Visión general de las várices gástricas y su tratamiento / Overview of gastric varices and their treatment

Las várices gástricas (VG) son un complejo de colaterales vasculares entre la circulación portal y sistémica, condición que se desarrolla como resultado de la presión elevada en el sistema venoso portal. Se encuentran en el 20 % de los pacientes con cirrosis, y son menos frecuentes que las várices esofágicas. Según la clasificación de Sarin, las VG se dividen en cuatro tipos según su ubicación en el estómago y su relación con las várices esofágicas (GOV1, GOV2, IGV1 e IGV2). Entender su hemodinámica con respecto a las rutas de drenaje de las VG es importante para guiar su tratamiento.

Gastric varices (GV) are a complex of vascular collaterals between portal and systemic circulation, a condition that develops as a result of elevated pressure in the portal venous system. They are found in 20% of patients with cirrhosis, and are less common than esophageal varices. According to the Sarin classification, GV are divided into four types based on their location in the stomach and their relationship with esophageal varices (GOV1, GOV2, IGV1, and IGV2). Understanding their hemodynamics with respect to GV drainage routes is important to guide their treatment.

ALPPS en cáncer colorrectal sincrónico en tiempos de COVID-19 / ALPPS in synchronous colorectal cancer in times of COVID-19

RESUMEN Durante la pandemia por SARS-CoV-2 evidenciamos un aumento de la morbimortalidad secundario a procedimientos quirúrgicos. Se estima una mortalidad a los 30 días del 19,1% en cirugías programadas y del 26% en procedimientos quirúrgicos de emergencia, y alrededor de la mitad de los pacientes que se someten a cirugía estando infectados con SARS-CoV-2 experimentan complicaciones pulmonares posoperatorias. Los tratamientos oncológicos sufrieron deficiencias en nuestro país debido a las limitantes secundarias a la emergencia sanitaria, en cuanto a capacidad de internación e implementación de los tratamientos quimioterápicos. Informamos la primera cirugía de ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) realizada en el nordeste argentino en una paciente con metástasis colorrectales múltiples en contexto de la pandemia por SARS-CoV-2, con buenos resultados.

ABSTRACT During the SARS-CoV-2 pandemic, we observed an increase in morbidity and mortality secondary to surgical procedures. The mortality rate for elective surgery is estimated at 19.1% and is 26% for emergency procedures. Additionally, approximately half of patients who undergo surgery while infected with SARS-CoV-2 experience postoperative pulmonary complications. Due to limitations caused by the health emergency, cancer treatments in our country have been affected in terms of hospitalization capabilities and implementation of chemotherapy treatments. We report the first ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) procedure performed in northeastern Argentina on a patient with multiple colorectal metastases during the SARS-CoV-2 pandemic, with successful outcomes.

¿Es la técnica de la ligadura del trayecto fistuloso interesfintérico (LIFT) la mejor alternativa para el tratamiento de la fístula anorrectal compleja?

La fistulotomía es aceptada como la técnica ideal en el tratamiento de la fístula anorrectal (FA) simple con porcentajes de curación superiores al 95% y mínimo daño al aparato esfinteriano, a pesar de que la técnica, por definición, incluye la sección inmediata de la porción distal del esfínter interno. En la FA compleja, el daño potencial a la continencia es una secuela temida, lo que ha motivado la búsqueda de múltiples alternativas terapéuticas, algunas dificultosas y/o que requieren instrumentos sofisticados. La ligadura del trayecto fistuloso interesfintérico (LIFT) es una técnica conservadora que ha sido investigada en forma exhaustiva en los últimos 13 años con resultados variables. Se analiza las posibles causas de las fallas del LIFT (40% como promedio) y las variantes propuestas, incluyendo la técnica preferida del autor en los últimos 15 años, que se caracteriza por un abordaje interesfinteriano del trayecto fistuloso que permite tratar tanto el foco interesfintérico como el orificio fistuloso interno y las glándulas afectadas mediante una setón interesfintérico ajustado, más un pequeño drenaje cutáneo externo. Es un procedimiento simple, reproducible y con óptimos resultados en cuanto a curación, sin sección inmediata del esfínter interno y sin alteración de la continencia. A pesar de ser una técnica promisoria, con la información disponible, el LIFT no cumple con los requisitos para ser considerada como la técnica de elección en el tratamiento de la FA compleja.

Fistulotomy is the best surgical technique to treat a simple anal fistula with success in more than 95% of the cases and minor damage of anal continence. Complex anal fistula is a challenging problem due to higher recurrence rates and incontinence associated to surgical procedures. New methods have been developed for the management of complex anal fistula and some of them include complex procedure and/or the use of sophisticated instruments. Relapses are caused by reactivation of the infection at the internal fistula orifice. This is left untreated by some technique including LIFT, a promising conservative technique that has shown success rates between 20% to 86%. We analyze the probably causes of the failure of LIFT and some variations proposed, including the alternative techniques of intersphincteric approach plus treatment of the pathological anal glands with immediate section of the internal sphincter. In the experience of the author over 15 years, the intersphincteric approach to the fistulous tract, the treatment of the internal fistula orifice with a loose seton and a small cutaneous drainage is the safest technique to cure the complex fistula anal with no damage to anal continence. The benefits of conservative techniques like LIFT must be counterbalanced with the relative high recurrence rates. The quality of current evidence is not good enough to consider LIFT as the gold standard in the treatment of complex anal fistula.

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance.

INTRODUCTION: While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. METHODS: The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. RESULTS: In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21-84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2-12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1-4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. CONCLUSIONS: While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.

