IBD-PODCAST Spain: A Close Look at Current Daily Clinical Practice in IBD Management.

BACKGROUND: Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) that contributes in part to irreversible bowel damage and long-term complications, reduced quality of life, invalidity, and economic burden. Suboptimal control of IBD is associated with higher healthcare resource utilization (HCRU), impaired quality of life (QoL), and reduced work productivity. AIMS: The IBD-PODCAST study aimed to assess the proportion of IBD patients with suboptimal control and its associated impact. METHODS: IBD-PODCAST is a cross-sectional, multicenter study that aimed to characterize the CD and UC population with optimal or suboptimal control according to the STRIDE-II criteria and patient- and physician-reported measures. Here we present the results of the Spanish cohort (n = 396). RESULTS: A total of 104/196 (53.1%) CD and 83/200 (41.5%) UC patients were found to have suboptimal disease control. Long-term treatment targets according to STRIDE-II were applied in 172 (87.8%) CD and 181 (90.5%) UC patients. 125 of 172 (72.7%) CD and 74 of 181 (40.9%) UC patients were currently treated with targeted immunomodulators. Patients with CD and UC and suboptimal disease control showed impaired QoL, higher HCRU and direct costs, and also loss of work productivity compared to those with optimal control. CONCLUSION: Despite a high rate of targeted immunomodulator therapy, a substantial proportion of IBD patients show suboptimal disease control according to the STRIDE II criteria. Those patients with suboptimal disease control exhibit impaired QoL, less work productivity, and higher HCRU, suggesting that there is considerable need for better treatment approaches in IBD.

Simple template-based optimization for pediatric total lymphoid irradiation (TLI) radiotherapy treatments.

Total lymphoid irradiation (TLI) is used in the management of pediatric allogeneic hematopoietic stem cell transplantation (HSCT. This work aims to simplify the treatment planning process for TLI via a proposed template using the volumetric modulated arc therapy (VMAT) technique. Fifteen pediatric patients were planned, prescribed to 8 Gy in 4 fractions. Cost functions included in the template were the ones for the planning target volume (PTV), and conformality cost function (CCF) for the rest of the patient's volume. Conformity index (CI), homogeneity index (HI), conformation number (CN), gradient index (GI), integral dose, and doses to the organs at risk achieved with the template were reported. Cost function influence over various indexes was studied by Wilcoxon signed ranks test. Same 15 patients were planned with 3-dimensional conventional radiotherapy (3D-CRT) technique for comparison. Mean CI and HI were 1.33 and 0.13, respectively, which indicates good dose conformation and homogeneity. Mean CN and GI values were 0.69 and 4.51, respectively. Mean PTV coverage was reached (V100% > 95%). No correlation between the CCF and indexes values was found (p > 0.05). Doses to organs at risk (OARs) were as low as possible without losing PTV coverage. VMAT plan showed higher levels of conformation and similar homogeneity as 3D-CRT plans. Doses to OARs were inferior with VMAT except for the right kidney. The proposed template simplifies the planning of TLI treatments, and it is able to create acceptable plans with little modification in order to reduce doses to certain organs like the kidneys or the heart. VMAT technique showed higher conformation and lower doses to OAR compared to 3D-CRT.

Laparoscopic longitudinal pancreaticojejunostomy for chronic pancreatitis: Systematic review of the literature.

BACKGROUND: Longitudinal pancreaticojejunostomy, also known as modified Puestow or Partington-Rochelle procedure, is a technique for the treatment of chronic pancreatitis. It is usually performed by laparotomy, but in a very small number of cases it has been performed using a laparoscopic or robot-assisted approach. We carried out a systematic literature review to clarify the current status of laparoscopic longitudinal pancreatojejunostomy (LLPJ). METHODS: Adhering to the PRISMA guidelines, a systematic search for LLPJ was performed in PubMed, Embase, and Cochrane Library, for articles published up to 31 December 2017. RESULTS: 357 articles were evaluated for eligibility and 17 were included for critical appraisal: eight case reports, eight retrospective case series, and one series of cases and controls without randomization. All of them had a grade of recommendation C and a level of evidence 4 according to the CEBM. Patients were relatively young (mean age 37 years), with a slight preponderance of males (ratio 1.3: 1). All had long-standing disease, ERCP prior to surgery and a dilated pancreatic duct (mean 11 mm). The surgery was usually performed laparoscopically using four trocars; the conversion rate was low (5%), bleeding was minimal, the morbidity rate was 11% and no mortality was reported. Mean hospital stay was 5.6 days. The follow-up period varied but was usually short (less than two years). The results for pain control were very good since 90% of patients reported no pain, although visual analog scales were rarely used. CONCLUSIONS: In conclusion, LLPJ seems to be a safe, feasible and effective technique in patients with chronic pancreatitis. However, the number of descriptions published to date is very small, and there are no studies with high scientific evidence comparing LLPJ with open surgery or with endoscopic treatment that would allow us to draw firmer conclusions at the present time.

