Sclerosing angiomatoid nodular transformation (SANT) of the spleen: review of the literature.

We present a sclerosing angiomatoid nodular transformation (SANT) case report in a 60 year-old-woman. SANT is an extremely rare benign disease of the spleen that it is radiologically similar to malignant tumors, and clinically difficult to differentiate from other splenic diseases. Splenectomy is both diagnostic and therapeutic in symptomatic cases. The analysis of the resected spleen is necessary to achieve the final diagnosis of SANT.

Prospective Study of Factors Associated With Postoperative Delirium After Urgent Abdominal Surgery. / Estudio prospectivo de los factores asociados al delirium en el postoperatorio de la cirugía abdominal urgente.

INTRODUCTION: Delirium is a frequent complication in elderly patients after urgent abdominal surgery. METHODS: Prospective study of consecutive patients aged ≥65years who had undergone urgent abdominal surgery from 2017-2019. The following variables were recorded: age, sex, ASA, physiological state, cognitive impairment, frailty (FRAIL Scale), functional dependence (Barthel Scale), quality of life (Euroqol-5D-VAS), nutritional status (MNA-SF), preoperative diagnosis, type of surgery (BUPA Classification), approach and diagnosis of postoperative delirium (Confusion Assessment Method). Univariate and multivariate analyses were performed to analyze the correlation of these variables with delirium. RESULTS: The study includes 446 patients with a median age of 78years, 63.6% were ASA ≥III and 8% had prior cognitive impairment. 13.2% were frail and 5.4% of the patients had a severe or total degree of dependence. 13.6% developed delirium in the postoperative period. In the univariate analysis, all the variables were statistically significant except for sex, type of surgery (BUPA) and duration. In the multivariate analysis the associated factors were: age (P<.001; OR: 1,08; 95%CI: 1,038-1,139), ASA (P=.026; OR: 3.15; 95%CI: 1.149-8.668), physiological state (P<.001; OR: 5.8; 95%CI: 2.176-15.457), diagnosis (P=.006) and cognitive impairment (P<.001; OR: 5.8; 95%CI: 2.391-14.069). CONCLUSION: The factors associated with delirium are age, ASA, physiological state in the emergency room, preoperative diagnosis and prior cognitive impairment.

The effect of a preoperative biliary prosthesis on the infectious complications of the pancreaticoduodenectomy.

INTRODUCTION: there is controversy about the effect of a preoperative biliary prosthesis (PBP) on complications of pancreaticoduodenectomy (PD). There are no recommendations for antibiotic prophylaxis in these patients. The objective of the study was to analyze the association of PBP, bacteriology and the development of complications after PD. METHODS: this was a retrospective observational study with 90 consecutive patients that underwent DP between 2015 and 2018. PBP was indicated in patients with total bilirubin levels > 12 mg/dl who could not be operated on within a reasonable time. Antibiotic prophylaxis with cefoxitin was administered in patients without PBP and a five-day treatment with piperacillin-tazobactam for PBP. A bile culture was systematically performed. RESULTS: the average age of the patient cohort was 69 years. Fifty-one patients suffered complications (56%), with a mortality rate of 3%. The average hospital stay was eleven days and PBP was placed in 51 patients (56%). Antibiotic prophylaxis was adequate in 62 patients (69%). The most frequently isolated bacteria were E. faecium (30%), E. coli (20%) and E. faecalis (19%). Patients with PBP had a significantly higher percentage of positive cultures (98% vs 25%, p < 0.01), a higher number of bacteria (2.9 vs 0.5, p < 0.01) and perioperative sepsis (31% vs 12%, p = 0.03), but without an increased hospital stay or overall morbidity. CONCLUSIONS: PBPs increase the risk of perioperative sepsis, the percentage of positive cultures and the average number of isolated bacteria. The protocol of prophylaxis with cefoxitin and the administration of pipercillin-tazobactan with PBP adequately treated 69% of patients. With this protocol, PBPs do not imply an increase in complications or hospital stay.

Survival, morbidity and mortality of pancreatic adenocarcinoma after pancreaticoduodenectomy with a total mesopancreas excision.

INTRODUCTION: pancreatic adenocarcinoma is the most common malignancy in the periampullary region, with a five-year survival rate around 20%. OBJECTIVE: the goal of our study was to determine the survival and safety data of a number of patients that underwent a cephalic duodenopancreatectomy (CDP) with total mesopancreas excision (TMPE). MATERIAL AND METHODS: a prospective observational study was performed of 114 patients with pancreatic adenocarcinoma who underwent duodenopancreatectomy and TMPE over the period 2008-2017. Demographic variables, tumor stage, number of lymph nodes excised, lymph node ratio, R classification, the prognostic factor disease-free interval and survival were all assessed in a multivariate analysis. RESULTS: complications were reported for 54 (47.3%) patients, of which 22 (19.3%) were categorized as serious. The mortality rate was 4.3% and the mean follow-up was 26.2 months. During this period, 73 (64%) patients relapsed after a mean interval of 40.9 months. The relapse pattern was mainly hepatic (26.3%), followed by local relapse (20%). Mean survival was 40.38 and actuarial survival was 26.6% at five years. Relapse-related factors included stage T3 or higher (RR 8.1 [1.1-61]) and an R1 resection (RR 13.4 [2.7-66.5]) and survival-related factors included an R1 resection (RR 10.7 [2.5-46.2]). CONCLUSION: TMPE ensures an adequate lymphadenectomy and lymph node ratio according to reported standards. The survival of patients that have undergone surgery for pancreatic adenocarcinoma in our institution is 68.4% at one year and 26.6% at five years. An R1 resection is the primary factor for both relapse and survival.

