Electrical stimulation therapy of the lower esophageal sphincter is successful in treating GERD: final results of open-label prospective trial.

BACKGROUND: Electrical stimulation of the lower esophageal sphincter (LES) improves LES pressure without interfering with LES relaxation. The aim of this open-label pilot trial was to evaluate the safety and efficacy of long-term LES stimulation using a permanently implanted LES stimulator in patients with gastroesophageal reflux disease (GERD). METHODS: GERD patients who were at least partially responsive to proton pump inhibitors (PPI) with abnormal esophageal pH, hiatal hernia ≤ 3 cm, and esophagitis ≤ LA grade C were included. Bipolar stitch electrodes were placed in the LES and an IPG was placed in a subcutaneous pocket. Electrical stimulation was delivered at 20 Hz, 215 µs, 3-8 mA in 30 min sessions. The number and timing of sessions was tailored to each patient's GERD profile. Patients were evaluated using GERD-HRQL, daily symptom and medication diaries, SF-12, esophageal pH, and high-resolution manometry. RESULTS: 24 patients (mean age = 53 years, SD = 12 years; 14 men) were implanted; 23 completed their 6-month evaluation. Median GERD-HRQL scores at 6 months was 2.0 (IQR = 0-5.5) and was significantly better than both baseline on-PPI [9.0 (range = 6.0-10.0); p < 0.001] and off-PPI [23 (21-25); p < 0.001] GERD-HRQL. Median% 24-h esophageal pH < 4.0 at baseline was 10.1 and improved to 5.1 at 6 months (p < 0.001). At their 6-month follow-up, 91 % (21/23) of the patients were off PPI and had significantly better median GERD-HRQL on LES stimulation compared to their on-PPI GERD-HRQL at baseline (9.0 vs. 2.0; p < 0.001). There were no unanticipated implantation- or stimulation-related adverse events or untoward sensation due to stimulation. There were no reports of treatment-related dysphagia, and manometric swallow was also unaffected. CONCLUSIONS: Electrical stimulation of the LES is safe and effective for treating GERD. There is a significant and sustained improvement in GERD symptoms, esophageal pH, and reduction in PPI usage without any side effects with the therapy. Furthermore, the therapy can be optimized to address an individual patient's disease.

Incidence of de Novo Hiatal Hernia after Laparoscopic Sleeve Gastrectomy.

PURPOSE: After laparoscopic sleeve gastrectomy (LSG), several studies have reported an increase in the incidence of gastroesophageal reflux (GERD). The etiopathogenesis of GERD post-LSG is multifactorial, and hiatal hernia (HH) is one of them. The primary objective was to measure the incidence of de novo HH post-LSG. The secondary objectives were to relate the presence of HH with GERD, the chronic use of proton pump inhibitors (PPI), and the time elapsed from LSG. MATERIALS AND METHODS: A surgical evaluation of the crura after LSG was performed. A retrospective cohort study of 74 consecutive patients with history of LSG submitted to an intra-abdominal surgery that allowed the evaluation of the crura. RESULTS: Of a total of 74 patients, 51 were included. At the time of surgery, 37 patients (72.5%) had a HH; 24 patients (47.1%) had GERD, and 23 patients (45.1%) were frequently using PPI. When patients with HH and those without HH were compared, GERD was observed in 56.8% versus 21.4% (p = 0.01) and frequent consumption on PPI was found in 54.1% versus 21.4% (p = 0.02). According to the data of LSG, with a follow-up of < 18 months, 60% presented HH; meanwhile, with a follow-up of > 18 months, 84.6% presented HH (p = 0.02). CONCLUSIONS: Patients submitted to LSG showed a high incidence of de novo HH. HH was associated with a higher incidence of GERD and PPI dependence. The longer the time elapsed from the LSG, the greater the incidence of HH.

Enhanced actions of insulin-like growth factor-I and interferon-alpha co-administration in experimental cirrhosis.