Ligadura de la arteria lingual: estrategia para hemorragias por lesión de la arteria en la base de la lengua: informe de dos casos / Lingual Artery Ligation: Strategy for Bleeding from Artery Injury at the Base of the Tongue: Report of Two Cases

La hemorragia producida por lesión de la arteria lingual en la base de la lengua por cirugías o por tumores es infrecuente. La mayor frecuencia en la indicación de abordajes transorales para tratar diferentes patologías que afectan la orofaringe requiere que el equipo quirúrgico tenga experiencia en el manejo de esta complicación. La ligadura de la arteria lingual en el cuello es una técnica quirúrgica muy eficaz para solucionar la hemorragia, pero es importante conocer las posibles variantes anatómicas que puede tener la arteria en su trayecto cervical. Debido a su baja incidencia se propone como objetivo describir dos casos clínicos de pacientes que tuvieron hemorragias graves por lesión de la arteria lingual en la base de la lengua, producidas por daño quirúrgico y por erosión por tumor. [AU]

The bleeding caused by injury to the lingual artery at the base of the tongue due to surgery or tumors is infrequent. The increased frequency in the indication of transoral approaches to treat different pathologies affecting the oropharynx requires the surgical team to have experience in managing this complication. Ligation of the lingual artery in the neck is a very effective surgical technique to solve the bleeding; however, it is essential to be aware of the possible anatomical variants the artery may have in its cervical trajectory. Due to its low incidence, we propose to describe two clinical cases of patients who had severe bleeding due to a lesion of the lingual artery at the base of the tongue, produced by surgical damage and erosion due to a tumor. [AU]

Use of non-invasive scales for detecting esophageal varices in paediatric patients with portal vein thrombosis. / Utilización de escalas no invasivas en la detección de varices esofágicas en pacientes con trombosis venosa portal.

INTRODUCTION: Portal vein thrombosis (PVT) is the most frequent cause of portal hypertension in paediatric population. Baveno VI Consensus considers endoscopic variceal ligation as the second therapeutic option after meso-Rex bypass (surgical shunt). AIM: Analyse the diagnostic profitability of non-invasive scales in order to predict the risk of oesophageal varices (OV) in children with PVT. MATERIAL AND METHODS: Descriptive retrospective study where every upper gastrointestinal endoscopy (UGE) carried on patients <15 years old with non-cirrhotic PVT were included. There were divided according to the presence of OV and sex, cause, age, previous gastrointestinal bleeding or treatments, results of UGE and scales (Clinical Prediction Rule - CPR), Varices Prediction Rule - VPR), King's Variceal Prediction Score - K-VaPS) and Platelet count/Spleen diameter Ratio - PSR). Qualitative variables were expressed as absolute frequency and percentage, and quantitative variables as median and interquartile range. U Mann-Whitney and Hanley-McNeil tests were used for comparisons. RESULTS: Forty-five UGE were analysed. 80% (n=36) presented OV: median of 3 (2-3) and 33.3% (n=12) required endoscopic variceal ligation. Statistical differences were demonstrated between both groups: CPR (142.39 [132.22-166.53] vs. 122.75 [115.24-133.15]; p=0.003), VPR (9.91 [9.36-11.75] vs. 5.6 [3.34-8.39]; p=0.001), K-VaPS (117.86 [99.66-126.58] vs. 99.64 [94.88-10.18]; p=0.019), PSR (2384.62 [1902.22-3201.63] vs. 1252.5 [579.6-2144.42]; p=0.05), with and area under the curve AUROC>75%, without statistical differences between scales. CONCLUSIONS: In paediatric patients with non-cirrotic PVT non-invasive scales can be used as a tool to predict the presence of OV and raise the indication of UGE.

Cirugía de desfuncionalización de glándulas salivales mayores en sialorrea masiva / Major salivary gland defunctionalization surgery in massive sialorrhea

Introducción: La sialorrea es la pérdida involuntaria de saliva de la boca, ya sea debido a la producción excesiva de saliva o disminución de la frecuencia de deglución. Se habla de sialorrea patológica cuando persiste más allá de los 4 años de edad. Además de las implicaciones sociales, cambios de ropa frecuentes, puede provocar neumonías por aspiración y deshidratación. El manejo de la sialorrea requiere una evaluación completa con un enfoque de equipo multidisciplinario para el tratamiento, que incluye terapias no farmacológicas, farmacológicas y quirúrgicas. Objetivo: Presentar resultados quirúrgicos y farmacológicos en el tratamiento de sialorrea masiva. Material y Método: Se realizó revisión de historias clínicas de 7 pacientes portadores de sialorrea masiva. Todos los pacientes incluidos fueron refractarios a tratamiento médico. El diagnóstico fue obtenido por un equipo multidisciplinario. Se les realizó desfuncionalización quirúrgica y farmacológica de glándulas salivales. Se les aplicó Escala de Severidad (DSS) y escala de frecuencia (DFS), previo a cirugía y posterior a procedimiento hasta el año. Resultados: Mejoría clínica subjetiva posterior a desfuncionalización quirúrgica con disminución de DSS y DFS. Disminución promedio de baberos a 10/día. Conclusión: Los resultados obtenidos son buenos, si se consideran las escalas DSS, DFS y el número de baberos al día, que son mediciones tanto subjetivas y objetivas respectivamente.

Introduction: Massive Sialorrhea is the involuntary loss of saliva from the mouth, either due to excessive saliva production or decreased swallowing frequency. We speak of pathological sialorrhea when it persists beyond 4 years old. In addition to the social implications and frequent clothing changes. It can cause aspiration pneumonia and dehydration. Treatment for sialorrhea requires a comprehensive evaluation with a multidisciplinary team approach. Including non-pharmacological, pharmacological, and surgical therapies. Aim: Presentation of the results of surgical defunctionalization of the salivary glands plus injection of Botulinum Toxin in the treatment of massive sialorrhea. Material and Method: A review of the clinical records of 7 patients with massive sialorrhea was carried out. All included patients were refractory to medical treatment. The diagnosis was obtained by a multidisciplinary team. Surgical and pharmacological dysfunctionalization of salivary glands was performed. Severity Scale (DSS) and Frequency Scale (DFS) were applied before surgery and after the procedure up to a year. Results: Subjective clinical improvement after surgical defunctionalization with decreased SHD and DFS. Average decrease in bibs to 10/day. Conclusion: The evaluated strategy presented similar benefits with respect to the literature. The SHD and DFS scales and the number of bibs per day are both subjective and objective measurements, respectively, and allow the clinical improvement and quality of life of patients undergoing surgery to be evaluated individually.