Delayed gastric emptying following pancreatoduodenectomy: a Roux-en-Y gastrojejunostomy vs Billroth II gastrojejunostomy randomized study.

INTRODUCTION: delayed gastric emptying (DGE) is the most common complication after pancreaticoduodenectomy (PD) and it occurs in 50% of cases. OBJECTIVES: the endpoint was to determine if there were any differences in the incidence of DGE between Roux-en-Y gastrojejunostomy (ReY) and Billroth II gastrojejunostomy (BII) in PD with pancreaticogastrostomy (PG). METHODS: this was a case-control prospective randomized study of all PD cases between 2013 and 2016. Sixty-four patients were included, 32 in each group. An intention-to-treat statistical analysis was performed. RESULTS: no significant differences were found with regard to morbidity and mortality or hospital stay. DGE was present in 25% of the patients in the BII group in comparison to 15.6% in the ReY group, which was not statistically significant (p = 0.35). There was a higher percentage of patients with primary DGE in the BII group, 12.5% versus 6.2%, but this was not statistically significant (p = 0.53). No difference in DGE severity was observed. Male gender (OR 8.38 [1.1; 129]), abdominal complications (OR 15 [1.7; 396.9]), pre-operative malnutrition (OR 99.7 [3.3, 11,126]) and hemorrhage (OR 9.4 [1.37, 107.94]) were the main risk factors for DGE according to the multivariate analysis. CONCLUSIONS: there were no significant differences in the incidence or severity of DGE between BII or ReY after PD with PG.

Quality standards in 480 pancreatic resections: a prospective observational study.

Pancreatic resection is a standard procedure for the treatment of periampullary tumors. Morbidity and mortality are high, and quality standards are scarce in our setting. International classifications of complications (Clavien-Dindo) and those specific for pancreatectomies (ISGPS) allow adequate case comparisons. The goals of our work are to describe the morbidity and mortality of 480 pancreatectomies using the international classifications ISGPS and Clavien-Dindo to help establish a quality standard in our setting and to compare the results of CPD with reconstruction by pancreaticogastrostomy (1,55) versus 177 pancreaticojejunostomy). We report 480 resections including 337 duodenopancreatectomies, 116 distal pancreatectomies, 11 total pancreatectomies, 10 central pancreatectomies, and 6 enucleations. Results for duodenopancreatectomy include: 62 % morbidity (Clavien > or = III 25.9 %), 12.3 % reinterventions, and 3.3 % overall mortality. For reconstruction by pancreaticojejunostomy: 71.2 % morbidity (Clavien > or = III 34.4 %), 17.5 % reinterventions, and 3.3 % mortality. For reconstruction by pancreaticogastrostomy: 51 % morbidity (Clavien > or = III 15.4%), 6.4 % reinterventions, and 3.2 % mortality. Differences are significant except for mortality. We conclude that our series meets quality criteria as compared to other groups. Reconstruction with pancreaticogastrostomy significantly reduces complication number and severity, as well as pancreatic fistula and reintervention rates.

[Training periods with experts improve results in colorectal laparoscopic surgery]. / Las estancias de formación con expertos mejoran los resultados en cirugía laparoscópica colorrectal.

OBJECTIVE: To analyse the effects of training in elective colorectal laparoscopic surgery with a minimum 6 months follow up to assess early and delayed complications, and comparing the first 40 cases in the 1st Period (P-1: 1996-2002) with the 100 cases in the 2nd Period (P-2: 2003-2008). One of the surgeons had two training courses between P-1 and P-2. MATERIAL AND METHODS: A total of 66 colorectal resections due to cancer were performed and 74 operations for benign disease. The cases of malignant diseases increased between P-1 and P-2 (P<0.001). (Odds-Ratio=0.16). RESULTS: There number of complex cases increased between P-1 and P-2 (Anterior resection-amputation, left hemicolectomy, total colectomy, rectopexy) vs. Others (Sigmoidectomy, right resections) (P<0.05), but the mean duration of the operations was reduced by 29 minutes P<0.01). There were 24% conversions, with no change in P-2 (P=0.85). Surgical mortality at 3 months (1.4%) showed no differences (P=0.49). The total complications rate (31%) was significantly lower in P-2 (P=0.001), because medical complications (P=0.05), the more serious surgical complications (with reintervention) (P=0.05) and wound infections (P=0.0001) were lower. There was no change in the other surgical complications (P=0.61). The overall mean stay was 7.8 days (3-36) (median=6 days), with no differences between P-1 and P-2 (P=0.165). Conversion significantly lengthened the mean hospital stay (P=0.015) (from 7.2+/-5 days to 10.1+/-7 days), but there was no increase in complications (P=0.31). CONCLUSION: Training in colorectal laparoscopy and training periods with experts improve results (duration, complications, more complex surgery). Conversions did not decrease with experience and the hospital stays lengthened, but they were not associated with more complications.