BACKGROUND: Cirrhosis is a diffuse process of hepatic fibrosis and regenerative nodule formation. The liver is the major source of circulating insulin-like growth factor-I (IGF-I) whose plasma levels are diminished in cirrhosis. IGF-I supplementation has been shown to induce beneficial effects in cirrhosis, including antifibrogenic and hepatoprotective effects. On other hand, interferon-alpha (IFN-alpha) therapy seems to suppress the progression of hepatic fibrosis. AIMS: The aim of this study was to investigate the effect of the co-administration of IGF-I+IFN-alpha to Wistar rats with CCl(4)-induced cirrhosis, exploring liver function tests, hepatic lipid peroxidation and histopathology. METHODS: The mechanisms underlying the effects of these agents were studied by reverse transcription-polymerase chain reaction, determining the expression of some factors [hepatocyte growth factor (HGF), transforming growth factor-beta (TGF-beta), alpha-smooth muscle actin, collagen, tissular inhibitor of metalloproteinases-1 and pregnane X receptor (PXR)] involved in fibrogenesis, fibrolysis and/or hepatoprotection. RESULTS: Both IGF-I and IFN-alpha exerted significant effects on fibrogenesis. IGF-I significantly increased serum albumin and HGF whereas IFN-alpha-therapy did not. The inhibition of TGF-beta expression was only observed by the effect of IFN-alpha-therapy. In addition, only the co-administration of IGF-I and IFN-alpha was able to increase the PXR. The combined therapy with both factors improved liver function tests, hepatic lipid peroxidation and reduced fibrosis, inducing a relevant histological improvement, reducing fibrosis and recovering hepatic architecture. CONCLUSION: The co-administration IGF-I+IFN enhanced all the beneficial effects observed with each factor separately, showing an additive action on histopathology and PXR expression, which is involved in the inhibition of fibrogenesis.

Teratoma gástrico. Caso clínico

Introducción: Reportamos los hallazgos clínicos, quirúrgicos, imagenológicos e histopatológicos de un paciente con Teratoma Gástrico. Materiales y Método: Se recopilaron variables clínico demográficas, imagenológicas, quirúrgicas y post operatorias, analizándolas de forma descriptiva. Resultados: Paciente masculino de 33 años que presenta cuadro de TVP (trombosis venosa profunda) que se decide complementar con Angiotc donde se constata aumento de volumen nodular en relación a la curvatura menor del estómago. Se complementa estudio con endoscopía digestiva alta que muestra lesión infiltrante, extensa en curvatura menor. Se decide realizar gastrectomía total laparoscópica. Estudio histopatológico muestra en curvatura menor, histopatología compatible con teratoma maduro. Paciente con evolución satisfactoria post operatoria se decide alta médica, control a los 7 meses post operado sin complicaciones. Discusión: El teratoma gástrico es un tumor infrecuente, se caracteriza por su composición heterogénea. Se diagnostica comúnmente en niños pequeños, aunque puede ocurrir a cualquier edad. La causa exacta del teratoma gástrico es desconocida, pero se cree que se desarrolla debido a anomalías durante el desarrollo embrionario. Su diagnóstico de teratoma implica una combinación de estudios. Histológicamente, los teratomas gástricos están compuestos de tejidos de diferentes capas de células germinales, incluyendo ectodermo, mesodermo y endodermo. Conclusión: los teratomas gástricos son tumores extremadamente inusuales, que pueden ser difíciles de diagnosticar y manejar, se requiere un enfoque multidisciplinario para un manejo óptimo.

Introduction: to present the clinical, surgical, imaging, and histopathological findings of a patient with a gastric teratoma. Materials and Methods: Descriptive analysis was conducted on clinical, demographic, imaging, surgical, and postoperative variables collected. Results: A 33-year-old male patient was diagnosed with deep vein thrombosis (DVT), and an angiotc scan revealed an increase in nodular volume in the lesser curvature of the stomach. Upper digestive endoscopy showed an infiltrating lesion extensively affecting the lesser curvature. Laparoscopic total gastrectomy was performed, and histopathological examination confirmed the presence of a mature teratoma in the lesser curvature. The patient experienced a satisfactory postoperative recovery and was discharged. Follow-up at 7 months postoperatively showed no complications. Discussion: Gastric teratoma is a rare tumor characterized by its heterogeneous composition. While it is typically diagnosed in young children, it can occur at any age. The exact cause of gastric teratoma is unknown, but it is believed to result from embryonic developmental anomalies. Diagnosis of teratoma involves a combination of diagnostic tests. Histologically, gastric teratomas consist of tissues derived from different layers of germ cells, including ectoderm, mesoderm, and endoderm. Conclusion: Gastric teratomas are extremely uncommon tumors that pose challenges in terms of diagnosis and management. An interdisciplinary approach is necessary for optimal management.

