Extended use of bemiparin as thromboprophylaxis during bariatric surgery: results of anti-factor Xa activity measurements.

BACKGROUND: The incidence of venous thromboembolism (VTE) in morbidly obese patients after obesity surgery is between .2% and 3.5%. Because there are a lack of prospective studies on the type of drug, the correct dosage, and the optimal duration, there are no specific recommendations found in the guidelines on thrombophylaxis. OBJECTIVES: To compare the incidence of VTE and hemorrhagic events in bariatric surgical patients receiving bemiparin thromboprophylaxis who have prophylactic and nonprophylactic Anti-factor Xa (AFXa) levels. SETTING: University General Hospital of Ciudad Real, Spain, public practice. METHODS: A cohort study of 122 morbidly obese patients who underwent bariatric surgery. The thromboprophylactic regimen consisted of bemiparin 5000 IU/24 hr for 30 days. AFXa levels were measured on the second and third day postoperation (prophylactic range: .3-.5 IU/mL). Body mass index, co-morbidities, prothrombotic risk factors, and thrombotic and hemorrhagic events were noted. RESULTS: The mean body mass index was 48.4 kg/m2. In 50 samples, the level of AFXa was within the prophylactic range; in 71, they were in the subprophylactic range. No VTEs were observed. Major hemorrhagic events were observed in 2.4%. We did not find a significant association between AFXa and thromboembolic and hemorrhagic events. There is a significant negative correlation between the level of AFXa and body mass index. CONCLUSION: A regimen of 5000 IU/24 hr of bemiparin for 30 days after obesity surgery appears to prevent VTE without increasing the risk of a major hemorrhage. The level of AFXa is not associated with postoperative thrombotic or hemorrhagic events occurring after bariatric surgery.

Rapid intraoperative determination of intact parathyroid hormone during surgery for primary hyperparathyroidism. Experience at our center.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is due to a single adenoma in 85%-95% of cases, and is often cured after adenoma removal. Intraoperative rapid determination of intact parathyroid hormone (PTHio) may be a tool for monitoring the effectiveness of PHPT surgery. The main objective of our study was to evaluate PTHio determination and to establish whether its successful implementation contributed to achieve minimally invasive surgery (MIS) and major ambulatory surgery (MAS) in the treatment of PHPT. MATERIAL AND METHODS: Retrospective study of a consecutive series of patients diagnosed and operated on for PHPT at the University General Hospital of Ciudad Real between January 2005 and January 2012. RESULTS: In the study period, 91 patients underwent surgery. 39 (42.9%) under general anesthesia, while 52 (57.1%) were candidates for regional anesthesia by cervical block. Seventy-six of all patients (83.5%) were amenable to MIS using a unilateral approach. Classical cervicotomy was performed in all other patients. PTHio determination was done in 75 patients, showing cure in the same surgery in 68 of them. MAS was performed in 70.3% (64) of patients. CONCLUSIONS: Determination of PTHio may allow for changing the surgical approach to PHPT at our department, allowing for performance of MIS on an outpatient basis in a significant proportion of patients with some cosmetic improvement, probably less pain, shorter hospital stay, and less potential complications than bilateral cervical exploration.

Nesidioblastosis. A case of hyperplasia of the islets of Langerhans in the adult.

INTRODUCTION: Nesidioblastosis is a rare disease caused by hyperplasia of pancreatic islets, developing a state of hypoglycemia due to an increase in the insulin production. It is the leading cause of hyperinsulinic hypoglycemia in childhood, whereas in adults it only represents the 0.5-5% of cases. The pathogenesis is still unknown. We have studied several genetic mutations associated with dependent potassium channel of ATP present in the beta cells of the pancreas, as well as in patients underwent bariatric surgery because of the metabolic changes involved. REPORT: Woman (38 years old) attends consultation of General Surgery derived from Endocrinology before symptoms of persistent hypoglycemia. Factitious hypoglycemia and syndromes of neuroendocrine origin were ruled out. Imaging tests failed to identify space-occupying lesions. The medical treatment failed, persisting hypoglycemia symptoms. Before the given analytical and radiological findings obtained, and the persistence of symptoms affecting the quality of life of the patient, we opted for surgical treatment performing a pancreatectomy of the 80% of the gland. The final pathologic diagnosis was nesidioblastosis. DISCUSSION: Nesidioblastosis is a rare pathology, but it must be present in the differential diagnosis of hypoglycemia symptoms with endogenous hyperinsulinism in adults, once the intake of sulfonylureas and possible pancreatic neoformations have been ruled out.

[Fibromatosis breast in the male. Case study]. / Fibromatosis mamaria en el varón. A propósito de un caso.

BACKGROUND: mammary fibromatosis is a rare pathology. It constitutes 0.2% of breast cancers, and case in men are exceptional. The definitive diagnosis is histological. CLINICAL CASE: we report the case of a male of 52 years, diagnosed with breast fibromatosis after pathologic study of tumor in the right breast. Programmed surgery for excision with wide margins was done. We performed a mastectomy of the subcutaneous fibromatosis with a pathologic study with clear margins. The postoperative course was uncomplicated and did not require adjuvant therapy. At 6 months follow-up he remains free of disease. The treatment of choice is surgical excision with wide margins. Adjuvant treatment is controversial. CONCLUSIONS: the fibromatosis in the breast is very rare and an exceptional occurrence in men. Surgery is the definitive treatment; few results exist for adjuvant therapy.

Antecedentes: la fibromatosis mamaria es una enfermedad rara; sus casos son 0.2% de las neoplasias de mama, y en los varones es aún más rara. El diagnóstico definitivo es anatomopatológico. Caso clínico: se comunica el caso de un varón de 52 años, con diagnóstico anatomopatológico de fibromatosis mamaria posterior al estudio de un tumor en la mama derecha. Se le practicó exéresis con amplios márgenes, luego mastectomía subcutánea, con estudio histológico de fibromatosis con márgenes libres. El postoperatorio transcurrió sin complicaciones y no requirió tratamiento coadyuvante. En el seguimiento a seis meses continuaba libre de enfermedad. El tratamiento de elección es la escisión con amplios márgenes y el oncológico coadyuvante es motivo de controversia. Conclusiones: la fibromatosis en la mama es poco frecuente y su aparición en el varón excepcional. El tratamiento quirúrgico es el definitivo, no así la terapia oncológica neoadyuvante que sigue suscitando controversia.

Merkel cell carcinoma: case report and literature review.

BACKGROUND: Merkel cell carcinoma is an aggressive neuroendocrine cell carcinoma arising in the epidermis of patients aged >60 years. This lesion is found in sun-exposed areas and presents as a small violet raised nodule. It is usually painless and rapidly growing. Although its clinical presentation and characteristic histology are usually sufficient, immunohistochemical features are helpful in making an accurate diagnosis. CLINICAL CASE: We present the case of a 62-year-old male with epidermoid carcinoma of the lung who was treated with surgery and local radiation for 2 months. He presented a painless 8-cm subcutaneous mass of some weeks of evolution, without inflammatory signs. Computerized tomography demonstrated a mass of probable lymph node origin. Fine-needle aspiration biopsy (FNAB) reported malignant cells and excisional surgery of the mass was performed, revealing a subcutaneous Merkel cell carcinoma. CONCLUSIONS: Merkel cell carcinoma is a rare entity that develops in mature patients, often in sun-exposed areas, and presents cutaneous injury in intact skin. Definitive diagnosis is done using immunohistochemistry.

Angiosarcoma primario de mama y carcinoma papilar de tiroides sincrónico: presentación de un caso / Primary breast angiosarcoma and synchronous papillary carcinoma of thyroid: a case report

Presentamos el caso excepcional de paciente con angiosarcoma primario de mama y carcinoma papilar de tiroides sincrónicos. Mujer de 34 años con angiosarcoma primario en la mama derecha sometida a mastectomía simple. En el estudio de extensión se halló un incidentaloma tiroideo derecho compatible con carcinoma papilar que requirió tiroidectomía total y linfadenectomía del compartimento central en segundo tiempo. Los angiosarcomas primarios suponen menos del 0,05% de todos los tumores primarios malignos de la mama. El diagnóstico definitivo de estos tumores viene definido por el estudio anatomopatológico, que define tres grados: alto, bajo, intermedio, los cuales se relacionan de forma directa con la supervivencia. La prevalencia de los incidentalomas malignos tiroideos objetivados por PET varía del 14% - 30,9%. La planificación del tratamiento quirúrgico de las neoplasias incidentales tiroideas en pacientes con otro tumor primario debe analizarse de forma individualizada, según la supervivencia esperada del tumor primario

