Type II intrapancreatic choledochal malignant cyst in adults: duodenopancreatectomy.

A 62-year-old female patient was admitted for abdominal pain and vomiting. Imaging tests revealed a solid-cystic lesion at the head of the pancreas communicating with the distal bile duct. A Todani type II choledochal cyst was diagnosed with neoplastic degeneration after cytological diagnosis with endoscopic ultrasound-guided puncture. The patient was treated with a cephalic duodenopancreatectomy with curative intention.

[Chondrosarcomatous metaplastic carcinoma of the breast, a rare tumor]. / Carcinoma metaplásico condrosarcomatoide de mama, una entidad inusual.

Metaplastic carcinomas of the breast are uncommon, accounting for less than 0.2% of all breast cancers. Clinically and radiologically, metaplastic carcinomas are indistinguishable from typical ductal carcinomas, and the diagnosis is made histologically by the finding of a mesenchymal component. We present a case of chondrosarcomatous metaplastic breast carcinoma whose definitive diagnosis required immunohistochemical techniques to confirm the malignant epithelial component of the tumor. Accurate diagnosis is important because this tumor behaves differently: it usually spreads through the blood (whereas typical epithelial carcinomas spread through the lymph vessels), metastases present during follow-up rather than before diagnosis, and the five-year survival rate is 35%.

Bundles reduce anastomosis leak in patients undergoing elective colorectal surgery. A propensity score-matched study.

Background: anastomosis leak still being a handicap in colorectal surgery. Bowel mechanical preparation and oral antibiotics are not a practice recommended in many clinical practice guides. The aim is to analyse the decrease in frequency and severity of postoperative complications, mainly related to anastomotic leak, after the establishment of a bundle. Methods: Single-center, before-after study. A bundle was implemented to reduce anastomotic leaks and their consequences. The Bundle group were matched to Pre-bundle group by propensity score matching. Mechanical bowel preparation, oral and intravenous antibiotics, inflammatory markers measure and early diagnosis algorithm were included at the bundle. Results: The bundle group shown fewer complications, especially in Clavien Dindós Grade IV complications (2.3% vs. 6.2% p < 0.01), as well as a lower rate of anastomotic leakage (15.5% vs. 2.2% p < 0.01). A significant decrease in reinterventions, less intensive unit care admissions, a shorter hospital stay and fewer readmissions were also observed. In multivariate analysis, the application of a bundle was an anastomotic leakage protective factor (OR 0.121, p > 0.05). Conclusions: The implementation of our bundle in colorectal surgery which include oral antibiotics, mechanical bowel preparation and inflammatory markers, significantly reduces morbidity adjusted to severity of complications, the anastomotic leakage rate, hospital stay and readmissions. Register study: The study has been registered at clinicaltrials.gov Code: nct04632446.

Gastrojejunal anastomosis stricture after laparoscopic gastric bypass. Our experience with 62 patients.

OBJECTIVE: Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass (LGBP), but its frequency is about 15% according to bibliography. Our aim is to present our experience after 62 LGBP. PATIENTS AND METHOD: From January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass (Wittgrove's technique). The gastrojejunal anastomosis is performed with auto suture material type CEAA No 21 termino-lateral (ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy, perform the anastomosis in the same way. Monitoring has a range of 3-35 months, conducted in 61 patients because one patient died of pulmonary thromboembolism in the immediate postoperative period after reoperation, after two weeks of gastric bypass, by necrosis of a small fragment of the remnant gastric. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation (recommending dilate the anastomosis to a maximum 1.5 cm). RESULTS: Five cases (8.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and in 1 case by endoscopy. Two patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion (circumferentially sclerosis within 48 hours of surgery and sclerosis of bleeding points). All cases were resolved by endoscopic dilatation. At follow-up has not been detected re-stricture. CONCLUSION: Clinically, gastrojejunal stricture results in a progressive oral intolerance, revealing stenosis between 1 and 3 months postoperatively. The situations of sclerosis of the bleeding lesions favor, especially in cases of extensive sclerosis. In cases of suspected barium transit offers us a high diagnostic yield. Endoscopic dilatation resolved, so far, all cases.

Adult intussusception - 14 case reports and their outcomes.

