Risk-adjusted treatment selection and outcome of patients with acute cholecystitis.

PURPOSE: Age and comorbidities increase the surgical risk for patients with acute cholecystitis and impact on the initial treatment selection. The aim of this article is the implementation of objective risk criteria that may be used to select the most appropriate treatment. METHODS: We carried out a prospective cohort study of all patients who were admitted to the hospital with a diagnosis of acute cholecystitis during 2014. They were initially allocated to three different treatment groups according to cholecystitis grade, number of days from clinical onset, and surgical risk scores as follows: immediate surgery by sepsis (EmergS), early surgery (EarlyS), or medical treatment group (MedT). Differences in the outcomes between the treatment groups were evaluated using bivariate and logistic regression analyses. RESULTS: A total of 149 patients were admitted; 44 % were >80 years old and 40 % were American Society of Anesthesiologists (ASA) > II. The mortality rate of the series was 0 % in EarlyS, 17 % in MedT, and 19 % in EmergS. The mortality rate was significantly associated with a higher degree of cholecystitis, age, and worse score values in risk scales and Charlson index. Logistic regression identified that the only independent predictors of death at the time of admission were the degree of cholecystitis (OR 2.87, p = 0.018) and the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) score (OR 1.14, p = 0.001). CONCLUSION: The evaluation for the initial treatment in acute cholecystitis should include a systematic determination of the degree of cholecystitis and a surgical risk assessment. Tokyo guideline recommendations should be reviewed.

[Surgical treatment of sternoclavicular osteomyelitis]. / Tratamiento quirúrgico de la osteomielitis esternoclavicular.

Osteomyelitis of the sternocosto-clavicular (SCC) articulation is a rare infection usually caused by Staphylococcus aureus and enterobacteria. It usually occurs in individuals with osteoarticular disease or predisposing factors. Prolonged antibiotic treatment and articular puncture are generally accepted. Authors do not agree on an established protocol. We report three cases of SCC septic arthritis in two previously healthy patients with two foci of infection (one perianal abscess and one dental extraction) and in one adult patient with Still's disease. Pain and intense inflammation was referred to the shoulder, with scarce leukocytosis and fever reaching 38 degrees C. The germs responsible were S. aureus, Bacteroides fragilis and B. oralis. Two of the patients had local, regional abscesses. Long-term antibiotic treatment failed in all cases and surgery for SCC resection and myoplasty of the pectoralis major muscle was required. Recovery was good and shoulder and arm mobility was excellent. We propose medical treatment and articular diagnostic-therapeutic puncture as the first line of therapy for this disease. When evolution is poor or when complications appear, such as abscesses or mediastinitis, we conclude that radical debridement and myoplasty of the pectoralis major muscle are indicated.

[Thoracic reconstruction with polytetrafluoroethylene prosthesis]. / Reconstrucción torácica con prótesis de politetrafluoroetileno.

Thoracic wall resections are performed to treat a wide variety of conditions. Reconstruction techniques have varied considerably since the introduction of synthetic prosthesis, the most recent of which are made of polytetrafluoroethylene (PTFE, or Gore-Tex). We describe our department's experience with PTFE prosthesis. PTFE was used in 21 patients treated for various diseases. Thirteen reconstructions were of the thoracic wall, 4 were of the diaphragm and 4 of the pericardium. Three of the 13 thoracic wall reconstructions involved bilateral myoplasty of the pectoralis major, 2 involved omentoplasty and 1 required use of a wide musculocutaneous flap. Complications included pneumonia in 2 cases and 1 seroma with chronic cutaneous fistula that required removal of the prosthesis after 9 months. Two patients died, 1 after 19 days and the other after 9 months, both as a result of causes unrelated to reconstruction. Follow-up of these patients ranged from 3 to 54 months. We recommend the prosthetic use of PTFE for thoracic wall reconstruction, along with plasty or musculocutaneous flaps when necessary.

Tumores gástricos estromales: factores pronósticos y tratamiento quirúrgico / Gastric stromal tumors: prognostic factors and surgical treatment

Introducción. Los criterios para determinar el grado de malignidad de los tumores gástricos estromales no están claramente definidos, por lo que el tratamiento quirúrgico de estas lesiones es controvertido. Métodos. Se han estudiado las características clínicas, morfológicas y quirúrgicas de 49 pacientes diagnosticados de tumor gástrico estromal entre 1968 y 1999. Se han analizado las tablas de frecuencias y se ha llevado a cabo un estudio de supervivencia. Resultados. Se han hallado 29 tumores malignos, mientras que el resto eran benignos. Los síntomas más frecuentes consistieron en un síndrome constitucional, hemorragia digestiva alta y masa abdominal en el 20 por ciento de los casos. El análisis de la supervivencia demostró que la presencia de masa abdominal, el tamaño tumoral mayor de 10 cm y la necrosis tumoral son indicadores de mal pronóstico, mientras que la presencia de ulceración indica buen pronóstico. Un índice mitótico elevado (> 10) y una resección quirúrgica amplia no tienen impacto en la supervivencia de estos pacientes. Conclusiones. Recomendamos una resección completa pero limitada de estos tumores dada la menor complejidad técnica, la menor morbilidad y el idéntico pronóstico que los asociados con resecciones más amplias (AU)