Comparison of the non-absorbable polymer clips, knot-tying, and loop ligature appendiceal stump closure methods in laparoscopic appendectomy.

OBJECTIVE: In laparoscopic appendectomy (LA), closure of the appendix stump is important. This method must be safe and easy-to-use as well as an economical one. We compared three methods of the appendix stump closure in terms of safety, easiness, and financial cost. MATERIALS AND METHODS: Three-hundred and ten LA patients operated between January 2011 and December 2019 and appendix stump was closed using one of the three methods, namely, non-absorbable polymeric clips (Group 1, n = 126), knot-tying group (Group 2, n = 101), and laparoscopic loop ligature group (Group 3, n = 83) were retrospectively analyzed in terms of stump leakage, infection, operation, and hospital stay duration. RESULTS: There were 148 female and 162 male patients. The mean age was 33.57 ± 12.60 years. There was not any appendiceal stump leakage nor intra-abdominal infection in none of the groups. Local trocar site infection in 11 patients was medically treated. Surgical site infection and hospital stay period did not show statistically important difference among the groups. The operation duration in Group 1 was found to be shorter compared to the other groups. CONCLUSIONS: All three techniques are safe in LA. Non-absorbable polymer clips provide a shorter operation time. Extracorporeal knot-tying with knot-pusher provides the cheapest closure of the stump.

OBJETIVO: En la apendicectomía laparoscópica (LA), el cierre del muñón del apéndice es importante. Comparamos tres métodos de cierre de tocones del apéndice en términos de seguridad, facilidad y costo financiero. MATERIALES Y MÉTODOS: Se incluyeron 310 pacientes de AL intervenidos entre 2011-2019 con cierre del muñón del apéndice mediante uno de los tres métodos: clips poliméricos no absorbibles (grupo 1), grupo de anudado (grupo 2) y grupo de ligadura de asa laparoscópica (grupo 3). Se analizaron las complicaciones, la operación y la duración de la estancia hospitalaria. RESULTADOS: Hubo 148 pacientes mujeres y 162 hombres. La edad media fue de 33.57 ± 12.60 años. No hubo ninguna fuga del muñón apendicular ni infección intraabdominal en ninguno de los grupos. La infección local del sitio del trocar en 11 pacientes fue tratada médicamente. La infección del sitio quirúrgico y el período de estancia hospitalaria no mostraron diferencias estadísticamente importantes entre los grupos. CONCLUSIONES: Las tres técnicas son seguras en LA. Los clips de polímero no absorbible brindan un tiempo de operación más corto. El atado de nudos extracorpóreo con empujador de nudos proporciona el cierre más económico del muñón.

O uso contínuo da terlipressina após a ligadura endoscópica em hemorragia varicosa aguda necessita de mais evidências: um estudo piloto / Rational for continuing terlipressin after endoscopic variceal ligation in acute variceal haemorrhage needs further evidence: a pilot study

ABSTRACT Background Variceal hemorrhage (VH) is a medical emergency. Prompt endoscopic variceal ligation (EVL) is therapeutic. Terlipressin is used in VH and continued for 2—5 days even after EVL. As hemostasis is primarily achieved by EVL, the benefit of continuing trelipressin after EVL is unknown. Objective To evaluate the efficacy of continuing terlipressin after EVL to prevent re-bleed and mortality. Methods In this pilot study, after EVL 74 patients of VH were randomized into two treatment groups TG2 & TG5, received terlipressin (1 mg IV bolus q 4 hourly) for 2 days and 5 days respectively and one control group (TG0), received 0.9% normal saline (10 mL IV bolus q 4 hourly) and followed up for 8 weeks. Results A total of 9 (12.6%) patients had re-bleed with maximum 4 (5.6%) patients in TG5 group followed by 3 (4.2%) in TG2 and 2 (2.8%) in TG0 groups (P=0.670). The overall mortality was 15 (21.1%) patients, 6 (8.5%) patients in TG0 group, followed by 5 (7.0%) in TG5 and 4 (5.6%) in TG2 group (P=0.691). Adverse drug reactions were significantly higher in treatment groups with maximum 18 (24.32%) patients in TG5, followed by 8 (10.8%) in TG2 and 2 (2.7%) in TG0 groups (P=0.00). Duration of hospital stay was also significantly higher in treatment group, 6.63 (±0.65) days in TG5 followed by 3.64 (±0.57) in TG2 and 2.40 (±0.50) days in TG0 groups (P=0.00). Conclusion The rational for continuing terlipressin after EVL is doubtful as it didn't have any benefit for the prevention of re-bleed or mortality; rather it increased the risk of adverse drug reactions and duration of hospital stay. Further randomized clinical trials are encouraged to generate more evidence in support or against continuing terlipressin after EVL.