Prevalence and Factors Associated With Fatigue in Patients With Inflammatory Bowel Disease: A Multicentre Study.

BACKGROUND AND AIMS: The aims of this study were to determine the prevalence of fatigue in patients with inflammatory bowel disease [IBD], to identify the factors associated with fatigue and its severity, to assess the impact of fatigue on quality of life [QoL], and to evaluate the relationship between fatigue and sleep disorders. METHODS: This was a prospective multicentre study conducted at 22 Spanish centres. Consecutive patients followed at IBD Units were included. Fatigue was evaluated with the Fatigue Severity Scale [FSS] and the Fatigue Impact Scale [FIS]. Quality of life and sleep quality were assessed using the IBD Questionnaire-Short Form [IBDQ-9] and the Pittsburgh Sleep Quality Index [PSQI], respectively. RESULTS: A total of 544 consecutive adult IBD patients were included [50% women, mean age 44 years, 61% Crohn's disease]. The prevalence of fatigue was 41% (95% confidence interval [CI] = 37-45%). The variables associated with an increased risk of fatigue were: anxiety [OR = 2.5, 95% CI = 1.6-3.7], depression [OR = 2.4, 95% CI = 1.4-3.8], presence of extraintestinal manifestations [EIMs] [OR = 1.7, 95% CI = 1.1-2.6], and treatment with systemic steroids [OR = 2.8, 95% CI = 1.4-5.7]. The presence of EIMs [regression coefficient, RC = 8.2, 95% CI = 2.3-14.2], anxiety [RC = 25.8, 95% CI = 20.0-31.5], depression [RC = 30.6, 95% CI = 24.3-37.0], and sleep disturbances [RC = 15.0, 95% CI = 9.3-20.8] were associated with severity of fatigue. Patients with fatigue had a significantly decreased IBDQ-9 score [p < 0.001]. CONCLUSIONS: The prevalence of fatigue in IBD patients is remarkably high and has a negative impact on QoL. Therapy with systemic steroids is associated with an increased risk of fatigue. The severity of fatigue is associated with anxiety, depression, sleep disorders, and the presence of EIMs. Fatigue was not associated with anaemia, disease activity or anti-TNF therapy.

Systematic review of the mesopancreas: concept and clinical implications

Background: In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP. Methods: An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian). Results: The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series. Conclusion: MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential

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Systematic review of the mesopancreas: concept and clinical implications.

BACKGROUND: In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP. METHODS: An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian). RESULTS: The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series. CONCLUSION: MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential.

Phenotype and natural history of elderly onset inflammatory bowel disease: a multicentre, case-control study.

BACKGROUND: Onset during old age has been reported in upto 10% of total cases of inflammatory bowel disease (IBD). AIM: To evaluate phenotypic characteristics and the use of therapeutic resources in patients with elderly onset IBD. METHODS: Case-control study including all those patients diagnosed with IBD over the age of 60 years since 2000 who were followed-up for >12 months, identified from the IBD databases. Elderly onset cases were compared with IBD patients aged 18 to 40 years at diagnosis, matched by year of diagnosis, gender and type of IBD (adult-onset). RESULTS: One thousand three hundred and seventy-four elderly onset and 1374 adult-onset cases were included (62% ulcerative colitis (UC), 38% Crohn's disease (CD)). Among UC patients, elderly onset cases had a lower proportion of extensive disease (33% vs 39%; P < 0.0001). In CD, elderly onset cases showed an increased rate of stenosing pattern (24% vs 13%; P < 0.0001) and exclusive colonic location (28% vs 16%; P < 0.0001), whereas penetrating pattern (12% vs 19%; P < 0.0001) was significantly less frequent. Regarding the use of therapeutic resources, there was a significantly lower use of corticosteroids (P < 0.0001), immunosuppressants (P < 0.0001) and anti-TNFs agents (P < 0.0001) in elderly onset cases. Regarding surgery, we found a significantly higher surgery rate among elderly onset UC cases (8.3% vs 5.1%; P < 0.009). Finally, elderly onset cases were characterised by a higher rate of hospitalisations (66% vs 49%; P < 0.0001) and neoplasms (14% vs 0.5%; P < 0.0001). CONCLUSIONS: Elderly onset IBD shows specific characteristics and they are managed differently, with a lower use of immunosuppressants and a higher rate of surgery in UC.