Effect of the closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: a prospective study.

BACKGROUND: Internal hernias (IH) are a recognized problem in laparoscopic Roux-en-Y gastric bypass (LRYGB) that can cause intestinal obstruction. The routine closure of the mesenteric defects (MDs) to prevent IH in the LRYGB remains controversial. OBJECTIVES: The main objective of our study was to evaluate the risk of reopening at the level of both MDs, the Petersen space, and the intermesenteric gap. SETTING: University hospital. METHODS: Prospective cohort of patients with a history of LRYGB, all with closure of both MDs, and in whom another intra-abdominal surgery was performed after the LRYGB, between January 2013 and December 2018. The status of both MDs was recorded. All analyses were performed with Stata version 15 software with a level of significance of .05. RESULTS: A total of 76 patients were included. The average time that elapsed between the LRYGB and the surgery that evaluated the state of the MDs was 22.8 months. The patients lost on average 34.7 kg, with a minimum of 8 kg and a maximum of 76 kg. The indications for the interventions were cholelithiasis (68.3%), recurrent abdominal pain (13.2%), intestinal obstruction (11.8%), malabsorption syndrome (7.3%), and bilateral inguinal hernia (2.4%). At the time of surgery, 52 patients (68.4%) had a completely closed Petersen space; 58 patients (76.3%) had a completely closed intermesenteric defect. Both MDs were closed in 36 patients (47.4%), and 33 patients (43.4%) had at least 1 of the MDs open. CONCLUSION: The closure of MDs eliminated the risk of IH in half of the operated patients of LRYGB in this series.

Antioxidant effects of insulin-like growth factor-I (IGF-I) in rats with advanced liver cirrhosis.

BACKGROUND: The exogenous administration of Insulin-like Growth Factor-I (IGF-I) induces hepatoprotective and antifibrogenic actions in experimental liver cirrhosis. To better understand the possible pathways behind the beneficial effect of IGF-I, the aim of this work was to investigate severe parameters involved in oxidative damage in hepatic tissue from cirrhotic animals treated with IGF-I (2 microg x 100 g(-1) x day(-1)). Iron and copper play an important role in oxidative mechanisms, producing the deleterious hydroxyl radical (*OH) that peroxides lipid membranes and damages DNA. Myeloperoxidase (MPO) and nitric oxide (NO) are known sources of free radicals and induce reduction of ferritin-Fe3+ into free Fe2+, contributing to oxidative damage. METHODS: Liver cirrhosis was induced by CCl4 inhalation in Wistar male rats for 30 weeks. Healthy controls were studied in parallel (n = 10). Fe and Cu were assessed by atomic absoption spectrometry and iron content was also evaluated by Perls' staining. MPO was measured by ELISA and transferrin and ferritin by immunoturbidimetry. iNOS expression was studied by immuno-histochemistry. RESULTS: Liver cirrhosis was histologically proven and ascites was observed in all cirrhotic rats. Compared to controls untreated cirrhotic rats showed increased hepatic levels of iron, ferritin, transferrin (p < 0.01), copper, MPO and iNOS expression (p < 0.01). However, IGF-treatment induced a significant reduction of all these parameters (p < 0.05). CONCLUSION: the hepatoprotective and antifibrogenic effects of IGF-I in cirrhosis are associated with a diminution of the hepatic contents of several factors all of them involved in oxidative damage.

Two-year results of intermittent electrical stimulation of the lower esophageal sphincter treatment of gastroesophageal reflux disease.