RESUMO Contexto A hemorragia varicosa (HV) é emergência médica. A ligadura endoscópica imediata das varizes (LEV) é terapêutica. A terlipressina é usada em HV e contínua por 2—5 dias mesmo após a LEV. Como a hemostasia é alcançada principalmente pela LEV, o benefício do uso contínuo da terlipressina após o evento é desconhecido. Objetivo Avaliar a eficácia da terlipressina contínua após a LEV para evitar o ressangramento e a mortalidade. Métodos Neste estudo piloto, após a LEV, 74 pacientes com HV foram randomizados em dois grupos de tratamento TG2 & TG5, que receberam terlipressina (1 mg EV em bolus a cada 4 horas) durante 2—5 dias, respectivamente, e um grupo controle (TG0), que receberam soro fisiológico normal de 0,9% (10 mL EV em bolus a cada 4 horas) e foram seguidos por 8 semanas. Resultados Um total de 9 (12,6%) pacientes tiveram ressangramento, 4 (5,6%) no grupo TG5, seguidos por 3 (4,2%) no TG2 e 2 (2,8%) no grupo TG0 (P=0,670). A mortalidade geral de pacientes foi de 15 (21,1%), 6 (8,5%) no grupo TG0, seguidos por 5 (7,0%) no TG5 e 4 (5,6%) no TG2 (P=0,691). As reações adversas de medicamentos foram significativamente maiores em grupos de tratamento em 18 (24,32%) pacientes no TG5, seguidos por 8 (10,8%) no TG2 e 2 (2,7%) em grupo TG0 (P=0,00). A duração da internação hospitalar também foi significativamente maior no grupo de tratamento, 6,63 (±0,65) dias no TG5, seguido por 3,64 (±0,57) em TG2 e 2,40 (±0,50) dias em grupos TG0 (P=0,00). Conclusão O uso racional para a continuação da terlipressina após a LEV é duvidoso, pois não teve qualquer benefício para a prevenção de ressangramento ou mortalidade; pelo contrário, aumentou o risco de efeitos adversos e duração da internação hospitalar. Outros ensaios clínicos randomizados são necessários para gerar mais evidências em apoio ou contra a terlipressina contínua após a LEV.

Fuentes de energía en apendicectomía laparoscópica en un programa académico de Cirugía general en Colombia / Energy sources in laparoscopic appendectomy in an academic program of General Surgery in Colombia

Introducción. La apendicectomía por laparoscopia se considera el patrón de oro en el tratamiento de la apendicitis aguda. Sin embargo, su disponibilidad es limitada en nuestro sistema de salud, principalmente por los costos asociados. El objetivo de este estudio fue evaluar la relación entre el uso de los diferentes tipos de energía y los métodos de ligadura de la base apendicular, con las complicaciones postoperatorias, al igual que describir los costos asociados. Métodos. Estudio observacional analítico de una cohorte retrospectiva de pacientes mayores de 15 años a quienes se les realizó apendicectomía por laparoscopia, en un hospital universitario entre los años 2014 y 2018. Se utilizaron modelos de regresión logística y lineal para evaluar la relación entre métodos de ligadura del meso y base apendicular, desenlaces operatorios y costos. Resultados. Se realizaron 2074 apendicectomías por laparoscopia, 58,2 % (n=1207) en mujeres, la edad mediana fue de 32 años. En el 71,5 % (n=1483) la apendicitis aguda no fue complicada. La energía monopolar para la liga-dura del meso apendicular fue la utilizada más frecuentemente en 57,2 % (n=1187) y el Hemolok® el más utilizado para la ligadura de la base apendicular en el 84,8 % (n=1759) de los pacientes. No se observaron diferencias estadísticamente significativas en la tasa de infección del sitio operatorio, reintervención o íleo. El uso de energía simple redujo los costos del procedimiento de manera significativa durante el período evaluado. Discusión. El uso de energía monopolar demostró ser una técnica segura, reproducible y de menor costo en comparación con el uso de energía bipolar, independientemente de la fase de la apendicitis aguda. Lo anterior ha permitido que se realicen más apendicectomías por laparoscopia y que los médicos residentes de cirugía general puedan realizar procedimientos laparoscópicos de forma más temprana

Introduction. Laparoscopic appendectomy is considered the gold standard in the treatment of acute appendicitis. However, its availability is limited in our health system mainly due to the associated costs. The objective of this study is to evaluate the relationship between the use of different types of energy and the methods of ligation of the appendicular base with postoperative complications, as well as to describe the associated costs. Methods. Retrospective observational study of a cohort of patients older than 15 years old who underwent laparoscopic appendectomy in a university hospital between 2014 and 2018. Logistic and linear regression models were used to evaluate the relationship between methods of ligation of the meso and appendicular base, operative outcomes and costs. Results: 2074 laparoscopic appendectomies were performed. Of those, 58.2% (n=1207) were women, median age was 32 years. In 71.5% (n=1483), acute appendicitis was uncomplicated. Monopolar energy for ligation was the most frequently used for ligation of the appendicular meso in 57.2% (n=1187) and Hem-o-lok® the most used for ligation of the appendicular base in 84.8% (n=1759) of the patients. There were no statistically significant differences in the rate of surgical site infection, reoperation, or ileus. The use of simple energy reduced the costs of the procedure significantly during the study period. Discussion. The use of monopolar energy proved to be a safe, reproducible and a lower cost technique compared to the use of bipolar energy, regardless of the phase of acute appendicitis. This has allowed more laparoscopic appendectomies to be performed and the general surgery residents to perform laparoscopic procedures earlier

LIFT procedure for posterior fistula-in-ano. Are outcomes good enough? A systematic review and meta-analysisis of observational studies. / Procedimiento LIFT en fístulas anales de localización posterior. ¿Son buenos los resultados? Revisión sistemática y metaanálisis de estudios observacionales.

