Necesidad de vaciamiento axilar en el cáncer de mama. Rigor en los métodos predictivos / Need for axillary lymph node dissection in breast cancer. Rigour in predictive methods

Introduccción: El objetivo es describir la validez diagnóstica y la seguridad de los métodos empleados en nuestro entorno para obviar el vaciamiento axilar en el tratamiento quirúrgico primario de mama en estadio inicial tras determinación de macrometástasis en el ganglio centinela. Métodos: Estudio observacional retrospectivo multicéntrico aprobado por el Comité de Ética. Determinación de sensibilidad, especificidad, valor predictivo positivo y negativo de los métodos: OSNA (punto de corte a 15.000 copias de ARN), score Tenon 5 (punto de corte en 5), perfil de alto riesgo (si no cumple T1G2RH+ HER-), criterios ACOSOG Z-11 y resultado de ganglio secundario. Se incluyó a pacientes con cáncer de mama dirigidas a tratamiento quirúrgico primario; tamaño T1-T2 y axila clínica y radiológicamente negativa; con resultado de ganglio centinela positivo para macrometástasis. Resultados: Se incluyó a 279 pacientes con macrometástasis en el ganglio centinela, de los cuales resultaron 69 (24,4%) linfadenectomías positivas. Los resultados de sensibilidad, especificidad, valor predictivo positivo y negativo fueron: OSNA (100%, 17%, 32%, 100%); Tenon 5 (91%, 34%, 31%, 92%); alto riesgo (82%, 32%, 28%, 85%), ACOSOG Z-11 (30%, 97%, 75%, 84%); ganglio secundario (86%, 76%, 55%, 94%). Conclusiones: El método más seguro, score Tenon 5, solo evitaría un tercio de linfadenectomías negativas. Un perfil de riesgo no ofrecería suficiente seguridad. La propuesta del grupo ACOSOG Z-11 sería el método menos seguro. La cuantificación de la macrometástasis por método OSNA no conseguiría validez diagnóstica. El análisis del ganglio secundario, siendo el método menos aplicado, sería el más válido, con mejor sensibilidad y especificidad conjunta. En nuestra valoración, ninguno de los métodos estudiados resultaría suficientemente riguroso pues no obtendrían resultados óptimos para permitir obviar la linfadenectomía

Introduction: The aim of this study was to describe the diagnostic validity and safety of the most commonly used methods to avoid axillary lymph node dissection (ALND) in the primary surgical treatment of initial-stage breast cancer after determination of sentinel node macrometastases. Methods: This multicenter, retrospective observational study was approved by the ethics committee and assessed the sensitivity, specificity, positive and negative predictive value of the following methods: OSNA (cut-off point of 15,000 RNA copies), Tenon 5 score (cut-off point 5), HIGH risk profile (RH+ HER-), ACOSOG Z-11 criteria and second-tier sentinel node outcome. We included patients with breast cancer undergoing primary surgical treatment, with T1-T2 tumours, clinically and radiologically negative axillae, and sentinel node macrometastases. Results: We included 279 patients, of whom 69 (24.4%) had a positive ALND. The results of sensitivity, specificity, positive predictive value and negative predictive value were as follows: OSNA (100%, 17%, 32%, 100%); Tenon 5 (91%, 34%, 31%, 92%); HIGH (82%, 32%, 28%, 85%), ACOSOG Z-11 (30%, 97%, 75%, 84%); SECOND (86%, 76%, 59%, 94%). Conclusions: The most accurate method, the Tenon score, would only avoid one-third of negative lymphadenectomies. Relying on a risk profile would not provide enough safety. The proposal of the ACOSOG Z-11 group was the least safe method. Quantification of macrometastases by OSNA would not be a valid diagnostic method. Second-tier sentinel node analysis, the least applied method, seems the most accurate, with the best sensitivity and specificity.In our analysis, none of the methods would be sufficiently rigorous to safely allow avoidance of ALND

[Laparoscopic treatment of perforated duodenal ulcer]. / Tratamiento laparoscópico de la úlcera duodenal perforada.