Perforación de divertículo duodenal: Una complicación poco frecuente / Perforated duodenal diverticulum: An infrequent complication

En torno al 95% de los divertículos duodenales son asintomáticos, siendo su diagnóstico de manera incidental tras la realización de pruebas de imagen por otros motivos. Entre sus complicaciones, la perforación es la menos frecuente. Presentamos el caso de un paciente con abdomen agudo secundario a divertículo duodenal perforado y manejo quirúrgico exitoso. Los divertículos duodenales son en su mayoría adquiridos y de localización periampular. Pueden asociar presencia de sintomatología vaga o desarrollar complicaciones como diverticulitis, obstrucción, sangrado o perforación, que pudiendo ser esta última espontánea, secundaria a diverticulitis o iatrogénica. La recomendación en cuanto al manejo de la perforación intestinal secundaria a divertículo duodenal es el tratamiento quirúrgico. También se ha descrito el manejo conservador con reposo digestivo, antibioterapia, y drenaje percutáneo de colecciones en pacientes con alto riesgo quirúrgico sin datos de sepsis

About 95% of the duodenal diverticula are asymptomatic, with incidental diagnosis after imaging tests for other reasons. Among its complications, perforation is the least frequent. We present a patient with acute abdomen secondary to perforated duodenal diverticulum and successful surgical management. The duodenal diverticula are mostly acquired and periampular localization. They may associate vague symptomatology or develop complications such as diverticulitis, obstruction, bleeding or perforation, which may be spontaneous, secondary to diverticulitis or iatrogenic. The recommendation for management of intestinal perforation secondary to duodenal diverticulum is surgical treatment. Conservative management with digestive rest, antibiotic therapy, and percutaneous drainage of collections have also been described in patients with high surgical risk with no sepsis data

Segmentación de volúmenes tumorales en imágenes PET mediante un método iterativo basado en valor umbral / Target volume segmentation of PET images by an iterative method based on threshold value

Objetivos. Se presenta un método de segmentación automático para imágenes de tomografía por emisión de positrones (PET) basado en una aproximación iterativa mediante valor umbral, que incluye la influencia tanto del tamaño de la lesión como del fondo presente durante la adquisición. Material y métodos. A partir de un estudio de imagen PET de un maniquí que contiene esferas de diversos tamaños y en diferentes entornos radiactivos conocidos, se determinan los valores umbral óptimos que suponen una correcta segmentación de volúmenes. Estos valores óptimos son normalizados al fondo y ajustados, mediante técnicas de regresión, a una función de 2 variables: volumen de la lesión y relación señal-fondo (RSF). Esta función de ajuste es usada para construir un método de segmentación iterativo, y, basándose en él, se propone un procedimiento de contorneo automático. Se valida dicho procedimiento sobre estudios en maniquí y se comprueba su viabilidad aplicándose, de manera retrospectiva, sobre 2 pacientes oncológicos. Resultados. La función de ajuste obtenida presenta una dependencia lineal con la RSF e inversamente proporcional y negativa con el volumen. Durante la validación del método iterativo propuesto se encuentra que las desviaciones de volumen respecto al valor real y al volumen TC están por debajo del 10 y del 9%, respectivamente, excepto para lesiones con un volumen por debajo de 0,6 ml. Conclusiones. El método automático de segmentación propuesto puede ser aplicado en la práctica clínica para la planificación de tratamientos de lesiones tumorales en radioterapia de manera sencilla y fiable con una precisión cercana a la resolución de la imagen PET (AU)