INTRODUCTION: Efficacy of the ligation of intersphincteric fistula tract (LIFT) procedure for posterior fistula-in-ano remains under debate. However, there is scarcity of quality evidence analysing this issue. Thus, the aim of this study is to evaluate outcomes of LIFT surgery in patients with posterior anal fistula. MATERIAL AND METHODS: Systematic review and meta-analysis to evaluate efficacy of LIFT procedure for posterior anal fistula. MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar data sources were searched for key-words (MeSH terms): "LIFT" OR "Ligation of the intersphincteric fistula tract" AND "posterior anal fistula" OR "posterior fistula-in-ano". Original, observational and experimental, non-language restriction studies published from January 2000 to March 2020 and reporting outcomes on LIFT procedure for posterior anal fistula were reviewed. Quality and potential biases were assessed using Newcastle-Ottawa scale, following AHRQ recommendations. Additional sensitivity analysis and publication bias evaluation (Beg and Egger's tets) were performed. RESULTS: No significant differences were found in recurrence rate among patients undergoing LIFT procedure for posterior fistula-in-ano in contrast to other locations (OR 1.36 [IC 95% 0.60-3.07]; p=.46). I2 test value was 77%, expressing a fair heterogeneity among included studies. The weighed median for overall recurrence was 37.8% (RI 18.3-47.7%); with a weighed median of 47.1% (RI 30.7 - 63.7%) and 36.3% (RI 15.8-51.3%) (p=.436) respectively for recurrence after LIFT for posterior fistula and fistula in other locations. There was not clear evidence about the sample size ("n") of included studies nor the disparities in quality assessment of those, could justify the observed heterogeneity. No significant publication bias was found. CONCLUSION: This systematic review and meta-analysis suggests that there are no clear data in the literature for not performing the LIFT procedure in posteriorly located fistulas.

Modelo experimental de infarto agudo do miocárdio em coelhos / Experimental model of acute myocardial infarction in rabbits

Relacionado às doenças cardiovasculares, o infarto agudo do miocárdio (IAM) é a primeira causa de morte entre pacientes com doença coronariana em todo o mundo. Estudos com animais são utilizados devido à similaridade com a fisiologia e anatomia humanas. Relatos demostram utilização experimental com coelhos, pois a sua anatomia coronariana é similar aos humanos. Esta pesquisa teve por objetivo reproduzir e validar o modelo experimental controlado de IAM da parede apical anterolateral do ventrículo esquerdo em coelhos através da ligadura do ramo da artéria coronária esquerda. Foi selecionado um coelho macho para indução de IAM por ligadura coronariana. A intervenção cirúrgica consistiu na ligadura do ramo coronariano por meio de toracotomia póstero-lateral esquerda. O coração foi submetido à avaliação anatomopatológica e morfométrica para se estimar o volume percentual infartado. Em conclusão, o IAM foi alcançado com a ligadura coronariana controlada, histologicamente transmural extenso, mostrando-se eficaz e reprodutível para avaliação de novas intervenções terapêuticas e abordagens regenerativas.

Related to cardiovascular diseases, acute myocardial infarction (AMI) is the leading cause of death among patients with coronary artery disease worldwide. Animal studies are used because of their similarity to human physiology and anatomy. Reports demonstrate experimental use with rabbits, as their coronary anatomy is similar to humans. This research aimed to reproduce and validate the controlled experimental model of AMI of the anterolateral apical wall of the left ventricle in rabbits through ligation of the branch of the left coronary artery. A male rabbit was selected for induction of AMI by coronary ligation. Surgical intervention consisted of ligation of the coronary branch through a left posterolateral thoracotomy. The heart was submitted to anatomopathological and morphometric evaluation to estimate the infarcted percentage volume. In conclusion, AMI was achieved with controlled, histologically extensive transmural coronary ligation, proving to be effective and reproducible for the evaluation of new therapeutic interventions and regenerative approaches.

A new mixed surgical treatment for grades iii and iv hemorrhoids: modified selective hemorrhoidectomy combined with complete anal epithelial retention / Um novo tratamento cirúrgico para hemorroidas mistas graus iii e iv: hemorroidectomia seletiva modificada combinada com retenção epitelial anal completa

ABSTRACT Background: Varicose veins appear above and below the dentate line in mixed hemorrhoids, which seriously affects anal function and quality of life. Aim: To propose an improvement in tissue-selecting therapy repair of anal pad combined with complete anal canal epithelial retention comparing with Milligan-Morgan surgery. Methods: A prospective randomized controlled study was designed enrolling 200 patients with grade III and IV hemorrhoids. They were divided into control and observation groups. The control received Milligan-Morgan surgery, and the observation the modified tissue-selecting therapy stapler combined with complete anal canal preservation surgery. All patients were followed for six months to evaluate the treatment differences. Results: In final, control group included 82 and observation 87. The average operation time of the control group was significantly lower than that of the observation, while the bleeding volume was significantly lower in control group. The control group VAS score was 3 (1, 4), and observation 4 (2, 5). There was no significant difference in the incidence of urinary retention, bleeding and wound margin edema after surgery at one month postoperatively. Digital incidence of anal stenosis in the observation group was significantly lower than in control; the same occurred with residual anal margins. The postoperative anal canal diameter was significantly larger than the control group. Wexner anal incontinence score showed that no anal incontinence occurred in both groups, and the control group scored was significantly higher than observation. In final six months follow-up, the observation group did not experience any relapse and four cases were found among controls. The treatment satisfaction of the observation group was better. Conclusions: In grades III and IV hemorrhoids, modified tissue-selecting therapy combined with complete anal canal preservation had better prognosis and treatment satisfaction than Milligan-Morgan procedure, and it is a new surgical method for patients with advanced mixed hemorrhoids.

