Immediate Breast Reconstruction with Prosthesis and Titanized Mesh Using a Dual-Plane Approach: Complications and Risk Factors Analysis.

INTRODUCTION: The immediate breast reconstruction after mastectomy has gained prominence in recent years and is considered one of the main procedures in oncoplastic surgery. In the case of reconstruction with prostheses, the use of a mesh to extend the pectoralis major muscle is often required to partially cover the implant. The main objective of this study was to determine the percentage of complications in immediate breast reconstructions with a titanized mesh using a dual-plane approach and establish risk factors for prosthesis complications and extrusion. MATERIALS AND METHODS: A retrospective study that included women who received postmastectomy reconstructions from January 2012 to December 2019 in a secondary hospital in Spain. RESULTS: A total of 57 immediate reconstructions were performed in 47 women. There were complications in 16 mastectomies (28.1%), of which seven (12.3%) were Clavien-Dindo ≤ IIIa and nine (15.7%) were IIIb. A total of three patients presented prosthetic extrusion, and the prosthesis was removed in five. The degree of contracture according to the Baker scale was I-II in 50 mastectomies (87.7%) and III-IV in seven (12.3%). CONCLUSION: The immediate breast reconstruction with a titanized mesh using a dual-plane approach is a technique with an acceptable percentage of complications. The need for a Wise pattern and the necrosis of the nipple-areola complex in the postoperative period are risk factors for implant loss. Patients undergoing radiotherapy and/or chemotherapy and with a previous surgery are more likely to present capsular contracture. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors.

Predictors for prolonged length of stay after laparoscopic appendectomy for complicated acute appendicitis in adults.

BACKGROUND: Appendicitis-related hospitalizations linked with peritonitis or postoperative complications result in longer lengths of stay and higher costs. The aim of the present study was to assess the independent association between potential predictors and prolonged hospitalization after laparoscopic appendectomy (LA) for complicated acute appendicitis (CAA). METHODS: A retrospective cohort study was conducted on adult patients diagnosed with CAA in which LA was attempted. The primary outcome was a prolonged length of stay (LOS) after surgery, defined as hospitalizations longer than or equal to the 75th percentile for LOS, including the day of discharge. Hierarchical regression models were run to elucidate the independent predictors for the variable of interest. RESULTS: The present study involved 160 patients with a mean age of 50.71 years. The conversion rate was 1.9%, and the overall postoperative morbidity rate was 23.8%. The median length of stay (LOS) was 5 days (75th percentile: 7 days). Multivariate analyses included nine variables that are statistically and/or clinically relevant to assess its relationship with a prolonged LOS: three preoperative (age, sex, and comorbidity), four intraoperative (appendix gangrene, perforation, degree of peritonitis, and drain placement), and two postoperative (immediate ICU admission and complications). The development of postoperative complications (OR 6.162, 95% CI 2.451-15.493; p = 0.000) and the placement of an abdominal drain (OR 3.438, 95% CI 1.107-10.683; p = 0.033) were found to be independent predictors for prolonged LOS. For patients not presenting postoperative complications, drain placement was the only independent predictor for the outcome (OR 7.853, 95% CI 1.520-40.558; p = 0.014). Sensitivity analyses showed confirmatory results. CONCLUSION: The intraoperative process of care has a clear impact on LOS after LA for CAA in adults; therefore, the decision of whether to drain in these situations should be made more restrictively yet with judicious caution.

Laparoscopic surgery and polycystic liver disease: Clinicopathological features and new trends in management.

BACKGROUND: Polycystic liver disease (PLD) has a low frequency overall in the worldwide population. As the patient's symptoms are produced by the expansion of hepatic volume, the different therapeutic alternatives are focused on reducing it. Surgery is still considered the most effective treatment for symptomatic PLD. The aim of this study was to evaluate the long-term outcomes of laparoscopic surgery for PLD. MATERIALS AND METHODS: This study included 14 patients who were diagnosed with symptomatic PLD and underwent surgery by a laparoscopic approach between 2004 and 2012. It involved collecting data on the characteristics of those patients and their liver disease, surgical procedures, intra- and postoperative complications, and the long-term follow-up. RESULTS: Twelve laparoscopic multiple-cyst fenestrations and two segmentary liver resections associated with remaining-cyst fenestration were performed. One procedure required conversion to laparotomy and the other was complicated by anhepatic severe bleeding. The rest of the procedures were uneventful. One patient developed persistent self-limited ascites in the immediate postoperative period. Symptoms disappeared after surgical intervention in all patients. During a median follow-up of 62 months (range 14-113 months), there were two clinical recurrences and one asymptomatic radiological recurrence. One patient required further surgery. CONCLUSION: Laparoscopic cystic fenestration and laparoscopic liver resection are safe and long-term, effective procedures for the treatment of symptomatic PLD. Severity and morphological characteristics of the hepatic disease will determine the surgical indication and the optimal approach for each patient.