AIMS: To analyze diagnostic and therapeutic options depending on the clinical symptoms, location, and lesions associated with intussusception, together with their follow-up and complications. PATIENTS AND METHODS: Patients admitted to the Morales Meseguer General University Hospital (Murcia) between January 1995 and January 2009, and diagnosed with intestinal invagination. Data related to demographic and clinical features, complementary explorations, presumptive diagnosis, treatment, follow-up, and complications were collected. RESULTS: There were 14 patients (7 males and 7 females; mean age: 41.9 years-range: 17-77) who presented with abdominal pain. The most reliable diagnostic technique was computed tomography (8 diagnoses from 10 CT scans). A preoperative diagnosis was established in 12 cases. Invaginations were ileocolic in 8 cases (the most common), enteric in 5, and colocolic in 2 (coexistence of 2 lesions in one patient). The etiology of these intussusceptions was idiopathic or secondary to a lesion acting as the lead point for invagination. Depending on the nature of this lead point, the cause of the enteric intussusceptions was benign in 3 cases and malignant in 2. Ileocolic invaginations were divided equally (4 benign and 4 malignant), and colocolic lesions were benign (2 cases). Conservative treatment was implemented for 4 patients and surgery for 10 (7 in emergency). Five right hemicolectomies, 3 small-bowel resections, 2 left hemicolectomies, and 1 ileocecal resection were performed. Surgical complications: 3 minor and 1 major (with malignant etiology and subsequent death). The lesion disappeared after 3 days to 6 weeks in patients with conservative management. Mean follow-up was 28.25 months (range: 5-72 months). CONCLUSIONS: A suitable imaging technique, preferably CT, is important for the diagnosis of intussusception. Surgery is usually necessary but we favor conservative treatment in selected cases.

Monitoring intraoperative neuromuscular blockade and blood pressure with one device (TOF-Cuff): A comparative study with mechanomyography and invasive blood pressure. / Monitorización intraoperatoria del bloqueo neuromuscular y la presión arterial con un solo dispositivo (TOF-Cuff): estudio comparativo con la mecanomiografía y la presión arterial invasiva.

OBJECTIVE: The overall objective of the study is to determine the ability of TOF-Cuff device (blood-pressure modified cuff, including stimulation electrodes) to monitor with the same device the non-invasive blood pressure (NIBP) and the depth of a neuromuscular blockade (NMB) induced pharmacologically, by stimulation of the brachial plexus at the humeral level and recording evoked changes in arterial pressure. MATERIAL AND METHOD: Clinical, single-centre, open-controlled study with 32 adult patients ASA I-III for scheduled elective surgery under general anaesthesia in supine position, for the validation of neuromuscular monitoring, comparing the values obtained from neuromuscular relaxation TOF-Cuff with those obtained by mechanomyography (MMG) (control method) during the recovery phase of NMB, when a TOF ratio>0.7 and>0.9 (primary endpoint) were reached respectively. And an additional consecutive study of 17 patients for validation of NIBP monitoring with TOF-Cuff device vs invasive blood pressure measured by an intra-arterial catheter. All data were analyzed using the Bland-Altman method. RESULTS: Recovery from NMB measured with the TOF-Cuff was earlier compared to MMG. Comparing TOF-ratio>0.9 measured with TOF-Cuff vs TOF-ratio>0.7 with MMG, a specificity of 91% and a positive predictive value of 84% were obtained. In NIBP measurement, the mean error and standard deviation of both systolic blood pressure (1.6±7mmHg) and diastolic blood pressure (-3.4±6.3) were within the European accuracy requirements for medical devices. CONCLUSIONS: The TOF-Cuff device has been shown to be valid and safe in the monitoring of NMB and in the measurement of NIBP, with no patient presenting any adverse events, skin-level lesions or residual pain. It is not interchangeable with MMG, having a TOF-ratio>0.9 quantified by the TOF-Cuff device, a good correlation with a TOF-ratio>0.7 on MMG.

Open vs laparoscopic repair of secondary lumbar hernias: a prospective nonrandomized study.

BACKGROUND: Lumbar hernias are uncommon defects of the posterior abdominal wall. Surgical treatment is still controversial in these cases. The aim of this study was to compare outcome and costs of the laparoscopic approach vs the open method. METHODS: We conducted a prospective nonrandomized study of 16 patients who underwent operation for secondary lumbar hernia between January 1997 and January 2003. Nine were treated via the laparoscopic approach and seven with an open technique. The following variables were analyzed: clinical data, hospital data (operating time and length of stay), patient comfort (consumption of analgesics and time to return to normal activities), and recurrences. Hospital costs were also analyzed. RESULTS: There were no differences between the two groups in terms of age and history, although the defects of the patients in the laparoscopic group were smaller. Mean operating time, postoperative morbidity, mean hospital stay, consumption of analgesics, and time to return to normal activities were significantly lower in the laparoscopic group (p < 0. 01). No were there any statistical differences between the two types of surgical procedure in terms of hospital costs. However, the final cost did show differences when expenses for readmissions and recurrences were taken into account (p < 0.01). CONCLUSION: The laparoscopic approach to secondary lumbar hernia repair is more efficient and more profitable than the traditional open technique.

[Spontaneous pneumomediastinum: descriptive study of our experience with 36 cases]. / Neumomediastino espontáneo: estudio descriptivo de nuestra experiencia basada en 36 casos.