RESUMO Racional: Veias varicosas aparecem acima e abaixo da linha dentada nas hemorroidas mistas, afetando seriamente a função anal e a qualidade de vida. Objetivo: Propor melhoria na terapia de seleção de tecido de reparo do coxim anal combinado com retenção completa epitelial do canal anal em comparação com a operação de Milligan-Morgan. Métodos: Estudo prospectivo randomizado controlado foi desenhado envolvendo 200 pacientes com hemorroidas graus III e IV. Eles foram divididos em grupos de controle e observação. O controle recebeu operação de Milligan-Morgan, e o de observação procedimento de seleção de tecido modificado combinado com operação completa de preservação do canal anal. Todos os pacientes foram acompanhados por seis meses para avaliar as diferenças de tratamento. Resultados: No final, o grupo controle incluiu 82 e o de observação 87. O tempo médio de operação do grupo controle foi significativamente menor do que o de observação, enquanto o volume de sangramento foi significativamente menor no grupo controle. O escore VAS do grupo controle foi 3 (1, 4) e no de observação 4 (2, 5). Não houve diferença significativa na incidência de retenção urinária, sangramento e edema da margem da ferida no pós-operatório de um mês. A incidência de estenose anal digital no grupo observação foi significativamente menor do que no controle; o mesmo ocorreu com as margens anais residuais. O diâmetro do canal anal pós-operatório foi significativamente maior nele do que o grupo controle. A pontuação de incontinência anal de Wexner mostrou que nenhuma incontinência ocorreu em ambos os grupos, e a pontuação do grupo de controle foi significativamente maior do que no de observação. Nos últimos seis meses de acompanhamento, o grupo observação não teve nenhuma recaída e quatro casos foram encontrados entre os controles. A satisfação com o tratamento do grupo observação foi maior. Conclusões: Nas hemorroidas graus III e IV, o tratamento de seleção de tecido modificado combinado com a preservação completa do canal anal teve melhor prognóstico e satisfação do que com o procedimento de Milligan-Morgan, e é um novo método cirúrgico para pacientes com hemorroidas mistas avançadas.

Persistent mycotic superficial femoral artery pseudoaneurysm after endovascular treatment: a case report / Pseudoaneurisma micótico persistente da artéria femoral superficial após tratamento endovascular: relato de caso

Abstract Mycotic pseudoaneurysms of the superficial femoral artery (SFA) are rare and are usually secondary to colonization of an atherosclerotic plaque during an episode of bacteremia. We describe the case of a 68 year-old diabetic male who presented to the Emergency Department with pyrexia and a painful expanding mass in the left thigh. He had a history of diarrhea and had been treated 16 days earlier for an SFA pseudoaneurysm that had been excluded with a covered stent with no adjunctive antibiotic therapy. Angio CT showed an abscess surrounding femoral vessels and stent thrombosis. Under general anesthesia, we performed extensive debridement, removal of the endovascular material, SFA ligation, and empirical antibiotic therapy. Blood and tissue cultures were positive for Escherichia coli. At the 3-months follow up visit, the patient reported he had no claudication. In selected patients, mycotic pseudoaneurysms can be treated by SFA ligation.

Resumo Pseudoaneurismas micóticos da artéria femoral superficial (AFS) são raros, e geralmente são secundários à colonização de uma placa aterosclerótica durante bacteremia. Relatamos o caso de um paciente masculino diabético de 68 anos que chegou ao Serviço de Emergência com pirexia e massa expansiva dolorosa na coxa esquerda. Apresentava histórico de diarreia e havia sido tratado 16 dias antes para pseudoaneurisma da AFS, que foi excluído com stent coberto e sem antibioticoterapia adjuvante. A angiotomografia computadorizada demonstrou um abscesso ao redor dos vasos femorais e trombose do stent. Sob anestesia geral, realizamos desbridamento extenso, remoção do material endovascular, ligadura de AFS e antibioticoterapia empírica. Culturas de sangue e tecidos foram positivas para Escherichia coli. Na consulta de seguimento aos 3 meses, o paciente negou claudicação. Em pacientes selecionados, pseudoaneurismas micóticos podem ser tratados com ligadura de AFS.

Ligadura de varices esofágicas por videoendoscopia en pacientes con hemorragia digestiva alta / Ligature of varicose veins by videoendoscopy in patients with upper digestive bleeding

Introducción: Las varices esofágicas son canales vasculares que unen la circulación venosa portal y la sistémica. Se forman como consecuencia de la hipertensión portal, predominantemente en la submucosa del tercio inferior del esófago. Objetivo: Caracterizar a pacientes con rotura de varices esofágicas según principales variables clinicoepidemiológicas y terapéutico-endoscópicas. Métodos: Se realizó un estudio observacional, descriptivo y longitudinal de 20 pacientes con hemorragia digestiva alta por rotura de varices esofágicas, los cuales recibieron tratamiento endoscópico con bandas elásticas en el Servicio de Gastroenterología del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba, de noviembre de 2016 a febrero de 2018. En el análisis estadístico se utilizó el porcentaje como medida de resumen y se aplicó la prueba de independencia de la Χ2 para identificar alguna asociación significativa entre variables. Resultados: Existió un predominio del sexo masculino (80,0 %) y del grupo etario de 51 a 60 años (40,0 %). La mayoría de los afectados presentó cirrosis hepática (60,0 %) como causa de la hipertensión portal y hematemesis (50,0 %) como forma de hemorragia digestiva alta; asimismo, el gran tamaño de las varices fue el principal factor de riesgo asociado a la rotura (70,0 %) y, luego de practicado el tratamiento endoscópico, no se produjo resangrado en la casi totalidad de los pacientes (95,0 %). Conclusiones: La aplicación de este procedimiento terapéutico resultó ser satisfactoria y no provocó complicación alguna.

Introduction: The esophageal varicose veins are vascular channels that unite the portal venous and systemic circulation. They are formed as consequence of the portal hypertension, predominantly in the submucosa of the inferior section of the esophagus. Objective: To characterize patients with break of esophageal varicose veins according to main clinical epidemiological and therapeutic-endoscopic variables. Methods: An observational, descriptive and longitudinal study of 20 patients with upper digestive bleeding due to break of esophageal varicose veins was carried out, they received endoscopic treatment with banding in the Gastroenterology Service of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba, from November, 2016 to February, 2018. In the statistical analysis the percentage was used as summary measure and the chi-square test was applied to identify the existence of some significant association among variables. Results: There was a prevalence of the male sex (80.0 %) and the 51 to 60 age group (40.0 %). Most of the patients presented liver cirrhosis (60.0 %) as cause of the portal hypertension and hematemesis (50.0 %) as form of upper digestive bleeding; also, the great size of the esophageal varicose veins was the main risk factor associated with the break (70.0 %) and, after the implementation of the endoscopic treatment, there was no second bleeding in almost all the patients (95.0 %). Conclusions: The application of this therapeutic procedure was satisfactory and it didn't cause any complication.