Robotic transanal total mesorectal excision: Is the future now?

Total mesorectal excision (TME) is the standard surgical treatment for the curative radical resection of rectal cancers. Minimally invasive TME has been gaining ground favored by the continuous technological advancements. New procedures, such as transanal TME (TaTME), have been introduced to overcome some technical limitations, especially in low rectal tumors, obese patients, and/or narrow pelvis. The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME. However, recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series. Robotic TaTME (R-TaTME) has been proposed as a novel technique incorporating the potential benefits of a perineal dissection together with precise control of the distal margins, and also offers all those advantages provided by the robotic technology in terms of improved precision and dexterity. Encouraging short-term results have been reported for R-TaTME, but further studies are needed to assess the real role of the new technique in the long-term oncological or functional outcomes. The present review aims to provide a general overview of R-TaTME by analyzing the body of the available literature, with a special focus on the potential benefits, harms, and future perspectives for this novel approach.

Real-time fluorescence image-guided gastrointestinal oncologic surgery: Towards a new era.

Technological improvements are crucial in the evolution of surgery. Real-time fluorescence-guided surgery (FGS) has spread worldwide, mainly because of its usefulness during the intraoperative decision-making processes. The success of any gastrointestinal oncologic resection is based on the anatomical identification of the primary tumor and its regional lymph nodes. FGS allows also to evaluate the blood perfusion at the gastrointestinal stumps after colorectal or esophageal resections. Therefore, a reduction on the anastomotic leak rates has been postulated as one of the foreseeable benefits provided by the use of FGS in these procedures. Although the use of fluorescence in lymph node detection was initially described in breast cancer surgery, the technique is currently applied in gastric or splenic flexure cancers, as they both present complex and variable lymphatic drainages. FGS allows also to perform intraoperative lymphograms or sentinel lymph node biopsies. New applications of FGS are being developed to assist in the detection of peritoneal metastases or in the evaluation of the tumor resection margins. The present review aims to provide a general overview of the current status of real-time FGS in gastrointestinal oncologic surgery. We put a special focus on the different applications of FGS, discussing the main findings and limitations found in the contemporary literature and also the promising near future applications.

The impact of age and comorbidity on the postoperative outcomes after emergency surgical management of complicated intra-abdominal infections.

Age-adjusted Charlson Comorbidity Index (a-CCI) score has been used to weight comorbid conditions in predicting adverse outcomes. A retrospective cohort study on adult patients diagnosed with complicated intra-abdominal infections (cIAI) requiring emergency surgery was conducted in order to elucidate the role of age and comorbidity in this scenario. Two main outcomes were evaluated: 90-day severe postoperative complications (grade ≥ 3 of Dindo-Clavien Classification), and 90-day all-cause mortality. 358 patients were analyzed. a-CCI score for each patient was calculated and then divided in two comorbid categories whether they were ≤ or > to percentile 75 ( = 4): Grade-A (0-4) and Grade-B ( ≥ 5). Univariate and multivariate regression analyses were performed, and the predictive validity of the models was evaluated by the area under the receiver operating characteristics (AUROC) curve. Independent predictors of 90-day severe postoperative complications were Charlson Grade-B (Odds Ratio [OR] = 3.49, 95% confidence interval [95%CI]: 1.86-6.52; p < 0.0001), healthcare-related infections (OR = 7.84, 95%CI: 3.99-15.39; p < 0.0001), diffuse peritonitis (OR = 2.64, 95%CI: 1.45-4.80; p < 0.01), and delay of surgery > 24 hours (OR = 2.28, 95%CI: 1.18-4.68; p < 0.02). The AUROC was 0.815 (95%CI: 0.758-0.872). Independent predictors of 90-day mortality were Charlson Grade-B (OR = 8.30, 95%CI: 3.58-19.21; p < 0.0001), healthcare-related infections (OR = 6.38, 95%CI: 2.72-14.95; p < 0.0001), sepsis status (OR = 3.98, 95%CI: 1.04-15.21; p < 0.04) and diffuse peritonitis (OR = 3.06, 95%CI: 1.29-7.27; p < 0.01). The AUROC for mortality was 0.887 (95%CI: 0.83-0.93). Post-hoc sensitivity analyses confirmed that the degree of comorbidity, estimated by using an age-adjusted score, has a critical impact on the postoperative course following emergency surgery for cIAI. Early assessment and management of patient's comorbidity is mandatory at emergency setting.

Mirizzi syndrome: a new insight provided by a novel classification.