BACKGROUND: Lower esophageal sphincter (LES) electrical stimulation therapy (EST) has been shown to improve outcome in gastroesophageal reflux disease (GERD) patients at 1 year. The aim of this open-label extension trial (NCT01578642) was to study the 2-year safety and efficacy of LES-EST in GERD patients. METHODS: GERD patients responsive partially to proton pump inhibitors (PPI) with off-PPI GERD health-related quality of life (HRQL) of ≥20, 24-hour esophageal pH ≤4.0 for >5% of the time, hiatal hernia ≤3 cm, and esophagitis LA grade C or lower participated in this trial. Bipolar stitch electrodes and a pulse generator (EndoStim BV, The Hague, The Netherlands) were implanted laparoscopically. LES-EST at 20 Hz, 215 µs, 3-8 mAmp was delivered over 30-minute sessions, 6-12 sessions per day, starting on day 1 after implantation. Patients were evaluated using GERD-HRQL, symptom diaries, Short Form-12, and esophageal pH testing at regular intervals. Stimulation sessions were optimized based on residual symptoms and esophageal pH at follow-up. RESULTS: Twenty-five patients (mean age [SD] = 52 [12] years; 14 men) were implanted successfully; 23 patients participated in the 2-year extension trial, and 21 completed their 2-year evaluation. At 2 years, there was improvement in their median GERD-HRQL on LES-EST compared with both their on-PPI (9 vs 0; P = .001) and off-PPI (23.5 vs. 0; P < .001) baseline scores. Median 24-hour distal esophageal acid exposure improved from 10% at baseline to 4% (per-protocol analysis; P < .001) at 2 years with 71% demonstrating either normalization or a ≥50% decrease in their distal esophageal acid exposure. All except 5 patients (16/21) reported complete cessation of PPI use; only 2 patients were using a PPI regularly (≥50% of days). There was significant improvement in sleep quality and daily symptoms of heartburn and regurgitation on LES-EST. At baseline, 92% of the subjects (22/24) reported that they were "unsatisfied" with their condition off-PPI and 71% (17/24) on-PPI compared with 0% (0/21) "unsatisfied" at the 24-month visits on LES-EST. There were no device- or therapy-related serious adverse events and no untoward sensation or dysphagia reported with LES-EST. CONCLUSION: LES-EST is safe and effective for treating patients with GERD over a period of 2 years. LES-EST resulted in a significant and sustained improvement in GERD symptoms, and esophageal acid exposure and eliminated PPI use in majority of patients (16 of 21). Further, LES-EST was not associated with any gastrointestinal side effects or adverse events.

Jejunal microvilli atrophy and reduced nutrient transport in rats with advanced liver cirrhosis: improvement by Insulin-like Growth Factor I.

BACKGROUND: Previous results have shown that in rats with non-ascitic cirrhosis there is an altered transport of sugars and amino acids associated with elongated microvilli. These alterations returned to normal with the administration of Insulin-Like Growth Factor-I (IGF-I). The aims of this study were to explore the evolution of these alterations and analyse the effect of IGF-I in rats with advanced cirrhosis and ascites. Thus, jejunal structure and nutrient transport (D-galactose, L-leucine, L-proline, L-glutamic acid and L-cystine) were studied in rats with ascitic cirrhosis. METHODS: Advanced cirrhosis was induced by CCl4 inhalation and Phenobarbital administration for 30 weeks. Cirrhotic animals were divided into two groups which received IGF-I or saline during two weeks. Control group was studied in parallel. Jejunal microvilli were studied by electron microscopy. Nutrient transport was assessed in brush border membrane vesicles using 14C or 35S-labelled subtracts in the three experimental groups. RESULTS: Intestinal active Na+-dependent transport was significantly reduced in untreated cirrhotic rats. Kinetic studies showed a decreased Vmax and a reduced affinity for sugar and four amino acids transporters (expressed as an increased Kt) in the brush border membrane vesicles from untreated cirrhotic rats as compared with controls. Both parameters were normalised in the IGF-I-treated cirrhotic group. Electron microscopy showed elongation and fusion of microvilli with degenerative membrane lesions and/or notable atrophy. CONCLUSIONS: The initial microvilli elongation reported in non ascitic cirrhosis develops into atrophy in rats with advanced cirrhosis and nutrient transports (monosaccharides and amino acids) are progressively reduced. Both morphological and functional alterations improved significantly with low doses of IGF-I.

Hematotesticular barrier is altered from early stages of liver cirrhosis: effect of insulin-like growth factor 1.