OBJECTIVE: To analyze the results obtained in patients undergoing laparoscopic surgery for perforated duodenal ulcer. PATIENTS AND METHOD: From January 2000 to August 2006, 15 consecutive patients with perforated duodenal ulcer underwent laparoscopic surgery after preoperative selection (ASA scores, time since onset of the perforation). RESULTS: The mean age was 44.6 +/- 15.5 years (range, 18-75). There were 10 men and five women. Fourteen patients were ASA I-II. Time since onset of perforation was more than 12 hours in only one patient. Operative time was 70.5 +/- 9.6 minutes. There were two conversions (13.3%) to the open approach and two postoperative complications (prolonged ileus in one patient and self-limiting leakage in another). There were no intra-abdominal collections or mortality in the entire series. The mean length of hospital stay was 6.5 +/- 2.1 days. CONCLUSIONS: In selected patients, laparoscopic treatment of perforated duodenal ulcer is safe and feasible. Technical standardization and appropriate patient selection are essential to define the real role of the laparoscopic approach in perforated duodenal ulcer.

Ursodeoxycholic acid in the treatment of intrahepatic cholestasis of pregnancy. A 12-year experience.

OBJECTIVE: To assess the efficacy of ursodeoxycholic acid (UDCA) in patients with intrahepatic cholestasis of pregnancy (ICP) and in the outcome of pregnancy. METHODS: Retrospective analysis of our 12-year experience treating ICP patients with UDCA. Thirty-two patients with pruritus starting before week 34 of pregnancy and with increased serum bile salts (BS) and alanine aminotransferase (ALT) received UDCA (15 mg/kg/day) for at least 3 weeks before delivery. They were compared with 16 historical controls who did not receive UDCA. All patients were followed up until delivery and in puerperium. Newborns were followed up during 3 months. RESULTS: UDCA treatment attenuated pruritus (P < 0.05), serum bilirubin and ALT decreased (P < 0.05) and BS declined. Delivery at term (> or = 37 weeks) occurred in 65.7% of UDCA-treated patients compared with only 12.5% in controls (P < 0.01). Infants born to mothers treated with UDCA weighed a mean of 500 g more than the controls (2882+/-582 vs 2385+/-582; P < 0.01). At 3 months, all infants developed normally. Twenty-six children whose mothers received UDCA were re-examined after 1-12 years and they and their mothers were healthy. CONCLUSIONS: UDCA improved pruritus and biochemical cholestasis, and facilitated deliveries at term in ICP patients, with a higher birthweight compared with historical controls. The drug was well tolerated and no adverse effects were detected in their infants.

La grasa saturada en la dieta disminuye la expresión hepática de APOA5 en ratones deficientes en apo E / Saturated fat from diet downregulates APOA5 hepatic expression in apo E-deficient mice

Introducción. En el desarrollo de la arteriosclerosis intervienen numerosos factores; en especial la edad, la dieta y la hiperlipidemia. La apolipoproteína (apo) A-V desempeña un papel destacado en el control del metabolismo lipídico. Nuestro objetivo es estudiar en ratones hiperlipémicos el efecto que la grasa de la dieta tiene en la expresión hepática del gen de la apo A-V (APOA5) y su relación con el desarrollo de la arteriosclerosis y sus factores de riesgo. Material y métodos. Utilizamos 72 ratones knock-out para el gen de la apo E (KO-APOE) separados en 3 grupos (n = 24): los que recibían dieta convencional de ratón o dieta rica en grasa saturada (20% aceite de palma) sola o suplementada con 0,25% de colesterol. Las muestras se tomaron a las 16, 24 y 32 semanas de edad. Las determinaciones analíticas incluyeron parámetros lipídicos e inflamatorios, la superficie de lesión arteriosclerótica en la aorta y la expresión de APOA5 en hígado. Resultados. La ingesta de dieta rica en grasa saturada disminuye un 48% (p = 0,001) de media la expresión hepática de APOA5 y la suplementación con colesterol revierte este efecto. Estos efectos se observaron a las diferentes edades de los ratones. La expresión hepática de APOA5 aumenta significativamente (p < 0,0001) en función de la edad, el número de lesiones arterioscleróticas en la aorta y el grado de inflamación en los ratones. Conclusiones. La grasa saturada de la dieta disminuye significativamente la expresión hepática de APOA5, que a su vez aumenta con la edad a todas las dietas suministradas y se correlaciona con el área ateromatosa y el estado inflamatorio (AU)