Repermeabilización portal intrahepática luego de ligadura de rama derecha de vena porta: reporte de un caso / Intrahepathic portal revascularization following right portal vein ligation: a case report / Repermeabilização portal intra-hepática após ligadura do ramo direito da veia porta: relato de caso

Resumen: La ligadura de una rama de la vena porta constituye un procedimiento con buenos resultados para evitar la falla hepática posoperatoria en caso de hepatectomías extremas al provocar la hipertrofia del hígado contralateral. Sin embargo, la repermeabilización de ésta ha sido demostrada por la presencia de anastomosis porto portales intrahepáticas, pudiendo determinar una disminución de la hipertrofia esperada o necesaria. Como objetivo documentamos un caso clínico de repermeabilización intrahepática de la vena porta, evento no deseado de la hepatectomía en dos tiempos para el tratamiento de metástasis hepáticas bilobares de origen colorrectal y describimos alternativas para evitar o tratar dicha repermeabilización.

Summary: Left or right portal vein ligation to prevent post-operative liver failure in the case of extreme hepatectomy constitutes a procedure with a good prognosis, as it causes contralateral liver hypertrophy. However, its revascularization has been proved by intrahepatic porto-portal anastomoses, which could result in a reduction of the expected or required hypertrophy. The study aims to record a clinical case of intrahepatic revascularization of the portal vein, an unwanted event of the two-stage hepatectomy to treat bilobar hepatic metastasis of colorectal origin, and describe alternatives to avoid or treat such revascularization.

Resumo: A ligadura de um ramo da veia porta é um procedimento com bons resultados para evitar a insuficiência hepática pós-operatória em hepatectomias extremas por causar hipertrofia do fígado contralateral. No entanto, sua repermeabilização tem sido demonstrada pela presença de anastomose porto-portal intra-hepática, que pode determinar diminuição da hipertrofia esperada ou necessária. Como objetivo, documentamos um caso clínico de repermeabilização da veia porta intra-hepática, um evento indesejado de hepatectomia em dois estágios para o tratamento de metástases hepáticas bilobares de origem colorretal, e descrevemos alternativas para evitar ou tratar essa repermeabilização.

Factores sociodemográficos y obstétricos relacionados con aplicación del consentimiento informado en procedimientos de oclusión tubárica. Cartagena-Colombia / Sociodemographic and obstetric factors related to the application of informed consent in procedures of tubal occlusion. Cartagena-Colombia

Introducción: La forma como se aplica el consentimiento informado (CI) en algunas instituciones prestadoras de salud, donde se realizan procedimientos de oclusión tubárica bilateral (OTB) en Cartagena, podría verse influenciado por factores de tipo sociodemográfico y factores de tipo obstétrico, que al final determinan la forma como se aplica el Consentimiento informado y que este sea más que un requisito para desligar responsabilidades por parte de profesionales en su relación médico- paciente. Objetivo: Determinar la influencia de los factores sociodemográficos y obstétricos en la aplicación del consentimiento informado, en procedimientos de OTB, en centros de salud de Cartagena. Material y Métodos: Se realizó un estudio descriptivo transversal prospectivo. Las fuentes de información consultadas son fuentes primarias; se encuestaron 196 pacientes que se realizaron procedimientos de cesárea por urgencias más oclusión tubárica bilateral. Se efectuó análisis Univariado y Bivariado para establecer tendencia a la asociación mediante la prueba de Chi cuadrado. Resultados: Dentro de las características sociodemográficas y obstétricas asociadas estadísticamente con conocer lo que es el consentimiento informado están tener más de 24 años (p= 0,033); ser de procedencia urbana (p=0,046); vivir en estrato superior a estrato 1 y 2 (p=0,0001), tener estudios superiores a primaria (p=0,0001); no tener más de dos embarazos (p=0,029) y asistir a control prenatal (p=0,0001). Conclusiones: La mayoría de las pacientes poseen en términos generales desconocimiento sobre el CI. El estrato socioeconómico, el nivel de escolaridad y la procedencia influyen en el nivel de conocimiento que tienen del CI, lo mismo que algunos factores obstétricos(AU)

Introduction: The way in which informed consent (IC) is applied in some healthcare institutions where bilateral tubal occlusion (OTB) procedures are performed in Cartagena could be influenced by sociodemographic and obstetric factors which ultimately determine the way at which informed consent is applied, being this more than a requirement for the professionals to be free of liability in their doctor-patient relationship. Objective: To determine the influence of sociodemographic and obstetric factors on the application of informed consent in OTB procedures in health centers in Cartagena. Material and Methods: A prospective cross-sectional descriptive study was carried out. Primary sources of information were consulted; a total of 196 patients who underwent cesarean section procedures for emergencies plus bilateral tubal occlusion were surveyed. Univariate and bivariate analyzes were performed to establish a tendency to association using the Chi-square test. Results: Some sociodemographic and obstetric characteristics statistically associated with knowledge about informed consent are to be over 24 years old (p=0.033); to be of urban origin (p=0.046); to live in stratum higher than stratum 1 and 2 (p=0.0001), to have higher education than primary (p=0.0001); not to have more than two pregnancies (p=0.029) and to attend prenatal care (p=0.0001), among others. Conclusions: Most patients are generally unaware of IC. The socioeconomic stratum, level of schooling, origin and some obstetric factors have an influence on their level of knowledge of IC(AU)

Sangrado tardío luego de tratamiento con macroligadura elástica de hemorroides / Late bleeding after hemorrhoid treatment with rubber macroband ligation

