both patients underwent surgical resection, followed by adjuvant radiotherapy, for SFT arising from the PS. The postoperative course was uneventful and both patients recovered well after the procedure. No recurrences were diagnosed during the followup. SFT of the PS is an infrequent entity. Surgical resection is the most used treatment, and adjuvant radiation should be considered in patients with recurrence risk factors or distant metastases.

[Biological behavior of meshes used for abdominal wall surgery. Preliminary results in an animal model]. / Comportamiento biológico de mallas para la reparación de paredes abdominales. Resultados preliminares en un modelo animal.

An adequate integration of the prosthetic materials used to repair abdominal wall defects is necessary for satisfactory outcomes. We aimed to evaluate, in an animal model, the biological behavior of meshes used for abdominal wall surgery. Four groups of 10 rats were separated. After laparotomy, intraperitoneal prostheses were placed: 1) Prolene® (polypropylene microporous, heavy-weight), 2) Ultrapro® (polypropylene + poliglecaprone, macroporous low-weight), 3) Proceed® (polypropylene + polidoxanone + regenerated oxidized cellulose, microporous medium-weight), 4) Physiomesh® (polypropylene + poliglecaprone, macroporous lowweight). Macroscopic and microscopic analyses were performed at 30 days. The results were evaluated by two independent observers and expressed in means with standard deviation. For statistical analysis p < 0.05 was considered significant. On macroscopic examination, mesh integration was greater than 75% in all cases. Microscopic analysis showed greater global inflammation and more multinucleated giant cells in Prolene® (p < 0.01). Less inflammatory cells were observed at the muscle-mesh interface in Physiomesh® vs. Ultrapro® (p < 0.05). Collagen fibers disposition was similar in all meshes, although, microporous meshes had higher collagen deposit in the interfilamentous spaces (p < 0.01). In conclusion, in our animal model, microporous and heavy-weight polypropylene meshes produce greater inflammatory and foreign body reaction. Thus, composite meshes would have greater biocompatibility and better tolerance by the host.

La falla en la reparación de los defectos de la pared abdominal se relaciona con una alteración en la integración del material protésico. El objetivo de este trabajo fue evaluar el comportamiento biológico de mallas utilizadas en cirugía de paredes abdominales en un modelo animal. Luego de la confección de un defecto parietal se colocó una malla intraperitoneal, utilizando 4 grupos de 10 ratas; 1) Prolene® (polipropileno microporo de alto peso), 2) Ultrapro® (polipropileno + poliglecaprone, macroporo de bajo peso), 3) Proceed® (polipropileno + polidoxanona + celulosa oxidada regenerada, macroporo de peso intermedio), y 4) Physiomesh® (polipropileno + poliglecaprone, macroporo de bajo peso). Se realizó análisis macroscópico y microscópico a los 30 días y los resultados fueron evaluados por dos observadores independientes. Al examen macroscópico, la integración de la prótesis fue > 75% en todos los grupos. El análisis microscópico mostró mayor inflamación global y número de células gigantes multinucleadas en Prolene® (p < 0.01) y menor cantidad de células inflamatorias en la interface músculo-malla en Physiomesh® < Ultrapro® (p < 0.05). La organización de las fibras de colágeno fue similar para todas las mallas, aunque hubo mayor depósito de colágeno en los espacios inter-filamento para las mallas macroporosas (p < 0.01). Concluimos que las mallas de polipropileno microporo y alto peso producen mayor reacción inflamatoria y de cuerpo extraño. Por lo tanto, las mallas compuestas tendrían una mejor biocompatibilidad y serían mejor toleradas por el huésped.

Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring?

INTRODUCTION: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. METHODS: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 min after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50% compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. RESULTS: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 min after its excision, IOPTH did not decrease in 9 patients (4.2%. OR 1.9%-7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 min and the waiting time for the third IOPTH result was 31 min. Performing IOPTH monitoring made the surgery about twice more expensive. CONCLUSIONS: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies.