Objectives. An automatic segmentation method is presented for PET images based on an iterative approximation by threshold value that includes the influence of both lesion size and background present during the acquisition. Material and methods. Optimal threshold values that represent a correct segmentation of volumes were determined based on a PET phantom study that contained different sizes spheres and different known radiation environments. These optimal values were normalized to background and adjusted by regression techniques to a two-variable function: lesion volume and signal-to-background ratio (SBR). This adjustment function was used to build an iterative segmentation method and then, based in this mention, a procedure of automatic delineation was proposed. This procedure was validated on phantom images and its viability was confirmed by retrospectively applying it on two oncology patients. Results. The resulting adjustment function obtained had a linear dependence with the SBR and was inversely proportional and negative with the volume. During the validation of the proposed method, it was found that the volume deviations respect to its real value and CT volume were below 10% and 9%, respectively, except for lesions with a volume below 0.6 ml. Conclusions. The automatic segmentation method proposed can be applied in clinical practice to tumor radiotherapy treatment planning in a simple and reliable way with a precision close to the resolution of PET images (AU)

Is radical surgery feasible in liver hydatid cysts in contact with the inferior vena cava?

BACKGROUND: Cysts in contact with the inferior vena cava (IVC) represent a challenge for hepato-pancreatico-biliary surgeons. Although the literature on the topic is scarce, the most widely accepted approach is conservative surgery. Partial cyst resection is recommended, because radical resection is considered a high-risk procedure. STUDY DESIGN: This was a retrospective study over the period January 2007-December 2012. We operated on 103 patients with liver hydatidosis. A total of 32 patients (31 %) had a liver cyst in contact with the IVC. We proposed a cyst classification based on location of the cyst and length of contact and degrees of involvement of the IVC. RESULTS: Median size of the contacting cyst measured by computed tomography (CT) was 12 cm. On CT, median length of contact with the IVC was 37 mm. The median degree of involvement was 90°. Radical surgery was performed in 20 patients (62.5 %). No IVC resection was done. Morbidity rate was 28 %, and mortality was 3 %. In follow-up (median 27 months), no relapses or problems related to IVC flow were detected. Postoperative stay and transfusion rate were higher in the conservative surgery group, but these patients presented fewer complications. There was no relationship between circumferential grades and length of contact with the IVC and the type of surgery performed. CONCLUSIONS: Liver hydatid cysts in contact with the IVC are large cysts usually located in the right liver. They do not normally cause clinical symptoms related to IVC contact. Radical surgery is feasible, and was performed in 60 % of our series, but it is technically demanding. We propose a classification of cysts in contact with the IVC.

[Target volume segmentation of PET images by an iterative method based on threshold value]. / Segmentación de volúmenes tumorales en imágenes PET mediante un método iterativo basado en valor umbral.

OBJECTIVES: An automatic segmentation method is presented for PET images based on an iterative approximation by threshold value that includes the influence of both lesion size and background present during the acquisition. MATERIAL AND METHODS: Optimal threshold values that represent a correct segmentation of volumes were determined based on a PET phantom study that contained different sizes spheres and different known radiation environments. These optimal values were normalized to background and adjusted by regression techniques to a two-variable function: lesion volume and signal-to-background ratio (SBR). This adjustment function was used to build an iterative segmentation method and then, based in this mention, a procedure of automatic delineation was proposed. This procedure was validated on phantom images and its viability was confirmed by retrospectively applying it on two oncology patients. RESULTS: The resulting adjustment function obtained had a linear dependence with the SBR and was inversely proportional and negative with the volume. During the validation of the proposed method, it was found that the volume deviations respect to its real value and CT volume were below 10% and 9%, respectively, except for lesions with a volume below 0.6 ml. CONCLUSIONS: The automatic segmentation method proposed can be applied in clinical practice to tumor radiotherapy treatment planning in a simple and reliable way with a precision close to the resolution of PET images.

Walled-off pancreatic necrosis.

Acute severe pancreatitits may be complicated by the development of 'walled-off pancreatic necrosis' (WOPN), which is characterised by a mixture of solid components and fluids on imaging studies as a consequence of organised pancreatic tissue necrosis. We present here an overview of the definition, clinical features, and diagnostic and therapeutic management of this clinical condition, which is mostly based on consensus as adequate clinical trials are lacking.

Cysto-biliary communication in liver hydatidosis.

BACKGROUND: Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree. AIM: The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree. RESULTS: Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm. CONCLUSIONS: The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Three trocars laparoscopic resection of angiomyolipoma of the liver.