AIM: The pathogenesis of hypogonadism in liver cirrhosis is not well understood. Previous results from our laboratory showed that IGF-1 deficiency might play a pathogenetic role in hypogonadism of cirrhosis. The administration of IGF-1 for a short period of time reverted the testicular atrophy associated with advanced experimental cirrhosis. The aim of this study was to establish the historical progression of the described alterations in the testes, explore testicular morphology, histopathology, cellular proliferation, integrity of testicular barrier and hypophyso-gonadal axis in rats with no ascitic cirrhosis. METHODS: Male Wistar rats with histologically-proven cirrhosis induced with carbon tetrachloride (CCl4) for 11 wk, were allocated into two groups (n = 12, each) to receive recombinant IGF-1 (2 microg/100 g.d, sc) for two weeks or vehicle. Healthy rats receiving vehicle were used as control group (n = 12). RESULTS: Compared to controls, rats with compensated cirrhosis showed a normal testicular size and weight and very few histopathological testicular abnormalities. However, these animals showed a significant diminution of cellular proliferation and a reduction of testicular transferrin expression. In addition, pituitary-gonadal axis was altered, with significant higher levels of FSH (P<0.001 vs controls) and increased levels of LH in untreated cirrhotic animals. Interestingly, IGF-1 treatment normalized testicular transferrin expression and cellular proliferation and reduced serum levels of LH (P = ns vs controls, and P<0.01 vs untreated cirrhotic group). CONCLUSION: The testicular barrier is altered from an early stage of cirrhosis, shown by a reduction of transferrin expression in Sertoli cells, a diminished cellular proliferation and an altered gonadal axis. The treatment with IGF-1 could be also useful in this initial stage of testicular disorder associated with compensated cirrhosis.

Evaluación de factores de riesgo asociados a dehiscencia anastomótica en cirugía colorrectal: análisis multivariado de 748 pacientes / Evaluation of the risk factors associated with anastomotic dehiscence in colorectal surgery: multivariate analysis of 748 pacients

INTRODUCCIÓN: La dehiscencia anastomótica (DA) es una complicación severa en cirugía colorrectal con una incidencia que oscila entre 2 y 19%. La literatura internacional muestra numerosos estudios sobre la identificación de factores de riesgo (FR), mientras que en la nacional existen solo dos series que analizan esta complicación. OBJETIVO: Realizar una caracterización descriptiva de resultados institucionales y establecer la tasa de DA, sus factores de riesgo asociados y la mortalidad. MATERIALES Y MÉTODO: Serie de casos no concurrente, cuya muestra son pacientes consecutivos intervenidos de patología colorrectal con anastomosis primaria con o sin ostoma derivativo entre los años 2004 y 2016. Se realiza modelo de regresión logística univariable y multivariable. RESULTADOS: Se obtuvieron 748 pacientes, 50,5% mujeres, media de edad fue 56,2. Las indicaciones quirúrgicas más frecuentes fueron cáncer colorrectal en 381 (50,9%) pacientes y enfermedad diverticular en 163 (21,8%). La DA fue de 5,6% (42/748) y la mortalidad fue de 2% (15/748), siendo de 1% para los electivos (7/681). En el análisis univariado encontramos que los FR que tuvieron significancia estadística fueron la albúmina (p < 0,001), altura anastomosis (p < 0,001), transfusión (p < 0,001), localización (colon derecho > izquierdo) (p = 0,011), mientras que en el análisis multivariado fueron la albúmina (p = 0,002) con un OR 3,64 (IC 95% 1,58-8,35) y transfusión (p = 0,015) con un OR 7,15 (IC 95% 1,46-34,91). CONCLUSIÓN: Nuestra serie es la más grande reportada en Chile, con resultados similares a estudios internacionales y nacionales. Establecemos que la hipoalbuminemia y la presencia de transfusiones intraoperatorias se asocian a alta tasa de DA.

INTRODUCTION: Anastomotic leakage (AL) is a severe complication in colorectal surgery, its incidence ranges from 2 to 19%. In international literature, we found numerous studies on the identification of risk factors (RF), while in the national there are only two series that analyze this complication. AIM: Perform a descriptive characterization of institutional results and establish the AL rate, its associated risk factors and mortality. MATERIALS AND METHOD: Non-concurrent series of cases, whose sample is consecutive patients operated for colorectal pathology with primary anastomosis with or without a derivative ostoma between 2004 and 2016. Univariate and multivariable logistic regression model was performed. RESULTS: There were 748 patients, 50.5% women, mean age was 56.2. The most frequent surgical indications were colorectal cancer in 381 (50.9%) patients and diverticular disease in 163 (21.8%). The AL was 5.6% (42/748) and the mortality was 2% (15/748), being 1% for the electives (7/681). In the univariate analysis, we found that the RF that had statistical significance were albumin (p < 0.001), anastomosis height (p < 0.001), transfusion (p < 0.001), location (right colon > left) (p = 0.011), while that in the multivariate analysis were albumin (p = 0.002) with an OR 3.64 (IC 95% 1.58-8.35) and transfusion (p = 0.015) with an OR 7.15 (IC 95% 1.46-34.91). CONLUSION: Our series is the largest reported in Chile, with similar results to international and national studies. We establish that hypoalbuminemia and the presence of intraoperative transfusions are associated with a high rate of AL.

