Classification of GIST and other benign gastric tumors based on minimally invasive surgical strategy.

PURPOSE: Gastrointestinal mesenchymal tumors (GMTs) include malignant, intermediate malignancy, and benign lesions. The aim is to propose a new surgical classification to guide the intraoperative minimally invasive surgical strategy in case of non-malignant GMTs less than 5 cm. METHODS: Primary endpoint is the creation of a classification regarding minimally invasive surgical technique for these tumors based on their gastric location. Secondary endpoint is to analyze the R0 rate and the postoperative morbidity and mortality rates. Tumors were classified in two groups based on their morphology (group A: exophytic, group B: transmural/intragastric). Each group is then divided based on the tumor location and consequently surgical technique used in subgroup: AI (whole stomach area) and AII (iuxta-cardial and pre-pyloric areas) both for the anterior and posterior gastric wall; BIa (greater curvature on the anterior and posterior wall), BIb (lesser curvature on the anterior wall); BII (iuxta-cardial and pre-pyloric area in the anterior and posterior wall, including the lesser curvature on the posterior wall). RESULTS: Forty-two patients were classified and allocated in each subgroup: 17 in AI, 2 in AII, 5 in BIa, 3 in BIb, and 15 in BII. Two postoperative Clavien-Dindo I complications (4.8%, subgroup BIa and BIb) occurred. One patient (2.4%, subgroup AI) underwent reintervention due to R0 resection. CONCLUSIONS: This classification proved to be able to classify gastric lesions based on their morphology, location, and surgical treatment, obtaining encouraging perioperative results. Further studies with wider sample of patients are required to draw definitive conclusions.

Influence of fibrin sealant in preventing postoperative seroma and normalizing the abdominal wall after laparoscopic repair of ventral hernia.

BACKGROUND: Seroma after laparoscopic ventral hernia repair (LVHR) has been related to certain complications of the technique, such as recurrences and postoperative pain. The aim of this study was to assess whether percutaneous application of fibrin sealant in the hernia sac after LVHR reduces the incidence and volume of the postoperative seroma, and to analyze whether the percentage of patients achieving complete normalization of the abdominal wall increases. METHODS: Prospective and comparative study. Patients were distributed into 2 control-case groups. Group 1 comprised patients submitted to LVHR using the double crown technique and a compressing bandage as the only method for prevent seroma. Group 2 comprised patients admitted to LVHR using the same technique together with percutaneous injection of fibrin sealant in the sac, and later applying the same bandage. Patients were examined clinically and radiologically at 7 days, 1 month, and 3 months after surgery. RESULTS: Twenty-five patients were included in each group. There were significant differences in the incidence of seroma by the day 7 after surgery (92% in group 1 vs. 64 % in group 2, p = 0.017) and by 1 month (72% in group 1 vs. 28% in group 2, p = 0.002). The difference was also significant regarding the achievement of normalization of the abdominal wall by day 7 (24% in group 1 vs. 52% in group 2, p = 0.041) and by month 1 (64% in group 1 vs. 88% in group 2, p = 0.047) after operation. Volume of seroma was larger among patients of group 1 after the week (p = 0.002) and 1 month after operation (p = 0.001). CONCLUSIONS: Fibrin sealant application after LVHR reduces the incidence and volume of the seroma 7 days and 1 month after surgery. The treated patients obtain a larger normalization of the abdominal wall 1 week and 1 month after the operation.

Single-port Roux-en-Y gastric bypass: toward a less invasive procedure with the same surgical results and a better cosmesis.

BACKGROUND: The current tendency to use increasingly less aggressive procedures has facilitated the development of new minimally invasive techniques. In this context, single-port (SP) access procedures can become an alternative to the conventional laparoscopic approach. METHODS: A total of 22 morbidly obese patients were submitted to pure SP Roux-en-Y gastric bypass without additional ports. Selection for this approach was based on distance from the xiphoid to the umbilicus less than 28 cm, body mass index (BMI) lower than 50 kg/m(2), and preferably peripheral obesity. Access to the cavity was obtained through a single transverse, transumbilical incision, with placement of a SILS Port device. RESULTS: The mean age of the patients was 41 ± 8.98 years, and 95 % of the patients were women. The mean BMI of the series was 42.68 ± 2.28 kg/m(2), and the mean body weight was 111.34 ± 10.66 kg. Surgery was performed successfully in all cases through a transumbilical incision with a mean length of 26.68 ± 5.27 mm. The mean surgical time was 114.05 ± 21 min, and the mean hospital stay was 3.27 ± 1.01 days. No intraoperative or immediate postoperative deaths or complications occurred. The median postoperative BMI during a mean follow-up period of 12 months was 28 kg/m(2) (range, 18-35 kg/m(2)). The median weight loss was 39 kg, and the percentage loss of excess body weight was 86 %. In relation to improvement of the comorbidities, two of the three patients with arterial hypertension showed normalization of their blood pressure values. Likewise, the blood glucose levels were corrected in two of the three diabetic patients, as well as in the patient with altered fasting blood glucose. CONCLUSIONS: Single-port Roux-en-Y gastric bypass surgery seems to be a safe, viable, and reproducible technique, but randomized studies involving larger patient series and longer follow-up periods are needed to compare the SP access and the multiple-port laparoscopic approach.