Spontaneous pneumomediastinum is defined as a primary process characterized by the presence of air or gas in the mediastinum. We report all the cases of spontaneous pneumomediastinum diagnosed in our hospital between January 1996 and December 2004. We developed a protocol for data collection that included the following: medical history, triggers, signs, radiology, treatment, hospital stay, and complications. During this period we diagnosed 36 cases--25 men (69.4%) and 11 women (27.5%)--with a mean age of 36.8 years (range, 11-90 years) and a mean hospital stay of 8.56 days (range, 1-53 days). The most common clinical presentation was chest pain, either isolated (27%) or with associated dyspnea (19.4%). A triggering factor was identified for 14 patients (38.8%). There was no associated morbidity or mortality. In view of our findings, we concluded that spontaneous pneumomediastinum is an uncommon entity with considerable clinical variability and that correct diagnosis requires a high level of suspicion. Radiography provides the best evidence for diagnosis.

[Computed tomographic colonography: applications, advantages and disadvantages]. / Colonografía tomográfica computarizada: aplicaciones, ventajas e inconvenientes.

INTRODUCTION: Complete preoperative study of the colon is required in the management of colorectal cancer, due to the frequent association of primary colonic neoplasms with colonic adenomas (28%) and/or synchronous carcinomas (5%) of the colon. We present a series of patients who underwent computed tomographic colonography, the indications for this procedure, and the results. PATIENTS AND METHODS: We performed a descriptive prospective study. Between May 2003 and August 2004, 50 computed tomographic colonographies were performed in 50 patients with suspected stenosing colorectal cancer and incomplete conventional colonoscopy. RESULTS: Fifty computed tomographic colonographies were performed. The findings were as follows: three were normal (6%), and in the remainder, one was a false positive for a suspected neoplastic pelvic mass (3.125%) and two were false positives (11.7%) for colonic polyps. Fifty percent of the findings (n = 32) were related to peritoneal metastases and colonic neoplasms. There were 12 technical complications [lack of cleaning of the colon (5), lack of distension (2), little air insufflation (5)]. Patient complications included vegetative manifestations in one (vomiting) and rectal bleeding in another. The overall complication rate was 27.4% (23.4% corresponded to technical complications and the remaining 4% were patient-related). There was no mortality related to the procedure. CONCLUSION: Because computed tomographic colonography is safe, effective and well tolerated by the patient, it should be considered as a technical alternative in the study of stenosing neoplasms of the proximal colon with incomplete colonoscopy. In addition, it allows other associated findings, both intra- and extracolonic, to be obtained and improves the diagnostic and therapeutic management of the patient.

Prognostic factors of thymomas.

Thymomas are uncommon tumours. This study analyses the prognostic value of certain clinical variables and of two different histological classifications. Thirty cases were analysed; 24 were women and six men, with a mean age of 50 years (range 22-69). The pre-operative study included: clinical data (Masaoka's and Osserman's clinical classification); chest radiography; and computed axial tomography. Surgery was divided into three categories: total tumour resection, partial resection and biopsy alone. For the pathological study we followed Salyer-Eggleston and Marino-Müller classifications. Follow-up averaged 5.5 years (range: 2-11). As a statistical method we used Kaplan-Meier's survival curves and Cox's regression model. Eleven of the patients had associated myasthenia gravis, this being the most common clinical type. Age, sex, association with myasthenia gravis, surgical technique and Salyer-Eggleston's classification showed no prognostic value; conversely, clinical staging and Marino-Müller's classification had a high prognostic value. The first treatment that should be considered is surgery, with an attempt to perform total tumour resection. Myasthenia gravis did not modify the prognosis of the disease. The factors of greatest prognostic significance were clinical staging and Marino-Müller's histological classification.

[The surgical treatment of the short bowel syndrome by creating reservoir pouches. An experimental study on rats]. / Tratamiento quirúrgico del síndrome de intestino corto mediante la construcción de bolsas frenadoras. Estudio experimental en ratas.

Intestinal pouches are one of the techniques for the surgical treatment of the short bowel syndrome. In a experimental study with rats, the influence of the intestinal pouches in a model of 85-90% small bowel resection are investigated. The pouches improve the transit time of the resected animal. However, there is no improvement in the weight curves after extensive small bowel resection. This negative effect is due to the establishment of a blind loop syndrome at the level of the pouch. The intestinal pouches have no place in the surgical treatment of the short bowel syndrome.

[Quantification of gastro-esophageal reflux in Barrett's esophagus]. / Cuantificación del reflujo gastro-esofágico en el esófago de Barrett.

In the present paper we analyze the importance of gastro-oesophageal reflux in 20 patients with Barrett's oesophagus and in 20 patients with esophagitis without Barrett's mucosa; ten of this last group had mild esophagitis and ten severe inflammatory changes. In all the cases the oesophageal pH was measured during 24 hours; the results showed that although the reflux was more important in the group of patients with Barrett's esophagus than in the whole group of patients with esophagitis without Barrett's esophagus, figures were similar in the group with severe oesophagitis and the group with Barrett's oesophagus. We conclude that the pathogenesis of Barrett's esophagus includes factors other than gastroesophageal reflux.