Tumor-Infiltrating Lymphocytes in Patients with Melanoma: Which Is Its Prognostic Value?

Oncological impact of tumor-infiltrating lymphocytes (TILs) in melanoma remains controversial. We aimed to determine the significance of TILs on melanoma-specific survival (MSS), recurrence-free survival (RFS), and sentinel lymph node status (SLN). A retrospective analysis of patients undergoing melanoma resection during the period 2009-2019 was performed. Using the Melanoma Institute Australia grading system for TILs, the cohort was divided into two groups: group 1 (G1), patients with TILs grades 1, 2, or 3 and Group 2 (G2), patients with TILs grade 0. From a total of 386 melanoma resections, 151 (39%) were included in G1 and 39 (10%) in G2. Among the 151 patients who underwent SLN biopsy, the positivity rate according to the TILs grades 0, 1, 2, and 3 was 32%, 18%, 14%, and 0%, respectively, p = 0.02. With an average follow-up of 48 months, the 5-year MSS (G1: 86% vs G2: 75%, p = 0.002) and the 5-year RFS (G1: 81% vs G2: 60%, p = 0.004) were significantly higher in G1 than G2. Tumor-infiltrating lymphocytes in melanoma are associated with the SLN status and with a better MSS and RFS.

Laparoscopic approach to colonic perforation due to colonoscopy.

BACKGROUND: Iatrogenic perforation due to colonoscopy is the most serious complication of this procedure. Usually, resolution of this event requires segmental resection. The laparoscopic approach could be an option to minimize the outcome of this complication. The aim of the present study was to assess the effectiveness of the laparoscopic approach in treating colonic perforations due to colonoscopy. METHODS: Between July 1997 and November 2008 data were collected retrospectively on all patients who underwent colonoscopy and had a perforation caused by the procedure. Patients with other complications after colonoscopy as well as other colonic perforations were excluded. According to the method employed for the approach, the series was divided in two groups: those treated by the laparoscopic approach (group I; GI) and those treated via laparotomy (group II; GII). Morbidity and recovery parameters were compared between the two groups. Statistical analysis was performed using Student's t-test and the chi square test. RESULTS: A total of 14,713 colonoscopies were performed during the study period. Of these, 10,299 (73 %) were diagnostics and 4,414 (27%) were therapeutics. There were 20 (0.13%) iatrogenic perforations (GI = 14 versus GII = 6). The mean age of the patients was 62 +/- 12.1 years. There were no differences in patient demographics, co-morbidities, and American Society of Anesthesiologists (ASA) grades between the groups. Seventeen patients had segmental colectomy with primary anastomosis (GI: 13 versus GII: 4). One patient in each group had simple suture with diverting ileostomy, and one patient from GII underwent a Hartmann's procedure. Patients from GI had a shorter hospital stay (GI: 4.2 +/- 2.06 days versus GII 11.5 +/- 8.8 days; P = 0.007) and there were no differences in complication rate compared with GII (GI: 3 versus GII: 5; P = 0.058). CONCLUSIONS: Laparoscopic colectomy is effective in resolving colonic perforation due to colonoscopy, and it might offer benefits over the open approach.

Rescue policy for discarded liver grafts: a single-centre experience of transplanting livers 'that nobody wants'.