Introduction. Many factors are involved in atherosclerosis development, especially age, diet and hyperlipidemia. Apolipoprotein (apo) A-V plays a key role in the control of lipid metabolism. The aim of this study was to determine the effect of dietary fat intake on hepatic expression of the apo A-V gene (APOA5) in hyperlipidemic mice and its association with risk factors for atherosclerosis and atherosclerosis development. Material and methods. We used 72 knock-out mice for the apo E gene (KO-APOE) divided in three groups (n=24) that received a chow diet, a diet rich in saturated fat (20% palm oil) alone, or a diet supplemented with 0.25% of cholesterol. Samples were obtained at 16, 24, and 32 weeks. Laboratory determinations included lipid and inflammatory parameters, area of atherosclerotic lesions in the aorta, and APOA5 expression in the liver. Results. Intake of a saturated fat-rich diet reduced mean hepatic expression of APOA5 by 48% (P=0.001), while cholesterol supplementation reversed this effect. These effects were found at the different ages of mice. Hepatic APOA5 expression significantly increased (P=0.001), depending on age, the number of atherosclerotic lesions in the aorta, and the degree of inflammation in these mice. Conclusions. Saturated dietary fat significantly downregulates hepatic APOA5 expression, which also increases with age, in all the diets administered and correlates with atheromatous area and inflammatory status (AU)

Tratamiento laparoscópico de la úlcera duodenal perforada / Laparoscopic treatment of perforated duodenal ulcer

Objetivo. Analizar los resultados obtenidos en los pacientes intervenidos de úlcera duodenal perforada por vía laparoscópica. Pacientes y método. Quince pacientes intervenidos consecutivamente desde enero de 2000 hasta agosto de 2006, previa selección preoperatoria (ASA y tiempo de evolución de la perforación). Resultados. La media de edad del grupo era de 44,6 ± 15,5 (intervalo, 18-75) años; 10 varones y 5 mujeres; 14 pacientes fueron clasificados como ASAI-II. Sólo en un paciente la duración de la clínica de perforación fue > 12 h. El tiempo quirúrgico fue de 70,5 ± 9,6 min. Se han producido 2 (13,3%) conversiones a cirugía abierta y 2 complicaciones postoperatorias: un paciente presentó íleo y el otro caso, una fístula autolimitada. No se han evidenciado dehiscencias de la sutura duodenal o absceso intraabdominal. No se han producido reintervenciones ni mortalidad. La estancia media hospitalaria fue de 6,5 ± 2,1 días. Conclusiones. En casos seleccionados el tratamiento laparoscópico de la úlcera duodenal perforada es seguro y factible. La estandarización de la técnica y una adecuada selección de los casos son las claves que, en un futuro, deberemos desarrollar a fin de establecer cuál es el papel real del tratamiento laparoscópico en la úlcera duodenal perforada (AU)

Objective. To analyze the results obtained in patients undergoing laparoscopic surgery for perforated duodenal ulcer. Patients and method. From January 2000 to August 2006, 15 consecutive patients with perforated duodenal ulcer underwent laparoscopic surgery after preoperative selection (ASA scores, time since onset of the perforation). Results. The mean age was 44.6 ± 15.5 years (range, 18-75). There were 10 men and five women. Fourteen patients were ASA I-II. Time since onset of perforation was more than 12 hours in only one patient. Operative time was 70.5 ± 9.6 minutes. There were two conversions (13.3%) to the open approach and two postoperative complications (prolonged ileus in one patient and self-limiting leakage in another). There were no intra-abdominal collections or mortality in the entire series. The mean length of hospital stay was 6.5 ± 2.1 days. Conclusions. In selected patients, laparoscopic treatment of perforated duodenal ulcer is safe and feasible. Technical standardization and appropriate patient selection are essential to define the real role of the laparoscopic approach in perforated duodenal ulcer (AU)

Efectos del ácido ursodeoxicólico en pacientes con colestasis gravídica / Effects of ursodeoxycholic acid in patients with cholestasis of pregnancy

In an open, pilot study, the efficancy and safety of ursodeoxycholic acid (UDCA) in the treatment of intrahepatic cholestasis of pregnancy was investigated. four patients received 1 g/ñday of UDCA during 20 days and another 2 patients received identical periods of treatment separated by a 14-day interval free of drug. Pruritus and serum levels of toal bile salts and glutamic-pyruvic transaminase improved significantly during treatment with UDCA. Although pruritus and the laboratory alterations had a relapse in the second week after UDCA was discontinued, they improved again in the patients who received a second treatment with UDCA. No adverse reactions were detected in the mothers or in their babies. All neuborns are thriving normally, in a follow-up lasted 3 to 6 months after delivery. It is concluded that UDCA appears to be safe when administered in late pregnancy; its primising efficacy in the treatment of intrahepatic cholestasis of pregnancy should now be confirmed in controlled clinical trials