Magnetic-assisted single-port sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy is a recent, purely restrictive procedure in bariatric surgery that has shown results similar to gastric bypass over the short and middle term. At the same time, single-port access surgery has fostered the development of new techniques and methods seeking better cosmetic results and less postoperative pain, while maintaining the satisfactory results obtained by the standard laparoscopic approach. One of the problems associated to single-access surgery is the lack of traction and the difficulties to retract the liver. The authors' aim was to try to avoid additional trocars or sutures in order to perform pure single-incision surgery, using 2 magnetic forceps. METHODS: The authors present the case of a 51-year-old morbidly obese female (body mass index = 44.82) who underwent a pure single-access laparoscopic sleeve gastrectomy with no additional trocars or sutures and assisted by 2 neodymium magnetic forceps: one to retract the liver and the other to retract the stomach in order to provide sufficient triangulation for adequate exposure of the surgical field during dissection. RESULTS: The procedure was completed in 120 minutes. No preoperative or postoperative complications were recorded, and the patient was discharged 2 days after surgery. CONCLUSION: Single-port access sleeve gastrectomy assisted by magnetic forceps is feasible and safe in the hands of experienced laparoscopic surgeons, solving one of the problems associated to this type of surgery, that is, the need for an additional trocar and needles or sutures to retract the liver and stomach in order to perform the operation.

Gastrostomies: experience and complications with three modalities in a tertiary centre over a 26-year period.

Objectives: To describe the complications associated with the different gastrostomy techniques [endoscopic (PEG), radiologic (PRG), and surgical (SG)] performed in the last 26 years in a terciary hospital. Methods: Retrospective observational study. Patients who underwent gastrostomy at the Virgen del Rocío University Hospital between 1995 and 2021 were included. For PEG, the PULL technique was performed until 2018 and subsequently the PUSH technique predominantly. For PRG, a pigtail catheter was used until 2003, a balloon catheter between 2003 and 2009, and a balloon catheter with gastropexy between 2015 and 2021. For SG, the conventional technique (CSG) was performed until 2009 and since then the laparoscopic assisted percutaneous gastrostomy (PLAG) technique. Descriptive analysis was performed obtaining the median and quartiles of the quantitative variables [P50 (P25-P75)] and the frequency for the qualitative variables [n (%)].The comparison of complications between patients who underwent different techniques was performed with Fisher's test. Results: n = 1,070 (PEG = 608, PRG = 344, SG = 118). The three most frequent indications were head and neck tumors, neurological diseases and gastroesophageal tumors. The percentage of patients who had any complication was 48.9% (PEG-PULL), 23.7% (PEG-PUSH), 38.5% (pigtail PRG), 39.2% (balloon PRG), 29.7% (balloon with gastropexy PRG), 87.3% (CSG), and 41.26% (PLAG). 2 (0.18%) patients died from gastrostomy-related complications. 18(1.68%) presented with peritonitis and 5 (0.4%) presented with gastrocolic fistula. The rest of the complications were minor. Conclusion: Gastrostomy in any of its modalities is currently a safe procedure with a low rate of complications, most of which are minor.

Endoscopic surgeons' preferences for inguinal hernia repair: TEP, TAPP, or OPEN.

INTRODUCTION: The use of endoscopic inguinal hernia repair has slowly increased in the past years, but the indications have remained vague. Some surgeons perform a tailored approach depending on patient or hernia characteristics, whereas others perform the same approach and technique for all hernias. METHODS: Based on these principles, a survey of 19 questions was conducted during the 18th Congress of the European Association of Endoscopic Surgeons, which took place in Geneva, Switzerland, in 2010, to determine surgeons' preference depending on the hernia and the patient. RESULTS: All surgeons who attended the session (N = 100) responded to all questions. Eighty two percent of surgeons preferred a tailored approach, whereas 18 % used the same technique in all cases. Endoscopic techniques are used more frequently than the open approach in bilateral (7 vs. 93 %) and recurrent hernias (19 vs. 81 %), whereas in primary unilateral hernias all three techniques were used with almost similar frequency (32 % open, 39 % TAPP vs. 29 % TEP). TAPP was used more frequently than TEP, and even those surgeons who are expert in TEP preferred to perform a TAPP in difficult hernias, such as in obese patients and large scrotal hernias. Based on the age of patients, the open approach is preferred in patients younger than 18 years and older than 70 years, whereas the endoscopic approach is preferred in young active males and females, with a trend to use TAPP (44 %) more frequently than TEP (40 %) in females. Surgeons tended to use the open (vs. endoscopic) approach in patients with hematologic disorders (58 % open vs. 42 % endoscopic), previous laparotomy (59 % open vs. 41 % endoscopic) or emergency surgery (66 vs. 33 % in incarcerated hernias and 74 vs. 26 % in strangulated hernia). CONCLUSIONS: This survey showed that most surgeons who perform an endoscopic approach for inguinal hernia as the first option are convinced that not all hernias are good indications for this approach. On the other hand, most surgeons think that it is better to be able to offer patients an endoscopic technique or an open approach depending on the case.

Infectious Endocarditis Caused by Pseudomona aeruginosa on Bicuspid Aortic Valve.

We report the case of a 53-year-old man with psoriatic arthritis, suffering from a malignant and recidivant myoepithelioma in his right axilla and arm, and undergoing two surgeries, with the last one being performed a month prior to actual admission. After the last surgery, he was admitted to hospital with fever without a source. After physical examination, laboratory tests, blood cultures and transthoracic and transesophageal echocardiography, he was diagnosed with infectious endocarditis (IE) on a bicuspid aortic valve (BAV) caused by Pseudomona aeruginosa (PA). Antibiogram-guided antibiotic therapy with meropenem and tobramicin was initiated. However, in the presence of repetitive spleen infarctions and a large vegetation, 12 days after admission, a bioprosthesis aortic valve implantation was performed. The postsurgical evolution was favorable and prolonged antibiotic course with meropenem and tobramicin was completed. The pathological anatomy and the native valve cultured confirmed an IE caused by PA. Gram-negative non-HACEK IE cases are infrequent, accounting for 1.8% of the total IE cases. PA is the second most frequent bacillus in this group, causing endocarditis more prevalently when associated with healthcare procedures rather than injectable drug use. No prior case study has identified IE caused by PA related to a BAV in the last years.

Brief Report: Patients' Experiences and Opinions After Desimplification of Their Single-Tablet Regimens for the Treatment of HIV Infection: A Survey in a Multicentre Cohort.

OBJECTIVES: The aims of this study were to describe patients' experiences after single-tablet regimen (STR) desimplification and its impact on self-reported treatment adherence and quality of life. METHODS: We performed a survey among all patients from the multicenter cohort of the Spanish HIV/AIDS Network who had desimplified the STRs dolutegravir/abacavir/lamivudine (DGT/ABC/3TC) or rilpivirine/tenofovir disoproxil fumarate/emtricitabine to their separate components (DTG + generic ABC/3TC or RPV + generic TDF/FTC) between December 2016 and November 2018. RESULTS: Among 216 patients who fulfilled inclusion criteria, 138 (63.9%) completed the questionnaire. Most of the patients (78.3%) knew what generic drugs are, only 8.7% believed that treatment with 2 pills is less effective than treatment with an STR, and 67.4% agreed that it is reasonable to take 2 pills instead of 1 for HIV treatment to decrease costs for the health care system. After desimplification, 13.0% of the patients stated they had more secondary effects, 8.0% had forgotten one or more doses more frequently than before, and 10.9% had sometimes forgotten to take 1 pill, but not the other. A proportion of 30.4% reported not being happy to take more pills a day, and 10.1% experienced a worse quality of life after the treatment desimplification. CONCLUSIONS: After STR desimplification, most of the patients had a fair knowledge about generic antiretrovirals, and they agreed to desimplify their STR to decrease costs. Although almost a third of the respondents were not happy to take 2 pills a day, only a minority reported worse adherence or quality of life.

Bartonella Endocarditis in Spain: Case Reports of 21 Cases.

Blood culture negative endocarditis (BCNE) is frequent in infective endocarditis (IE). One of the causes of BCNE is fastidious microorganisms, such as Bartonella spp. The aim of this study was to describe the epidemiologic, clinical characteristics, management and outcomes of patients with Bartonella IE from the "Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España (GAMES)"cohort. Here we presented 21 cases of Bartonella IE. This represents 0.3% of a total of 5590 cases and 2% of the BCNE from the GAMES cohort. 62% were due to Bartonella henselae and 38% to Bartonella quintana. Cardiac failure was the main presenting form (61.5% in B. hensalae, 87.5% in B. quintana IE) and the aortic valve was affected in 85% of the cases (76% in B. henselae, 100% in B. quintana IE). Typical signs such as fever were recorded in less than 40% of patients. Echocardiography showed vegetations in 92% and 100% of the patients with B. henselae and B. quintana, respectively. Culture was positive only in one patient and the remaining were diagnosed by serology and PCR. PCR was the most useful tool allowing for diagnosis in 16 patients (100% of the studied valves). Serology, at titers recommended by guidelines, only coincided with PCR in 52.4%. Antimicrobial therapy, in different combinations, was used in all cases. Surgery was performed in 76% of the patients. No in-hospital mortality was observed. One-year mortality was 9.4%. This article remarks the importance for investigating the presence of Bartonella infection as causative agent in all BCNE since the diagnosis needs specific microbiological tools and patients could benefit of a specific treatment.

Total intracorporeal anastomosis during single-port laparoscopic right hemicolectomy for carcinoma of colon: a new step forward.

BACKGROUND: Laparoscopic surgery is a feasible option for colonic carcinoma as short-and long-term results show. This technique is as safe and effective as the open approach. Single-port access surgery is considered a new minimally invasive approach in the search for better cosmetic results and less postoperative pain. One of the goals of single-port surgery is to preserve the satisfactory oncological results obtained by standard laparoscopy. This study presents the first single-port access right hemicolectomy for carcinoma of colon with intracorporeal anastomosis. METHODS: The authors report a single-port access right hemicolectomy in a 59-year-old male patient with a neoplasm of the cecum stage IIA (T3, N0) according to the TNM classification. RESULTS: A transumbilical single-port access right hemicolectomy was performed with no additional trocars and total intracorporeal anastomosis. Operative time was 140 minutes. No intraoperative or postoperative complications were reported. CONCLUSION: Single-port access right hemicolectomy with intracorporeal anastomosis is a feasible and safe technique when performed by experienced laparoscopic surgeons. This approach must follow the basic principles of laparoscopic right hemicolectomy to achieve the same oncological results. The advantages of a total intracorporeal anastomosis include that there is no need to enlarge the umbilical incision and that avoid traction of the pedicle of the mesenterium of the transverse colon during the extracorporeal anastomosis.

Transcriptome Sequencing of Peripheral Blood Mononuclear Cells from Elite Controller-Long Term Non Progressors.

The elite controller (EC)-long term non-progressor (LTNP) phenotype represent a spontaneous and advantageous model of HIV-1 control in the absence of therapy. The transcriptome of peripheral blood mononuclear cells (PBMCs) collected from EC-LTNPs was sequenced by RNA-Seq and compared with the transcriptomes from other phenotypes of disease progression. The transcript abundance estimation combined with the use of supervised classification algorithms allowed the selection of 20 genes and pseudogenes, mainly involved in interferon-regulated antiviral mechanisms and cell machineries of transcription and translation, as the best predictive genes of disease progression. Differential expression analyses between phenotypes showed an altered calcium homeostasis in EC-LTNPs evidenced by the upregulation of several membrane receptors implicated in calcium-signaling cascades and intracellular calcium-mobilization and by the overrepresentation of NFAT1/Elk-1-binding sites in the promoters of the genes differentially expressed in these individuals. A coordinated upregulation of host genes associated with HIV-1 reverse transcription and viral transcription was also observed in EC-LTNPs -i.e. p21/CDKN1A, TNF, IER3 and GADD45B. We also found an upregulation of ANKRD54 in EC-LTNPs and viremic LTNPs in comparison with typical progressors and a clear alteration of type-I interferon signaling as a consequence of viremia in typical progressors before and after receiving antiretroviral therapy.