BACKGROUND: There is a worldwide need to expand the donor liver pool. We report a consecutive series of elective candidates for liver transplantation (LT) who received 'livers that nobody wants' (LNWs) in Argentina. METHODS: Between 2006 and 2009, outcomes for patients who received LNWs were analysed and compared with outcomes for a control group. To be defined as an LNW, an organ is required to fulfil two criteria. Firstly, each liver must be officially offered and refused more than 30 times; secondly, the liver must be refused by at least 50% of the LT programmes in our country before our programme can accept it. Principal endpoints were primary graft non-function (PNF), mortality, and graft and patient survival. RESULTS: We transplanted 26 LNWs that had been discarded by a median of 12 centres. A total of 2666 reasons for refusal had been registered. These included poor donor status (n= 1980), followed by LT centre (n= 398) or recipient (n= 288) conditions. Incidences of PNF (3.8% vs. 4.0%), in-hospital mortality (3.8% vs. 8.0%), 1-year patient (84% vs. 84%) and graft (84% vs. 80%) survival were equal in the LNW and control groups. CONCLUSIONS: Transplantable livers are unnecessarily discarded by the transplant community. External and internal supervision of the activity of each LT programme is urgently needed to guarantee high standards of excellence.

[Laparoscopic approach in the treatment of malignant adrenal tumours]. / Abordaje laparoscópico en el tratamiento de las tumoraciones adrenales malignas.

BACKGROUND: Malignant primary or secondary adrenal tumours are uncommon. For most of them early surgery with adrenalectomy is the only means of cure. Although controversy exists on this issue, the increasing experience in laparoscopic surgery extends the indication for laparoscopic adrenalectomy to potentially malignant and to metastatic adrenal tumours. Our aim was to evaluate the technical feasibility of laparoscopic adrenalectomy for malignant neoplasias, describing the results of our consecutive series of patients. MATERIAL AND METHODS: We retrospectively analysed 13 patients who underwent laparoscopic adrenalectomy for malignant neoplasia between March 1999 and June 2009, at the Hospital de Clínicas of the Universidad of Buenos Aires and at the Hospital Alemán of Buenos Aires. A transperitoneal laparoscopic approach was used in all patients. The mean follow up was 37.9 months (2-84). RESULTS: Thirteen laparoscopic adrenalectomies were performed due to malignant neoplasia. Mean age was 55.2+12 years. The relationship between male and female was 10/3. Five patients had an adrenal carcinoma, 1 patient a malignant phaeochromocytoma, and 7 patients had metastatic tumours. Three patients required conversion to laparotomy. Average operation time was 146.4 min. There were two perioperative complications and no mortality. Average length of hospital stay was 4.6 days (1-35). The survival at 3 years was 46%. The cause of death was the underlying disease in all cases. CONCLUSION: Laparoscopic adrenalectomy is a reasonable technique for malignant adrenal tumours, when the open oncological resection can be reproduced by the laparoscopic approach.

[Long-term survival after small doses of radioiodine therapy for brain metastases of thyroid cancer]. / Supervivencia prolongada luego de pequeñas dosis de terapia con radioyodo en metástasis cerebral de cáncer de tiroides.

Differentiated thyroid cancer is generally accompanied by a long term survival. However, in some cases distant metastases can develop and among them, brain localizations are of poor prognosis. The aim of this presentation is to communicate the clinical case of a 65 year-old woman who consulted for diplopia in vertical gaze which had appeared one month earlier. MRI showed a big mass at the level of the occipital condyle. Diagnosis of primary brain tumor was made so she was operated twice with incomplete tumor resection. The pathological study was confirmatory of a metastatic lesion of thyroid carcinoma. A total thyroidectomy with resection of a papillary cancer of the follicular variant was performed. Then, she was successfully treated with small repetitive radioiodine amounts for a total accumulated dose of 325 mCi 131I, with a long-term survival.

El cáncer diferenciado de tiroides generalmente se acompaña de una supervivencia a largo plazo. Sin embargo, en algunos casos pueden desarrollarse metástasis a distancia y, entre ellas, las localizaciones cerebrales son de mal pronóstico. El objetivo de esta presentación es comunicar el caso clínico de una mujer de 65 años que consultó por diplopía en la mirada vertical que había aparecido un mes antes. La resonancia magnética mostró una gran masa a nivel del cóndilo occipital. Se realizó el diagnóstico de tumor cerebral primario, por lo que fue operada dos veces con resección tumoral incompleta. El estudio histopatológico confirmó una lesión metastásica de carcinoma de tiroides. Se realizó una tiroidectomía total con resección de un cáncer papilar de la variante folicular. Luego, fue tratada con éxito con pequeñas cantidades repetitivas de yodo radiactivo para una dosis total acumulada de 325 mCi 131I, con una supervivencia a largo plazo.

Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring? / Estudios preoperatorios coincidentes para el diagnóstico de hiperparatiroidismo primario por adenoma simple: ¿podemos evitar la PTH intraoperatoria?

INTRODUCTION: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. METHODS: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 minutes after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50%compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. RESULTS: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 minutes after its excision, IOPTH did not decrease in 9 patients (4.2% OR 1.9% - 7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 minutes and the waiting time for the third IOPTH result was 31minutes. Performing IOPTH monitoring made the surgery about twice more expensive. CONCLUSIONS: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies.

Is a laparoscopic approach useful for treating complications after primary laparoscopic colorectal surgery?

PURPOSE: Although the use of laparoscopy for the management of postoperative complications has been previously well documented for different pathologies, there is scarce information regarding its use after laparoscopic colorectal surgery. METHODS: Data were prospectively collected from all patients undergoing laparoscopic colorectal surgery between June 2000 to October 2007. Patients were divided into two groups according to the approach used for the reoperation: laparoscopy (Group I) or laparotomy (Group II). Data were statistically analyzed by using Student's t-test and chi-squared test. RESULTS: In all, 510 patients were analyzed. Twenty-seven patients (5.2 percent), 14 men and 13 women (men/women Group I: 10/7 vs. Group II: 4/6; P = not significant (NS)), required a second surgery because of postoperative complications (Group I: 17 (63 percent); Group II: 10 (37 percent)). Mean age was 60 +/- 17 years (Group I: 61.7 +/- 17.7 vs. Group II: 57.1 +/- 16 years; P = NS). Fifteen patients (55.5 percent) had anastomotic leaks (Group I 13/17 (76.5 percent) vs. Group II 2/13 (15 percent); P = 0.004). The were no differences between the groups regarding the length of stay or postoperative complications (Group I: 11.9 +/- 9.6 vs. Group II: 18.1 +/- 19.7 days: P = NS; Group I: 1 vs. Group II: 3; P = NS). CONCLUSIONS: Laparoscopic approach is a useful tool for treating complications after laparoscopic colorectal surgery, especially anastomotic leaks. Randomized, controlled trials are necessary to validate these findings.

Acalculous cholecystitis in a patient with metastatic renal cell carcinoma treated with sunitinib.

A 62-year-old woman was treated with sunitinib as a second-line therapy for metastatic clear-cell renal carcinoma. She was given oral sunitinib 50 mg once daily, 4 weeks on followed by 2 week off. During the fourth week of her first cycle, the patient was admitted to our hospital because of an acute-onset, right upper quadrant pain associated with nausea and vomiting. She was diagnosed with acute acalculous cholecystitis, which was treated with broad-spectrum antibiotics, and sunitinib therapy was discontinued. A follow-up computed tomography scan of the abdomen revealed a complete resolution of gallbladder changes. Our patient did not have major risk factors for developing an acalculous cholecystitis except for a relative immunosuppressed state secondary to her advanced renal cancer. The Naranjo Adverse Drug Reaction Probability Scale score for this event was 5, indicating a probable association of the event with sunitinib. Because the use of sunitinib is expanding in clinical practice, we want to alert the oncology community about this uncommon and life-threatening complication in patients receiving sunitinib or another agent with antiangiogenic activity.

Patients with less than three episodes of diverticulitis may benefit from elective laparoscopic sigmoidectomy.