Objetivo: Presentar el caso infrecuente de sangrado tardío posterior al tratamiento con macroligadura elástica de hemorroides, tratamiento propuesto por A. Reis Neto. Caso Clínico: Mujer de 26 años con tratamiento de hemorroides con macroligadura elástica. A los 28 días es admitida en urgencia por proctorragia abundante sin signos de shock hipovolémico. Laboratorio: Hematocrito 27%, Hemoglobina 8,9 mg/dl. Se realiza colonoscopia evidenciando la cicatriz de macroligadura con signos de coágulo desprendido sin sangrado activo. Se decide conducta expectante con tratamiento de la hipovolemia incial y anemia. Evoluciona sin resangrado con control endoscópico a los 60 y 180 (sin sangrado y excelentes resultados). Discusión: La macroligadura es una técnica alternativa para el tratamiento de hemorroides con excelentes resultados anatómicos y funcionales. Presenta menor dolor postoperatorio, bajo índice de complicaciones (ninguna severa o propia del método). No existen comunicaciones sobre sangrado tardío grave tanto en ligaduras convencionales como macroligadura. Conclusiones: Se presenta el primer caso comunicado a la fecha de un sangrado tardío en macroligaduras que fue resuelto en forma conservadora.

Objetive: To present an infrequent clinical report of a case of late bleeding after rubber macroband ligation. Case report: A 28-year-old female with severe rectal bleeding but no associated shock was presented 28 days after rubber macroband ligation at emergency room. Blood samples showed acute anemia. An urgent colonoscopy was performed which showed a scar without acute bleeding. Medical treatment was settled. There was no secondary bleeding in follow up. Endoscopic control was done at 60 and 180 days. Discusion: Hemorrhoidal rubber macroband ligation is a modification of conventional rubber band ligation. It was proposed and developed by J.A. Reis Neto (Campinas, SP, Brazil). Morbidity is low and results are excellent. There is no previous report of delayed bleeding considering both rubber band and macroband ligation. Conclusion: The First case of late bleeding after rubber band ligation treated with conservative measures.

Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants / Desfechos clínicos após tratamento mais conservador da persistência do canal arterial em prematuros

Abstract Objective: Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation. Method: Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared. Results: This study included 188 patients (27 ± 2 weeks, 973 ± 272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p < 0.001) and surgical closure (34.5% P1 versus 16.1% P2, p < 0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p = 0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p = 0.403), necrotizing enterocolitis (15.5% versus 6.9%, p = 0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p = 0.264), mortality (17.5% versus 15.2%, p = 0.690) or survival-without-morbidity adjusted OR = 1.10 (95% CI: 0.55-2.22); p = 0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n = 82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p = 0.019) and more survival-without-morbidity (20% versus 45.6%, p = 0.028) were found. Conclusion: A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated.

Resumo Objetivo O tratamento da persistência do canal arterial ainda é controverso. Nosso objetivo foi descrever o impacto de uma abordagem mais conservadora em nossas taxas de tratamento e nos principais desfechos da prematuridade, especialmente em prematuros com < 26 semanas de gestação. Método Revisão de prontuários de lactentes com ≤ 30 semanas e persistência do canal arterial entre 2009-2016 em dois centros. Em 2011, mudamos o manejo da persistência do canal arterial: no primeiro período (2009-2011), os pacientes que não apresentaram sucesso com o tratamento clínico foram submetidos a fechamento cirúrgico; no segundo período (2012-2016), apenas aqueles com comprometimento cardiopulmonar foram submetidos ao fechamento cirúrgico. Comparamos o tratamento clínico, fechamento cirúrgico, mortalidade e sobrevida sem morbidade. Resultados Foram incluídos 188 pacientes (27 ± 2 semanas, 973 ± 272 gramas); 63 em P1 e 125 em P2. Em P2, foram observadas taxas significativamente mais baixas de tratamento clínico (85,7% no P1 versus 56% no P2, p < 0,001) e fechamento cirúrgico (34,5% no P1 versus 16,1% no P2, p < 0,001). Não foram encontradas diferenças em relação à doença pulmonar crônica (28,8% versus 13,9%, p = 0,056), retinopatia grave da prematuridade (7,5% versus 11,8%, p = 0,403), enterocolite necrosante (15,5% versus 6,9%, p = 0,071), hemorragia intraventricular grave (25,4% versus 18,4%, p = 0,264), mortalidade (17,5% versus 15,2%, p = 0,690) ou OR ajustado pela sobrevida sem morbidade = 1,10 (IC95%: 0,55-2,22); p = 0,783. Em P2, 24,5% dos pacientes receberam alta com persistência do canal arterial. O subgrupo nascido entre 23 a 26 semanas (n = 82) apresentou diferenças significativas, foram encontradas menor incidência de doença pulmonar crônica (50% versus 19,6%, p = 0,019) e maior sobrevida sem morbidade (20% versus 45,6%, p = 0,028). Conclusão Uma abordagem conservadora em prematuros com persistência do canal arterial pode evitar tratamentos clínicos e cirúrgicos, sem um impacto significativo na sobrevida sem morbidade. No entanto, dois terços dos prematuros com menos de 26 semanas ainda são tratados.

Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants.

OBJECTIVE: Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation. METHOD: Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared. RESULTS: This study included 188 patients (27±2 weeks, 973±272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p<0.001) and surgical closure (34.5% P1 versus 16.1% P2, p<0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p=0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p=0.403), necrotizing enterocolitis (15.5% versus 6.9%, p=0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p=0.264), mortality (17.5% versus 15.2%, p=0.690) or survival-without-morbidity adjusted OR=1.10 (95% CI: 0.55-2.22); p=0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n=82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p=0.019) and more survival-without-morbidity (20% versus 45.6%, p=0.028) were found. CONCLUSION: A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated.