Predictive risk model of recurrence of acute diverticulitis after the first episode.

INTRODUCTION: The recurrence of acute diverticulitis (AD) of the colon is frequent and leads to hospital readmissions and the need for elective surgery in selected cases. It is important to individualize risk factors and develop predictive tools for their identification. MATERIALS AND METHODS: This prospective observational study included 368 patients who were diagnosed with AD between 2016 and 2021 in a tertiary general university hospital during their first episode and who had a good response to antibiotic, percutaneous, or peritoneal lavage treatment. Univariate and multivariate Cox regression analyses of the variables associated with recurrence were performed. Subsequently, a predictive risk score was developed and validated through survival studies. RESULTS: After a median follow-up of 50 months, there were 71 (19.3%) cases of recurrence out of a total of 368 patients. The mean time of recurrence was 15 months, and 73.3% of cases of recurrence occurred before 2 years of follow-up. Recurrence was independently associated with presentation with colonic perforation in the antimesenteric location (HR 3.67 95% CI [1.59-8.4]) and a CRP level greater than 100 mg/dl (HR 1.69 95% CI [1.04-2.77). A score with 5 variables was created that differentiated two risk groups: intermediate risk (0-3 points), with 19% recurrence and high risk (more than 3 points), with 42% recurrence. CONCLUSIONS: The risk of recurrence after the first episode of diverticulitis can be estimated using predictive scores. The detection of high-risk patients facilitates the individualization of follow-up and treatment.

Analysis of the impact of bariatric surgery on medium-term pharmacological expenditure.

INTRODUCTION: Obesity and associated diseases represent an important health and economic problem since pharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric and metabolic surgery decreases the medication requirements of patients for these diseases but may result in other types of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharmacological expenditure after bariatric surgery. MATERIAL AND METHODS: Retrospective cross-sectional analysis of patients who were treated in our centre between 2012 and 2016, comparing different associated comorbidities and pharmacological expenses one month before and 2 years after surgery. RESULTS: 400 patients were operated. The results were presented, showing the differences between the resolution of the different comorbidities and the pharmacological savings generated for each of the surgical techniques studied. The most cost-effective comorbidity in the study was type 2 diabetes mellitus (DM2). The surgical technique with the best results was metabolic bypass, presenting a cost difference after surgery of 507 euros per month (P < 0.001). CONCLUSIONS: In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases and associated pharmacological expenditure was observed, showing the efficiency of this intervention over the medium term.

Analysis of the impact of bariatric surgery on medium-term pharmacological expenditure. / Análisis del impacto de la cirugía bariátrica en el gasto farmacológico a medio plazo.

INTRODUCTION: Obesity and associated diseases represent an important health and economic problem since pharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric and metabolic surgery decreases the medication requirements of patients for these diseases but may result in other types of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharmacological expenditure after bariatric surgery. MATERIAL AND METHODS: Retrospective cross-sectional analysis of patients who were treated in our centre between 2012 and 2016, comparing different associated comorbidities and pharmacological expenses one month before and 2years after surgery. RESULTS: 400 patients were operated. The results were presented, showing the differences between the resolution of the different comorbidities and the pharmacological savings generated for each of the surgical techniques studied. The most cost-effective comorbidity in the study was type2 diabetes mellitus (DM2). The surgical technique with the best results was metabolic bypass, presenting a cost difference after surgery of 507euros per month (P<.001). CONCLUSIONS: In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases and associated pharmacological expenditure was observed, showing the efficiency of this intervention over the medium term.

Rare Site Hepatocellular Carcinoma Metastasis.

INTRODUCTION: Besides more common sites such as lung or peritoneum, hepatocellular carcinoma (HCC) can metastatize to rare sites. We report herein a new metastatic site of HCC: the nail-bed. We also review other recently reported rare site HCC metastases (RSHM). CASE REPORT: A 66-year-old woman with a 12-year history of resected-stage IA HCC who later presented lung, spleen and brain metastases treated with surgery, systemic therapies (sorafenib, sunitinib, capecitabine) and radiotherapy. The patient was referred to us because of a painful and rapidly evolving mass in the nail-bed of the left thumb. Biopsy confirmed nail-bed HCC metastasis, and the finger was amputated. The patient died few weeks later. CONCLUSION: This case was an opportunity for us to review RSHM. This type of metastasis seems to be an early event, in the context of advanced stage HCC with elevated protein induced by vitamin K absence-II (PIVKA II). The Lee nomogram is useful in detecting patients at high risk of developing RSHM. We would suggest insisting on systemic treatment in these metastatic patients although overall survival after RSHM diagnosis is poor.

Factores de riesgo para la aparición de abscesos intrabdominales tras la apendicectomía / Risk factors for the appearance of intra-abdominal abscesses after appendectomy

RESUMEN Introducción: Los abscesos intrabdominales son las complicaciones posapendicectomía que más frecuentemente provoca ingresos hospitalarios. Objetivo: Estudiar los factores de riesgo para la aparición de abscesos intrabdominales posapendicectomía. Métodos: Se realizó un estudio retrospectivo de pacientes mayores de 14 años, intervenidos por sospecha de apendicitis aguda mediante apendicectomía laparoscópica, desde el 1 de enero de 2007 al 31 de diciembre de 2010. Se utilizaron los tests estadísticos Chi cuadrado, Prueba exacta de Fisher, T de Student y regresión logística. Resultados: Durante los 4 años del estudio, 672 pacientes padecieron con síntomas y signos compatibles con apendicitis aguda. Apareció un absceso intrabdominal en 35 casos (5,2 por ciento). En el análisis multivariante mediante regresión logística se constataron como posibles factores de riesgo: las formas avanzadas de apendicitis (p < 0,0001), las cuales aumentaron el riesgo en unas 6 veces (IC 95 por ciento 2,2-14,9) y el sexo masculino (p = 0,033), también podrían aumentar el riesgo unas 2,5veces (IC 95 por ciento 1-6). Conclusiones: Los posibles factores de riesgo para la aparición de abscesos intrabdominales tras apendicectomía son el sexo masculino y el estadio avanzado, siendo este último el factor más influyente(AU)

ABSTRACT Introduction: Intra-abdominal abscesses are the post-appendectomy complications that most frequently cause hospital admissions. Objective: To study the risk factors for the appearance of post-appendectomy intra-abdominal abscesses. Methods: A retrospective study of patients over 14 years of age, operated on for suspected acute appendicitis by laparoscopic appendectomy, was performed from January 1, 2007 to December 31, 2010. Chi-square statistical tests, Fisher's exact test were used. Student's t and logistic regression. Results: During the 4 years of the study, 672 patients suffered with symptoms and signs compatible with acute appendicitis. An intra-abdominal abscess appeared in 35 cases (5.2 percent). In the multivariate analysis using logistic regression, the following possible risk factors were found: advanced forms of appendicitis (p < 0.0001), which increased the risk by about 6 times (95 percent CI 2.2-14.9) and male sex (p = 0.033), could also increase the risk about 2.5 times (95 percent CI 1-6). Conclusions: Possible risk factors for the appearance of intra-abdominal abscesses after appendectomy are male sex and advanced stage, the latter being the most influential factor(AU)

Modelling the probability of erroneous negative lymph node staging in patients with colon cancer.

BACKGROUND: Patients in who with insufficient number of analysed lymph nodes (LNs) are more likely to receive an incorrect LN staging. The ability to calculate the overall probability of undiagnosed LN involvement errors in these patients could be very useful for approximating the real patient prognosis and for giving possible indications for adjuvant treatments. The objective of this work was to establish the predictive capacity and prognostic discriminative ability of the final error probability (FEP) among patients with colon cancer and with a potentially incorrectly-staged LN-negative disease. METHODS: This was a retrospective multicentric population study carried out between January 2004 and December 2007. We used a mathematical model based on Bayes' theorem to calculate the probability of LN involvement given a FEP test result. Cumulative sum graphs were used to calculate risk groups and the survival rates were calculated, by month, using the Kaplan-Meier method. RESULTS: A total of 548 patients were analysed and classified into three risk groups according to their FEP score: low-risk (FEP < 2%), intermediate-risk (FEP 2%-15%), and high-risk (FEP > 15%). Patients with LN involvement had the lowest overall survival rate when compared to the three risk groups. This difference was statistically significant for the low- and intermediate-risk groups (P = 0.002 and P = 0.004, respectively), but high-risk group presented similar survival curves to pN+ group (P = 0.505). In terms of disease-free survival, the high-risk group presented similar curves to the intermediate-risk group until approximately 60 months' follow-up (P = 0.906). After 80 months' follow-up, the curve of high-risk group coincided with that of the pN+ group (P = 0.172). Finally, we summarized the FEP according to the number of analysed LNs and accompanied by a contour plot which represents its calculation graphically. CONCLUSIONS: The application of Bayes' theorem in the calculation of FEP is useful to delimit risk subgroups from among patients without LN involvement.

Quality control techniques in surgery: Application of cumulative sum (CUSUM) charts. / Técnicas de control de calidad en cirugía. Aplicación de las gráficas de control cumulative sum.

Cumulative sum graphs are quality control charts that are possibly the most frequently used for monitoring clinical-care processes. One of their main advantages is the use in rare cases and in events with low incidence, where it would be necessary to obtain a large sample and a long follow-up time with conventional statistical methods, which is impossible in certain cases. This is also why they are useful for studying learning curves, the introduction of new technologies and, in general, for assessing the quality of care outcomes themselves, because their profile is sensitive to very subtle changes in trends (positive or negative), which would not be observed with other methods. On the other hand, their use can be expanded beyond quality control or monitoring, which is a new aspect in clinical research.

CUSUM charts in the quality control of colon cancer lymph node analysis: a population-registry study.

BACKGROUND: The most important determinant of survival in patients with colon cancer is the presence or absence of regional lymph node metastases. This factor is consistently associated with long-term and disease-specific survival. Cumulative summation of differences (CUSUM) charts can help to discriminate abnormalities that cannot be explained by the general variability of a process. We used CUSUM charts to analyse the quality of nodal analysis in colon cancer and to use a population-registry cancer database to estimate the optimal number of lymph nodes for adequate prognostic analysis. METHODS: This was a multicentre population-registry cancer study from January 2004 to December 2007. We used these data to produce the different CUSUM curves, focusing on the main variables. To calculate survival, we used the Kaplan-Meier method. RESULTS: In this study, we examined 548 patients. The CUSUM curves were calculated for overall mortality, specific mortality, and recurrence according to (1) the number of lymph nodes analysed and affected and (2) compared the ratio of the number of lymph nodes affected to the number analysed. Finally, the lymph node ratio was compared to the overall survival CUSUM curve. DISCUSSION: This CUSUM control chart analysis reinforces the unquestionable importance of analysing at least 12 lymph nodes in patients with colon cancer in order to accurately estimate their prognosis. However, our findings indicate that the analysis of at least 20 lymph nodes is a more appropriate cutoff point for accomplishing the demanding objective of diagnosing a high-quality prognosis in colon cancer patients.

The lymph node status as a prognostic factor in colon cancer: comparative population study of classifications using the logarithm of the ratio between metastatic and nonmetastatic nodes (LODDS) versus the pN-TNM classification and ganglion ratio systems.

BACKGROUND: pN stage in the TNM classification has been the "gold standard" for lymph node staging of colorectal carcinomas, but this system recommends collecting at least 12 lymph nodes for the staging to be reliable. However, new prognostic staging systems have been devised, such as the ganglion quotients or lymph node ratios and natural logarithms of the lymph node odds methods. The aim of this study was to establish and validate the predictive and prognostic ability of the lymph node ratios and natural logarithms of the lymph node odds staging systems and to compare them to the pN nodal classification of the TNM system in a population sample of patients with colon cancer. METHODS: A multicentric population study between January 2004 and December 2007. The inclusion criteria were that the patients were: diagnosed with colon cancer, undergoing surgery with curative intent, and had a complete anatomopathological report. We excluded patients with cancer of the rectum or caecal appendix with metastases at diagnosis. Survival analysis was performed using the Kaplan-Meier actuarial method and the Log-Rank test was implemented to estimate the differences between groups in terms of overall survival and disease-free survival. Multivariate survival analysis was performed using Cox regression. RESULTS: We analysed 548 patients. For the overall survival, the lymph node ratios and natural logarithms of the lymph node odds curves were easier to discriminate because their separation was clearer and more balanced. For disease-free survival, the discrimination between the pN0 and pN1 groups was poor, but this phenomenon was adequately corrected for the lymph node ratios and natural logarithms of the lymph node odds curves which could be sufficiently discriminated to be able to estimate the survival prognosis. CONCLUSIONS: Lymph node ratios and natural logarithms of the lymph node odds techniques can more precisely differentiate risk subgroups from within the pN groups. Of the three methods tested in this study, the natural logarithms of the lymph node odds was the most accurate for staging non-metastatic colon cancer. Thus helping to more precisely adjust and individualise the indication for adjuvant treatments in these patients.

Rendimiento diagnóstico de la punción aspiración con aguja fina de tejido tiroideo / Diagnostic efficacy of fine needle aspiration of thyroid tissue

Introducción. La punción aspiración con aguja fina (PAAF) de la glándula tiroides constituye un proceso diagnóstico que permite determinar de forma segura y fiable, si un nódulo tiroideo es benigno o maligno. Objetivo. El objetivo del estudio fue evaluar la eficacia diagnóstica de la PAAF en nuestro centro. Material y métodos. Se llevó a cabo de 2009 a 2013 un estudio retrospectivo de pacientes con nódulo tiroideo sospechoso de ser maligno. Las variables del estudio fueron: edad, sexo, tamaño del nódulo tiroideo, realización de PAAF, estudio anatomo-patológico de la biopsia y diagnóstico definitivo. Se comparó el rendimiento diagnóstico de la PAAF frente a los resultados de la biopsia posoperatoria. Resultados. Durante los cinco años del estudio, se practicó PAAF de tejido tiroideo a 112 pacientes (30,2 %, hombres, y 69,8 %, mujeres), con un tamaño medio nodular de 2 cm (rango: 1 a 4). La PAAF fue positiva para neoplasia maligna en 26 casos (23,2 %) y negativa en 86 casos (76,8 %). Los resultados del rendimiento de la prueba fueron: sensibilidad de 45,5 % (intervalo de confianza 95 % [IC95%] 28,1-63,6), especificidad de 86,1 % (IC95% 76,5-92,8), valor predictivo positivo de 57,7 % (IC95% 36,9-76,6) y valor predictivo negativo de 79,1 % (IC95% 69-87,1). Conclusión. Tras este análisis, se obtiene un resultado malo con posibilidad de ser mediocre, por lo que habría que replantearse la utilidad de esta prueba invasiva en nuestro centro y la búsqueda de posibles errores.

Background: Thyroid fine needle aspiration (FNA) is a safe and reliable diagnostic procedure for determining if a thyroid nodule is benign or malignant. Objective: The objective of this study was to evaluate the efficacy of FNA diagnosed in our center. Material and methods: Retrospective study of patients with thyroid nodule suspicious for malignancy, in the period 2009 to 2013. The variables used in this study were: age, sex, size of thyroid nodule, FNA performance, pathology and definitive diagnosis. The diagnostic accuracy of FNA was compared with the results of postoperative biopsy. Results: During the 5-year study, FNA of thyroid tissue was performed at 112 patients (30.2% men and 69.8% women), with nodules of average size of 2 cm (range 1-4). FNA was positive for malignancy in 26 cases (23.2%) and negative in 86 cases (76.8%). The performance results of the test were: sensitivity 45.5% (confidence interval [CI] 95%: 28.1% -63.6%), specificity of 86.1% (95% CI: 76.5 % - 92.8%), positive predictive value of 57.7% (95% CI: 36.9% - 76.6%) and negative predictive value of 79.1% (95% CI: 69% - 87 1%) Conclusion: A bad result with the possibility of being mediocre is obtained with this analysis, which should rethink the usefulness of this invasive test in our center and search for possible errors.

Primary esophageal melanoma: report of a case.

INTRODUCTION: Primary malignant melanoma of the esophagus is a rare tumor representing only 0.1-0.2% of esophageal malignancies. The goal of the study was to report on the management of a new case diagnosed and treated in our site. CASE REPORT: A 67-year-old patient presented with dysphagia to solids with no other remarkable history or associated skin lesions. He underwent gastroscopy, which revealed a polypoid mass suggestive of neoplasm in the distal third of the esophagus. Biopsy indicated melanoma with positive immunohistochemical markers S100 and HMB45, and negative cytokeratins and CEA. Computerized tomography (CT) and positron-emission tomography (PET) scans showed no local infiltration or distant metastases. An Ivor-Lewis esophagectomy procedure was performed with regional lymphadenectomy. Postoperative stay lasted for three weeks, and no remarkable postsurgical complications arose. The pathological study of the specimen confirmed the diagnosis of primary esophageal melanoma. DISCUSSION: Primary malignant melanoma of the esophagus has an unfortunate prognosis as it is an aggressive tumor usually diagnosed at an advanced stage, with local invasion and metastatic disease. Currently, surgery is the treatment of choice, with the remaining adjuvant therapies obtaining limited results.

[Local recurrence based on size after conservative surgery in breast cancer stage T1-T2. A population-based study]. / Relación del tamaño tumoral con la recidiva tras cirugía conservadora en el cáncer de mama en estadio tumoral T1-T2. Estudio poblacional.

BACKGROUND: Conservative surgery can be regarded as the standard treatment for most early stage breast tumors. However, a minority of patients treated with conservative surgery will present local or locoregional recurrence. Therefore, it is of interest to evaluate the possible factors associated with this recurrence. METHODS: A population-based retrospective study using data from the Tumor Registry of Castellón (Valencia, Spain) of patients operated on for primary nonmetastatic breast cancer between January 2000 and December 2008 was designed. Kaplan-Meier curves and log-rank test to estimate 5-year local recurrence were used. Two groups of patients were defined, one with conservative surgery and another with nonconservative surgery. Cox multivariate analysis was conducted. RESULTS: The total number of patients was 410. Average local recurrence was 6.8%. In univariate analysis, only tumor size and lymph node involvement showed significant differences. On multivariate analysis, independent prognostic factors were conservative surgery (hazard ratio [HR] 4.62; 95% confidence interval [CI]: 1.12-16.82), number of positive lymph nodes (HR 1.07; 95% CI: 1.01-1.17) and tumor size (in mm) (HR 1.02; 95% CI: 1.01-1.06). CONCLUSIONS: Local recurrence after breast-conserving surgery is higher in tumors >2 cm. Although tumor size should not be a contraindication for conservative surgery, it should be a risk factor to be considered.

Antecedentes: la cirugía conservadora es un patrón de referencia del tratamiento de la mayor parte de los tumores mamarios en estadios iniciales. Sin embargo, una minoría de pacientes intervenidas con esta opción tendrá recurrencia local o locorregional. Por ello resulta de interés evaluar los posibles factores relacionados con esta recurrencia. Material y métodos: estudio retrospectivo, con base poblacional, efectuado con base en los datos del Registro de Tumores de Castellón (Comunidad Valenciana, España) de pacientes intervenidas de cáncer primario de mama no metastático de enero de 2000 a diciembre de 2008. Se utilizaron las curvas de Kaplan-Meier y la prueba de log-rank para estimar la recurrencia local a cinco años. Se definieron dos grupos de pacientes, uno con cirugía conservadora y otro con cirugía no conservadora de la mama. Se realizó un estudio multivariado de Cox. Resultados: se encontraron 410 pacientes con promedio de 6.8% de recurrencias locales. En el análisis univariado sólo el tamaño tumoral y la afectación ganglionar demostraron diferencias significativas. En el análisis multivariado los factores pronóstico independientes fueron: la cirugía conservadora (Hazard ratio [HR] 4.62; IC [intervalo de confianza] 95% 1.12-16.82), el número de ganglios linfáticos positivos (HR 1.07; IC 95% 1.01-1.17) y el tamaño del tumor en milímetros (HR 1.02; IC 95% 1.01-1.06). Conclusiones: la recurrencia local postcirugía conservadora de mama es mayor en tumores de más de 2 cm. Aunque el tamaño del tumor no debería ser una contraindicación para esta cirugía sí deben tomarse en cuenta como un factor de riesgo.

[Diagnostic yield of pancreatic percutaneous puncture depending on the size of the lesion]. / Rentabilidad diagnóstica de la punción percutánea pancreática en función del tamaño de la lesión.

INTRODUCTION: The aim of the present study was to study the diagnostic efficacy of the percutaneous puncture of pancreatic tissue. MATERIAL AND METHODS: A retrospective study was conducted on patients with suspicion of pancreatic neoplasm, and with a percutaneous biopsy of pancreatic tissue, from 2000 to 2011. For the statistical comparative analysis, the sample was stratified by tumour size: ≤ 3cm and > 3cm. RESULTS: A total of 90 biopsies were performed. Pancreatic neoplasm diagnosis was made in 47 cases (52%), with 16 false negatives (18%), no false positives, and chronic pancreatitis in 24 cases (27%). The efficacy of the test results were: an overall sensitivity of 75% (95% CI: 62%-85%), a specificity of 100% (95% CI: 87%-100%), a positive predictive value of 100% (95% CI: 92%-100%), and a negative predictive value of 63% (95% CI: 46%-77%). For tumour sizes ≤ 3cm the sensitivity was 70% (95% CI: 45%-88%), with a specificity of 100% (95% CI 66%-100%), a positive predictive value of 100% (95% CI: 76%-100%, and a negative predictive value 60% (95% CI: 32%-83%). For tumours greater than 3cm, the sensitivity was 88% (95% CI: 70%-98%), the specificity was 100% (95% CI: 75%-100%), with a positive predictive value of 100% (95% CI: 85%-100%) and a negative predictive value of 81% (95% CI: 54%-96%). CONCLUSIONS: Pancreatic percutaneous biopsy efficacy was strongly determined by lesion size. For tumour sizes less than 3cm, the sensitivity and negative predictive value are unacceptably low, as negative results would not reliable.