BACKGROUND: This study was designed to asses the predictive factors of postoperative complications in patients who underwent a laparoscopic elective approach for recurrent diverticulitis and to determine the relationship between the number of acute episodes and surgical morbidity. METHODS: A retrospective analysis was performed on patients with colonic diverticular disease treated by an elective laparoscopic approach between July 2000 and November 2007. The variables studied were age, sex, BMI, ASA, number of previous acute episodes, local severity, abdominal surgery history, comorbidity, and laparoscopic training of the surgeon. Logistic regression analysis was used to establish significant results. RESULTS: A total of 137 patients were analyzed; 87 (63.5%) were men with a mean age of 56.7 (range, 27-89) years. Intraoperative and postoperative complications occurred in 2.9% (n = 4) and 12.4% (n = 17) of the patients respectively. Conversion rate was 9.4% (n = 13). Local severity (odds ratio (OR), 16.34; 95% confidence interval (CI), 4.1-64.5, p = 0.00007), history of abdominal surgery (OR, 3.02; 95% CI, 0.8-11.5; p = 0.02), and the training of the operating surgeon (OR, 4.8; 95% CI, 1.02-22.7; p = 0.001) were significant risk factors related to surgery conversion. A history of three or more acute episodes was significantly associated with a high severity of local process and was a risk factor related to conversion (OR, 2.6; 95% CI, 0.5-12.3; p = 0.22). The severity of the local process seems to be a risk factor for perioperative complications. A significant association (chi2, 4.45; p = 0.03) between conversion and postoperative complications also was observed (OR: 3.79, 95% CI, 1.02-14.07; p = 0.04). CONCLUSIONS: A history of three or more acute episodes of diverticulitis with conservative treatment is associated with a high severity of the local process during laparoscopic sigmoidectomy and increases the rate of conversion and perioperative complications.

Self-estimation of surgical skills and competencies based on the learning curve theory in medical residents and fellows.

OBJECTIVE: The aim was to explore how in-training junior physicians perceive their surgical performance compared with the one externally rated by their senior surgeon trainers, using a general learning curve model. METHODS: Between April and June 2018, a prospective study was conducted at a community hospital associated with a school of medicine. To assess how in-training physicians estimated their surgical performance, 48 surgical residents and fellows were invited to choose one among six options using a scale ranging from "novice" to "automatic expert." In addition, five senior surgeons who supervised the residents/fellows were asked to give their own opinions on each surveyed physician's expertise level, according to the same categories. Concordance analysis was done to compare residents' and fellows' self-perceived skills and their actual performance as estimated by senior surgeons. RESULTS: Self-assessments tended to overestimate residents' and fellows' position on the learning curve; particularly for "proficient" over "competent," and for "automatic expert" over "expert" categories (p = 0.025). The average degree of agreement among senior physicians was 50.0%. Comparison between residents' and fellows' perceived skills and their performances as estimated by senior surgeons showed a weak concordance (kappa = 0.494, 95% confidence interval 0.359-0.631, p < 0.0001). CONCLUSIONS: Nearly 51% of the residents/fellows included in some surgical specialty training program overestimated his/her actual performance as evaluated by classical learning curve categories. Underestimation of self-assessed performance was also observed in 17% of respondents. A better feedback from expert observers to in-training surgeons could result in a more accurate self-perception of their real surgical skills and competencies.