Análisis de variables relacionadas con la morbimortalidad de la anastomosis ileocólica después de hemicolectomía derecha / Analysis of variables related to morbidity and mortality of the ileocolic anastomosis after right hemicolectomy

Introducción: La hemicolectomía derecha con anastomosis ileocólica es una cirugía frecuentemente realizada para la que existen muchas formas de realizarla. Objetivo: Evaluar cuál es la mejor anastomosis ilecólica en términos de morbimortalidad y realizar una evaluación comparativa de la evolución clínica posoperatoria según el tipo de configuración anastomótica. Pacientes y Método: Estudio observacional analítico, con criterios de inclusión y exclusión definidos. Las variables a estudiar las dividimos en dos grupos, las relacionadas a la técnica quirúrgica y su configuración anastomótica, y las variables relacionadas con resultados de la intervención quirúrgica, creando una tabla de contingencia en que se cruzan los datos. Análisis de datos con STATA 13.0. Resultados: 216 pacientes con anastomosis ileocólica, destacando significancia estadística al cruzar: A) reoperación y tipo de sutura (p = 0,044), con un OR 3,4 (IC 95% 0,94-18,6), siendo de mayor riesgo la mecánica; B) mortalidad y urgencia (p = 0,001) con un OR 7,76 (IC 95% 1,56-49,29), siendo de mayor riesgo la cirugía de urgencia. Las anastomosis isoperistálticas possen eliminación de gases (p < 0,001), tránsito intestinal (p = 0,009) e ingesta de sólidos (p = 0,005) más precoz. Hay expulsión de gases antes en el abordaje laparoscópico, sutura manual, configuración término lateral e isoperistáltica de la anastomosis y cirugía electiva. Conclusión: Existe gran variabilidad de técnicas para realizar la anastomosis ileocólica. La anastomosis manual muestra menor probabilidad de necesitar una reintervención quirúrgica, la cirugía electiva tiene menor mortalidad que la realizada de urgencia. Sugerimos realizarla vía laparoscópica, con sutura manual, término lateral, isoperistáltica y de forma electiva, por tener una recuperación más corta.

Introduction: Right hemicolectomy with ileocolic anastomosis is a frequent surgery with many ways to perform it. Objective: To evaluate which is the best ileocolic anastomosis in terms of morbidity and mortality and to make a comparative evaluation of the postoperative clinical evolution according to the type of anastomosis. Patients and Method: Analytical observational study, with defined inclusion and exclusion criteria. The variables to be studied are divided into two groups, those related to the surgical technique and its anastomotic configuration, and the variables related to the results of the surgical intervention, creating a contingency table that crosses the data. Data analysis with STATA 13.0. Results: 216 patients with ileocolic anastomosis, highlighting statistical significance when crossing: A) reoperation and type of suture (p = 0.044), with UN or 3.4 (95% CI 0.94 to 18.6), being of greater risk the mechanics; B) mortality and urgency (p = 0.001) with an OR 7.76 (95% CI 1.56-49.29), with emergency surgery being of greater risk. Isoperistaltic anastomosis with gas elimination (p < 0.001), intestinal transit (p = 0.009) and solid intake (p = 0.005) earlier. There is earlier expulsion of gases in the laparoscopic approach, manual suture, end-to-side and isoperistaltic of the anastomosis and elective surgery. Conclusion: There is great variability of techniques to perform the ileocolic anastomosis. Manual anastomosis is less likely to require surgical reoperation, elective surgery has a lower mortality than that of emergency surgery. We suggest performing it laparoscopically, with manual suture, lateral term, isoperistaltic and electively, for having a shorter recovery.