Present the exceptional case of a female patient with diagnostic of primary angiosarcoma of the breast and synchronous thyroid papillary carcinoma, we review the literature. Patient female 34 year old with diagnostic of primary angiosarcoma in the right breast, it was removed,in the extension study found an incidental thyroid papillary carcinoma that required total thyroidectomy and central lymphadenectomy in a second time. The primary angiosarcomas account for less than 0.05% of all primary malignant tumors of the breast. The definitive diagnosis is determined by the pathology study, which defines three grades: high, low and intermediate, which relate directlyto the survival. The prevalence of malignant thyroid incidentalomas was observed by PET varies from 14% to30,9%, according to different studies. Planning the surgical treatment of incidental thyroid malignancies in patients with other primary tumor should be analyzed individually,according the expected survival of the primary tumor

Proximal-type epithelioid sarcoma in pubis. Case report and review of the literature.

BACKGROUND: The "proximal-type" epithelioid sarcoma (PES) is a rare variant of conventional epithelioid sarcoma. It has been described in older patients in the proximal portion of the extremities with a predilection for the pelvis and perineum. It is clinically more aggressive, showing a higher incidence of recurrence, metastasis, resistance to chemotherapy and a higher mortality. We report the case of a patient with a PES of the pubic region and we review the previous literature. CLINICAL CASE: We report the case of a 57-year-old female with a painless, progressively growing mass in the region of the pubis. We performed surgical resection of the lesion with clear margins and histological and immunohistochemical study allowed the definitive diagnosis of PES. After 4 disease-free years, the patient had a tumor recurrence at the same location. We performed en bloc resection of the lesion and immunohistochemical study confirmed the recurrence of PES. The patient refused adjuvant therapy. Today, after 4 years of follow-up, the patient remains asymptomatic and without evidence of recurrence or distant disease. CONCLUSIONS: Diagnosis of PES is complex because histological findings may be confused with multiple tumors; therefore, immunohistochemical study is definitive. PES shows positivity for epithelial markers (cytokeratin and EMA), mesenchymal markers (vimentin) as well as CD34. According to what has been reported in the literature, surgical treatment with free margins is indicated, with adjuvant therapies when the risk of recurrence is high.

[Single port laparoscopic cholecystectomy in major ambulatory surgery (MAS)]. / Colecistectomía laparoscópica de puerto único en un programa de CMA.

INTRODUCTION: Natural orifice endoscopic surgery is a new surgical procedure still in the development phase. The most natural entry for surgeons is to use an already existing scar, such as the navel. The recent introduction of trocars designed for this purpose has made it possible to put this into practice. MATERIAL AND METHODS: We present our preliminary experience in single trans-umbilical incision laparoscopic cholecystectomy, by means of a prospective study which included 26 patients operated on between January 2009 and January 2010. We also attempt to find out whether it can be performed in a MAS programme. RESULTS: All patients had uncomplicated cholelithiasis, although in 5 of them cholecystitis was identified during the surgery. The mean surgical time was 51.2 min. The mean hospital stay was 25.7h, and 76.92% of patients were admitted for less than 24h. There were no re-admissions or significant intra-operative or post-operative complications. CONCLUSIONS: On looking at our results, single port laparoscopic cholecystectomy could be included in a major ambulatory surgery programme.

Angiomyofibroblastoma of the right ischiorectal fosa.

BACKGROUND: angiomyofibroblastoma is a soft-tissue lesion. The vulvovaginal region of middle-aged females is the most frequent localization. Angiomyofibroblastoma is a well-circumscribed subcutaneous tumor at the vulva and perineum region. It is a painful and slow-growing tumor. It is often thought to represent a Bartholin's gland cyst. Treatment of choice is surgical excision. CLINICAL CASE: We describe the case of a 49-year-old female with a right vulvar tumor that had been growing for 2 years. Ultrasonography, computed tomography and magnetic resonance revealed a tumor at the right ischiorectal fossa. Diagnosis after surgical excision was angiomyofibroblastoma. CONCLUSIONS: angiomyofibroblastoma must be considered in the differential diagnosis of vulvovaginal tumors because its treatment differs from others lesions of that region.