OBJETIVO: Evaluar cómo los médicos en formación (juniors) perciben su propio desempeño quirúrgico en comparación con la calificación otorgada por sus instructores (seniors) según un modelo de curva de aprendizaje. MÉTODOS: Entre abril y junio de 2018 se realizó un estudio prospectivo en un hospital comunitario. Para evaluar cómo los médicos juniors estimaban su propio desempeño, 48 residentes/becarios de especialidades quirúrgicas eligieron una entre seis opciones excluyentes en una escala entre «novicio¼ y «experto automático¼. Además, cinco cirujanos que supervisaban a los residentes/becarios dieron sus propias opiniones sobre el nivel de desempeño de cada médico encuestado, usando las mismas categorías. Se realizó un análisis de concordancia para comparar las habilidades autopercibidas y el desempeño real según lo estimado por los cirujanos seniors. RESULTADOS: Cuarenta y siete juniors y 50 seniors completaron la encuesta. El 51% sobrestimó y el 17% subestimó su ubicación en la curva de aprendizaje con respecto a los observadores externos (p = 0.025). El grado promedio de acuerdo entre seniors fue del 50%. La comparación entre la autopercepción de los juniors con respecto a sus observadores seniors mostró una concordancia pobre (kappa = 0.494; intervalo de confianza del 95% [IC 95%]: 0.359-0.631; p < 0.0001; sesgo promedio de Bland-Altman: 0.40; IC 95%: 0.11-0.70). CONCLUSIONES: La mitad de los residentes/fellows sobrestimó, y uno de cada seis subestimó, su verdadera ubicación en la curva de aprendizaje en comparación a la opinión de los seniors. Un mejor conocimiento de la existencia de este sesgo de estimación del propio desempeño podría redundar en una mejor confiabilidad del juicio médico.

Laparoscopic-assisted proctocolectomy using complete intracorporeal dissection.

PURPOSE: Although many studies have demonstrated good results using laparoscopic proctocolectomy in patients with ulcerative colitis (UC), most surgical procedures require at least one additional incision larger than 5 cm to complete the surgery. The aim of this study was to evaluate the use of laparoscopic proctocolectomy with ileoanal J pouch, with a complete intracorporeal dissection using a 4-5 cm right lower quadrant (RLQ) incision. METHODS: Data were collected prospectively from all patients with UC that were subjected to a proctocolectomy with ileoanal J pouch between August 2003 and December 2006. The dissection was performed completely by laparoscopy using a medial-lateral approach for the colon and a total mesorectal excision for the rectum. Once the rectum was resected laparoscopically, a 4-5 cm incision in the RLQ was performed to resect the specimen and then an end or a loop ileostomy was implanted at the RLQ wound. The surgery was performed in two (proctocolectomy with ileoanal J pouch and loop ileostomy) or three steps (subtotal colectomy and end ileostomy with sigmoid fistula; proctectomy with ileoanal J pouch; and loop ileostomy). RESULTS: A total of 47 surgical procedures were performed in 32 patients with a mean age of 34.5 +/- 15.7 years, of which 56% were male. The mean body mass index was 21 +/- 16 kg/m(2); 50% of patients underwent surgery in two steps and the other 50% in three steps. Surgery was converted in five (10.6%) cases due to megacolon in one case, narrow pelvis in two, and difficult rectal dissection in two; the overall morbidity rate was 14.9%. Two patients required reoperation and no mortality was registered. The mean operative time was 248 +/- 62 min; proctocolectomy 292 +/- 61 min, subtotal colectomy 203 +/- 43 min, and proctectomy 248 +/- 47 min. The mean hospital stay was 4.8 +/- 1.9 days, and the mean interval time to close loop ileostomies was 64 +/- 12 days. CONCLUSIONS: A complete laparoscopic proctocolectomy dissection is feasible and safe for surgical treatment of UC.

Seguridad y factibilidad de la reconstrucción microquirúrgica en tumores de cabeza y cuello en pacientes mayores de 70 años / Safety and feasibility of free-flap reconstruction in head and neck tumors in patients aged 70 years or older