Aplicabilidad del Colon Leakage Score como predictor de filtración anastomótica en cirugía de cáncer colorrectal / Applicability of the Colon Leakage Score as an anastomotic leakage predictor in colorectal cancer surgery

Introducción: La filtración anastomótica (FA) en cirugía colorrectal aumenta la morbimortalidad. La identificación de factores de riesgo y la creación de un modelo predictivo ayudaría en la decisión de crear un ostoma desfuncionalizante, hecho que, actualmente, recae en el criterio del cirujano. Dekker creó el Colon Leakage Score (CLS) estableciendo criterios objetivos. Objetivo: Establecer el CLS en pacientes intervenidos por cáncer de colon izquierdo y recto en Clínica INDISA, estableciendo valores de corte locales, su sensibilidad y especificidad. Pacientes y Método: Corresponde a un estudio de pruebas diagnósticas, cuya intervención es la aplicación del CLS comparándolo con la presencia de filtración anastomótica (gold standard), definida por criterios clínicos y radiológicos. Se utilizó análisis de curvas ROC, índice de Youden y regresión logística. Resultados: De 180 pacientes, hubo FA en 12 (6,6%). La media de CLS en quienes hubo FA fue de 11,5 y en quienes no hubo FA de 6,9 (p = 0,0001). El área bajo la curva para predicción de FA con el CLS fue de 0,829 (IC 95% 0,69-0,96), con un valor de corte de 11, sensibilidad de 67% y especificidad de 89%. En el análisis de regresión logística, el OR para la predicción de FA utilizando el CLS fue de 1,48 (IC 95% 1,22-1,79 p < 0,001). Conclusión: El CLS es una herramienta que permite predecir el riesgo de FA en pacientes intervenidos por cáncer de colon izquierdo y recto. Ante un valor mayor o igual a 11 se debería crear un ostoma protector, generando un cambio en la práctica clínica.

Introduction: Anastomotic filtration increases morbidity and mortality in colorrectal surgery. Identification of risk factors and creation of a predictive model would help the decision of creating a defunctionalizing ostoma, that currently is taken by the surgeon. Dekker created de Colon Leakege Score (CLS) with objective criteria. Objective: Establish CLS in patients that underwent left colon and rectum surgery with cancer diagnosis in Clinica INDISA, define the local cutting value, it's specificity and sensibility. Patients and Methods: Corresponds to a diagnostic test's study, that intervention is CLS application, comparing with the presence of anastomotic filtration (gold standard), defined by clinical and radiologic criteria. For the analysis, ROC curves, Youden's index and logistic regression. Results: From 180 patients, anastomotic filtration was present in 12 (6.6%). Average CLS score in patients with anastomotic filtration was 11.5 and in those without anastomotic filtration was 6.9 (p = 0.0001). Area under the curve for anastomotic filtration prediction using CLS was 0.829 (CI 95% 0.69-0.96) with a cutting value of 11, 67% of sensibility and 89% of specificity. Logistic regression analysis, OR for anastomotic filtration prediction using CLS was 1.48 (CI 95% 1.22-1.79 p < 0.001). Conclusion: CLS is a tool that permits predicting anastomotic filtration risk in patients that underwent left colon and rectum surgery. With a CLS value equal or more than 11, we should create a protective ostoma, generating a clinical practice local change.

[Endocarditis due to Bartonella spp. Three new clinical cases and Spanish literature review]. / Endocarditis por Bartonella spp. Aportación de tres nuevos casos y revisión de la literatura nacional.

INTRODUCTION: Infections by Bartonella spp. include a wide spectrum of emerging and re-emerging infectious diseases, such as culture-negative endocarditis. METHODS: Description of 3 cases of endocarditis due to Bartonella spp. and review of those previously reported in Spain. RESULTS: Including these 3 new cases of endocarditis due to Bartonella spp., a total of 6 cases have been reported in Spain. The median age of the patients was 51.6 years and 83.3% were men. There was history of contact with cats in 66.7%, and 50% were alcoholic. Only one patient had prior valvular disease. There were no clinical manifestations typical to any of the Bartonella species. The aortic valve was the one most commonly affected. In all cases, B. henselae was the agent implicated. The diagnosis was made by serology in 5 cases (83.3%). The outcome was favorable in all patients, although 4 of them (66.7%) required valve replacement. CONCLUSION: Endocarditis due to Bartonella spp. is present in Spain and is likely to be underestimated. We should suspect this pathogen in patients with negative blood cultures and a history of chronic alcoholism, homeless patients, and those who have had contact with cats or who have been bitten by fleas or lice, as well as patients with endocarditis and positive serology against Chlamydia spp.