Clinical features and outcomes of bacteraemia due to OXA-48-like carbapenemase-producing Klebsiella pneumoniae in a tertiary hospital. / Características y evolución clínica de las bacteriemias por Klebsiella pneumoniae productora de carbapenemasa tipo OXA-48 en un hospital de tercer nivel.

INTRODUCTION: Limited therapeutic options and high mortality make the management of OXA-48-like carbapenemase-producing Klebsiella pneumoniae (KPOXA-48) bacteraemia complicated. The aim of the study was to describe the clinical characteristics of KPOXA-48 bacteraemia between October 2013 and December 2016. MATERIAL AND METHODS: The variables to analyse were retrospectively collected from medical records. Carbapenemase production was confirmed by phenotypic and molecular methods. RESULTS: A total of 38 patients with bacteraemia were included, mainly classified as hospital-acquired (n=31). The majority of cases were secondary bacteraemia (n=26), most commonly arising from the urinary tract (n=11). All isolates presented a multidrug-resistant profile with the extended spectrum beta-lactamase CTX-M-15 and the carbapenemase OXA-48-like production. The crude mortality rate with adequate targeted antibiotic therapy was 0%, rising to 55% with inadequate treatment (p=0.0015). CONCLUSIONS: This study highlights the importance of identifying this resistance mechanism, the patient factors, type of bacteraemia and adequacy of antibiotic therapy in the outcome of bacteraemia.

Evaluation of patient satisfaction in gastrointestinal endoscopy.

OBJECTIVE: Patient satisfaction questionnaires are a useful method for detecting opportunities for improvement on the basis of patient opinion. The aim of this study was to identify by means of a satisfaction questionnaire the main reasons for dissatisfaction in patients undergoing gastrointestinal endoscopy. PATIENTS AND METHODS: Five hundred and thirty-seven patients (age 49+/-15 years, 53% women) who attended a gastrointestinal endoscopy unit were interviewed 3 weeks after undergoing upper endoscopy or colonoscopy, using a previously translated and validated GHAA-9 questionnaire modified for use in gastrointestinal endoscopy. In each case, the overall score median and the percentage of patients who gave negative (poor or fair) appraisals on each of the seven main questions were estimated. These data were used to perform a Pareto analysis. RESULTS: The overall questionnaire score median was 29 (interquartiles 25 and 75 over 26 and 32, respectively). Negative appraisal percentages for each of the seven questions were: waiting time until the appointment, 9.3%; waiting time on the day of examination, 3.5%; explanations, 3.9%; personal manner of staff, 0.5%; personal manner of the physician, 0.6%; discomfort, 3.5%; overall rating, 1.9%. The vital few found by Pareto analysis were questions regarding waiting time for appointment and adequacy of explanations regarding procedure. These questions accounted for 61% of the total number of problems encountered by patients. CONCLUSION: Questionnaires on satisfaction or quality perceived by patients allow the most frequent causes for dissatisfaction to be identified. The main problems patients encountered were waiting time until the appointment and explanations.

Tropheryma whipplei endocarditis in Spain: Case reports of 17 prospective cases.

Tropheryma whipplei endocarditis is an uncommon condition with very few series and <90 cases reported in the literature. The aim of the study was to analyze the epidemiological, clinical, and outcome characteristics of 17 cases of T. whipplei endocarditis recruited in our country from a multicentric cohort from 25 Spanish hospitals from the Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España.From a total of 3165 cases included in the cohort, 14.2% were diagnosed of blood culture negative endocarditis (BCNE) and 3.5% of these had T. whipplei endocarditis. This condition was more frequent in men. The average age was 60.3 years. Previous cardiac condition was present in 35.3% of the cases. The main clinical manifestation was cardiac failure (76.5%) while fever was only present in the 35.3%. Ecocardiography showed vegetations in 64.7% of patients. Surgery was performed in all but 1 cases and it allowed the diagnosis when molecular assays were performed. A broad range rRNA 16S polymerase chain reaction was used for first instance in all laboratories and different specific targets for T. whipplei were employed for confirmation. A concomitant Whipple disease was diagnosed in 11.9% of patients. All patients received specific antimicrobial treatment for at least 1 year, with no relapse and complete recovery.T. whipplei endocarditis is an uncommon condition with an atypical presentation that must be considered in the diagnosis of BCNE. The prognosis is very good when an appropriate surgical management and antimicrobial-specific treatment is given.