RESUMEN Antecedentes: debido al aumento en la expectativa de vida, se ha incrementado la incidencia de tumores de cabeza y cuello en pacientes añosos. Objetivo: evaluar los resultados de la reconstrucción con colgajos microquirúrgicos luego de la resección radical (RRMC) de tumores de cabeza y cuello en pacientes de 70 años o mayores. Material y métodos: se analizó una serie de pacientes sometidos a RRCM por tumores de cabeza y cuello en el período 2000-2020. Se dividió la muestra en dos grupos: G1: ≥ de 70 años y G2: < de 70 años. Se analizaron variables demográficas, quirúrgicas, posoperatorias y factores de riesgo de trombosis del colgajo en los pacientes ≥ de 70 años. Resultados: se incluyó un total de 178 pacientes, 61 en G1 y 117 en G2. Ambos grupos fueron homogéneos respecto del sexo, IMC (índice de masa corporal), alcoholismo, tabaquismo, tratamiento neoadyuvante e incidencia de HPV (virus del papiloma humano). Hubo mayor cantidad de pacientes con riesgo ASA ≥ III en G1 vs. G2; (p: 0,005). En G1, 33 (54%) correspondieron a estadio oncológico ≥ III vs. 99 (87%) en G2 (p: 0,001). Cuarenta y dos (69%) pacientes en G1 recibieron adyuvancia vs. 94 (83%) en G2 (p: 0,02) y no hubo diferencias en la morbimortalidad global y en fallas del colgajo. El sexo femenino fue el único factor de riesgo de trombosis del pedículo vascular (p: 0,05). Conclusión: la RRCM para tumores de cabeza y cuello es factible y segura en pacientes añosos, con una incidencia de morbimortalidad similar a la del resto de la población.

ABSTRACT Background: The higher life expectancy has increased the incidence of head and neck tumors in elder patients. Objective: the aim of this study was to evaluate the outcomes of free flap reconstructions after radical resection (FFRR) of head and neck tumors in patients aged 70 years or older. Material and methods: We analyzed a series of patients undergoing FFR due to head and neck tumors between 2000-2020. The patients were divided into two groups: G1: ≥ 70 years, and G2: < 70 years. The demographic, operative and postoperative variables and the risk factors for flap thrombosis in patients ≥ 70 years were analyzed. Results: A total of 178 patients were included, 61 in G1 and 117 in G2. Both groups were homogeneous regarding sex, BMI (body mass index), alcohol consumption, smoking habits, neoadjuvant treatment, and incidence of HPV (human papillomavirus). The incidence of ASA grade ≥ III was significantly higher in G1 vs. G2; (p: 0,005). In G1, 33 patients (54%) corresponded to cancer stage ≥ III vs. 99 (87%) in G2 (p: 0.001). Forty-two (69%) patients in G1 received adjuvant therapy vs. 94 (83%) in G2 (p = 0.02) and there were no differences in overall morbidity and mortality and in flap failure. Female sex was the only predictor of vascular flap thrombosis (p = 0.05). Conclusion: FFRR in head and neck tumors is feasible and safe in elderly patients, with morbidity and mortality rates similar to those of the general population.

Biochemical results of reoperations for medullary thyroid carcinoma.

BACKGROUND: The calcitonin is a sensitive marker for the presence of medullary thyroid carcinoma, therefore, invaluable in the follow-up of patients who have been treated. Biological cure of the medullary thyroid cancer refers to a basal plasma calcitonin of less than 10 ng/l without elevation after stimulation tests. STUDY DESIGN: Biochemical results of reoperations for medullary thyroid carcinoma were reviewed from a series of 35 patients who underwent 47 reinterventions. RESULTS: The indications for reoperation were: hypercalcitoninemia with clinical evidence of the disease (32 cases); hypercalcitoninemia after an inadequate primary surgery (6 cases); persistent hypercalcitoninemia with biochemical evidence of the disease (2 cases); liver metastases (1 case); and palliative surgery for relieving symptoms (1 case). Only three patients of the series had biochemical cure after reoperation (patients with an inadequate primary surgery). CONCLUSIONS: This study is consistent with the bibliographic reviews supporting that the cervical reoperation, eventually mediastinal, for residual hypercalcitoninemia after primary surgical treatment is indicated when the initial intervention did not follow the French Calcitonin Tumour Study Group (GETC) recommendations or when a specific lesion is evidenced by imaging studies without systemic dissemination.