BACKGROUNDS/AIMS: Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis. The aim of this study is to evaluate our 15-year experience in this challenging entity and to propose a new classification for this disease. METHODS: A retrospective study including patients diagnosed with Mirizzi syndrome and undergoing surgical procedures for Mirizzi syndrome between January 2000 and October 2015 was conducted. Data collected included clinical, surgical procedure, postoperative morbidity. Patients were evaluated according to the Csendes classification and the proposed system, in which patients were divided into three types and three subtypes. RESULTS: 28 patients were included for analysis. They accounted as the 0.5% of a total of 4853 cholecystectomies performed in the study period. There were 21 women and 7 men. Initial laparotomic approach was performed in 12 patients and in 16 patients laparoscopic procedures were attempted. The procedure was completed in only 6 patients, 5 presenting type I and 1 type II Mirizzi syndrome. Mean postoperative stay was 15±9 days. Postoperative morbidity rate was 28%. Postoperative mortality was none. CONCLUSIONS: Laparoscopic surgery for Mirizzi syndrome has been shown succesful only in early stages. A novel classification is proposed, based on the types of common bile duct injuries and in the presence cholecystoenteric fistula.

Holmium YAG Photocoagulation: Safe and Economical Alternative to Transurethral Resection in Small Nonmuscle-Invasive Bladder Tumors.

OBJECTIVE: To analyze our experience in the treatment of recurrences of bladder tumor using Holmium-YAG (Ho:YAG) laser, assessing recurrence rates, tumor progression, degree of safety, and patient satisfaction, as well as the economic repercussions of the technique. MATERIALS AND METHODS: The study included 109 patients between February 2013 and 2016, who had a superficial recurrence of bladder tumor. Patients were treated by Ho:YAG laser photocoagulation on an outpatient basis and under local anesthetic. Cytology and previous biopsy were collected. The number of tumors, size, time of technique, and any complications were recorded. Subsequently, urine culturing was carried out and we recorded the visual analogue scale, a satisfaction questionnaire, and possible complications. The economic cost of the procedures was calculated. Data were analyzed using a chi-square test for continuous variables and Student's t for independent samples for dichotomous qualitative-quantitative variables. RESULTS: We carried out 139 procedures on 25 women (20%) and 114 men (80%) with a mean age of 67.85 ± 10.41 years and 246 tumors were treated. The consultation time was 21.5 minutes and the photocoagulation time was 7 minutes (1-35). As intraoperative complications, two patients presented monosymptomatic hematuria without requiring treatment and there were no postoperative complications. The total recurrence rate at 6 months was 20%. A value ≤4 on the EVA scale was reported for 94.7% of the patients. The saving per procedure compared with transurethral bladder resection was calculated at €2,007.09. CONCLUSION: The treatment of small recurrences of bladder tumor by photocoagulation with Ho:YAG laser is a well-tolerated technique that offers an acceptable level of cancer control and a lower cost compared with transurethral resection.

Experiencia de la cirugía del cáncer de mama durante la pandemia de COVID-19 / Experience of breast cancer surgery during the COVID-19 pandemic

Introducción: La pandemia por COVID-19ha tenido un importante impacto en todos los ámbitos; uno de los más afectados ha sido la sanidad. La pandemia ha supuesto una reorganización de los recursos tanto humanos como materiales, dada la saturación del sistema sanitario. Como especialistas en el cáncer de mama hemos tenido que adaptarnos a esta situación, reorganizando y ajustando los cuidados a los medios profesionales e infraestructuras de los que disponíamos en cada momento. La incidencia variable a lo largo del año ha permitido desarrollar una actividad normalizada en algunas ocasiones. Nos proponemos describir nuestra experiencia en la cirugía del cáncer de mama durante este año de pandemia de COVID-19.Material y métodos: Estudio observacional retrospectivo de pacientes intervenidas de neoplasia de mama desde el 14 de marzo de 2020 hasta el 14 de marzo de 2021.Resultados: Se han intervenido 138 neoplasias de mama en 136 mujeres.La edad media fue de 62 años (36-88). Hubo 86 pacientes (63,2%) en régimen de cirugía mayor ambulatoria y 50 pacientes (36,8%) con ingreso. El tiempo medio desde el diagnóstico hasta la visita en consultas externas fue de 5,7 días y el tiempo medio desde el diagnóstico hasta el inicio del tratamiento de 45 días.Conclusiones: Durante este año de pandemia de COVID-19 hemos podido asegurar la asistencia y tratamiento de las mujeres con cáncer de mama con adecuados intervalos entre el diagnóstico y el tratamiento. A este proceso ha contribuido la implementación previa de la cirugía mayor ambulatoria en el cáncer de mama. (AU)

Introduction: The COVID-19 pandemic has had an important impact in all areas; health service has been one of the most affected. The pandemic has led to a reorganization of human and material resources and has caused a saturation of the health service. As specialists in breast cancer, we have adapted to this situation by reorganizing and adapting care to the professional environments and infrastructures that were available when necessary. The incidence has varied during 2020 and it has made possible to normalize the work on some occasions. We would like to describe our experience in breast cancer surgery during this COVID-19 pandemic year.Material and methods: Retrospective observational study of patients operated on breast cancer from 14th March 2020 to 14th March 2021.Result: A number of 138 breast cancer have been operated on 136 women. The average age is 62 years (36-8); there were 86 patients operated on major ambulatory surgery regimen (63.2%) and 50 patients (36.8%) were hospitalized. The average time from diagnosis to outpatient visit was 5.7 days and the average time from diagnosis to the beginning of the treatment of 45 days.Conclusions: During this COVID-19 pandemic year, we have been able to ensure the care and treatment of women with breast cancer with adequate time intervals between diagnosis and treatment. This process has also been favored by the prior establishment of major ambulatory surgery in our medical center.

Repercusión en el manejo quirúrgico de la ecografía de reevaluación para caracterización de lesiones detectadas en resonancia magnética / Effect on surgical management of second-look ultrasound to characterise lesions detected by magnetic resonance imaging

INTRODUCCIÓN: La ecografía de reevaluación, o de «second-look» (ESL), es útil para caracterizar lesiones de nueva aparición identificadas durante el estudio mediante resonancia magnética (RM). También puede ayudar a optimizar el tratamiento quirúrgico, ya que permite realizar biopsias y obtener un resultado anatomopatológico de las lesiones. El objetivo de este estudio es determinar la utilidad de la ESL para la identificación y la caracterización de lesiones detectadas incidentalmente por RM, así como la repercusión posterior en el manejo quirúrgico. MATERIAL Y MÉTODO: Se realizó un estudio observacional retrospectivo en el que se incluyen mujeres diagnosticadas de cáncer de mama a las que se les realiza ESL tras RM, entre 2013 y 2015. Se recogieron datos epidemiológicos, del tumor primario, características de las lesiones identificadas por RM y posteriormente por ESL, procedimientos quirúrgicos y resultados anatomopatológicos. RESULTADOS: Se identificaron 168 lesiones nuevas mediante RM en 110 pacientes. De ellas, 123 (73,2%) fueron objetivadas posteriormente en la ESL. De acuerdo con el sistema BI-RADS, 88 (71,6%) lesiones se caracterizaron como BI-RADS3 y 24 (19,5%) como BI-RADS4. El resultado de la biopsia tras ESL fue de malignidad en 17 lesiones, lo cual conlleva un cambio de actitud quirúrgica en 15 pacientes. CONCLUSIONES: La ESL puede ser útil para optimizar el tratamiento quirúrgico de las pacientes con cáncer de mama en las que se detecta una nueva lesión mediante RM, permitiendo caracterizar, localizar dicha lesión y realizar biopsias para obtener un resultado anatomopatológico que nos ayude a decidir si es necesaria su exéresis

INTRODUCTION: Second-look ultrasound (SLU) is useful to characterise new lesions identified by magnetic resonance imaging (MRI). SLU may also help to optimise surgical treatment since it allows the performance of biopsies and histopathological analysis of the lesions. The aim of this study was to determine the utility of SLU to identify and characterise lesions initially detected by MRI, as well as its subsequent influence on surgical management. MATERIAL AND METHOD: We performed an observational retrospective study that included women diagnosed with breast cancer who underwent SLU after MRI between 2013 and 2015. We collected data on epidemiological factors, the primary tumour, the characteristics of the lesions identified by MRI and subsequently by SLU, surgical procedures, and histopathological results. RESULTS: A total of 168 new lesions were identified by MRI in 110 patients. Of these, 123 (73.2%) were subsequently identified in SLU. Using the BI-RADS system, 88 (71.6%) lesions were classified as BI-RADS3 and 24 (19.5%) as BI-RADS4. The result of biopsy after SLU was malignancy in 17 lesions, leading to a change of surgical management in 15 patients. CONCLUSIONS: SLU can be useful to optimise the surgical treatment of patients with breast cancer and detection of a new lesion by MRI. SLU allows these lesions to be characterised and localised and biopsies to be taken. This in turn allows histopathological analysis, which helps to determine the need for extirpation of the lesion

Perforación intestinal secundaria a linfoma T entérico en un paciente sin intolerancia al gluten / Intestinal perforation secondary to T-enteric lymphoma in a patient without celiac disease

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