Angiomyolipoma of the liver (AML) is an infrequent neoplasm composed of three tissues (adipose, muscle and vessels). In spite of advances in radiology, preoperative correct diagnosis is difficult. Clasically, a conservative management strategy was adopted in patients with asymptomatic tumors less than 5 cm with undoubtful diagnosis. But after publishing some few cases of malignant angiomyolipoma a more radical has been advocated. Laparoscopic resection of liver tumors is becoming a excellent approach for operating on benign liver tumors. Usually is performed using five trocars but in some cases a less invasive technique with three trocars could be used. We present a laparoscopic resection of liver angiomyolipoma in a 65 year-old male using only three trocars and also discuss the optimal management of AML and technical tips of three-trocar technique.

Long-term results of lunocapitate arthrodesis with scaphoid excision for SLAC and SNAC wrists.

When treating the degenerative arthritis that follows scapholunate instability or scaphoid pseudarthrosis, excision of the scaphoid must be combined with a stabilisation of the midcarpal joint. Two alternatives have been proposed for that purpose: fusing the lunate, triquetrum, capitate and hamate (four corner fusion), 4CF; or limiting the arthrodesis to the lunate and capitate, preserving or excising the triquetrum. Previous reports have attributed a high level of complications to lunocapitate arthrodesis, mainly in respect of nonunion. We have reviewed 17 patients who had been treated with a lunocapitate fusion, after an 8 to 12-year follow-up period, and found similar results compared with 4CF, even with a major degree of motion in ulnar-radial deviation. Recent work on the innervation of the radiotriquetral ligaments has given relevance to the preservation of lunotriquetral motion in maintaining proprioception. Also if the triquetrum is excised to gain more motion, the proprioceptive role of the radiotriquetral ligaments is compromised.

Artroscopia trapeciometacarpiana. Clasificación y algoritmo terapéutico / Trapeziometacarpal arthroscopy: classification and therapeutic algorithm

Introducción. La enfermedad de Ribbing es una displasiaósea esclerosante que raramente es sintomática. Se diagnostica por exclusión y el tratamiento quirúrgico mediante fresado endomedular es el más efectivo.Caso clínico. Mujer de 48 años de edad con clínica de dolor en la pierna izquierda de 7 meses de evolución. En la radiografía se apreciaba una lesión esclerosa en el centro de la diáfisis. La tomografía computarizada mostraba esclerosis endomedular y periostal con obliteración del canal medular; en la resonancia magnética no se apreciaba afectación de partes blandas y en la gammagrafía ósea se observó hipercaptaciónal nivel de la lesión. El estudio anatomopatológicode la biopsia incisional mostraba cambios inespecíficos ydescartó patología neoplásica o infecciosa. Se diagnosticó enfermedad de Ribbing y la paciente fue tratada mediante fresado endomedular. El dolor mejoró inmediatamente.Conclusiones. La enfermedad de Ribbing es una entidadpoco frecuente en la que una buena historia clínica y familiar, un estudio iconográfico exhaustivo y la histología pueden ayudar a su diagnóstico

Introduction. Ribbing disease is a sclerosing bone dysplasia that is rarely symptomatic. This condition is diagnosed by exclusion, and the most effective surgical treatment is intramedullary reaming.Clinical case. A forty eight year-old woman presented with a seven-month history of pain in the lower left extremity. Plain films showed a sclerotic area in the mid tibial shaft. CT scan revealed endosteal and cortical thickening with narrowing of the medullary canal. MRI did not show involvement of the surrounding soft tissues and technetium 99m bone scanning showed high uptake at the level of the lesion. Histological examination of a tibial cortex sample obtainedby incisional biopsy revealed an area of new bone formation with non specific changes excluding neoplastic or infectious causes. The patient was diagnosed with Ribbing Disease and treated by intramedullary tibial reaming. The pain subsided immediately.Conclusion. Ribbing disease is a rare condition where relevant clinical information combined with imaging and histological evaluation are critical diagnostic tools

Perioperative fracture-dislocation of the humeral head during a resurfacing hemiarthroplasty.

We report a case of perioperative fracture-dislocation of the humeral head produced during the reaming for a resurfacing replacement hemiarthroplasty (RRH) in a 79-year old woman. This is a surgical complication not previously described in the literature for this type of prosthesis design. Resurfacing humeral head implant has been noted as a useful treatment for glenohumeral arthropathies, also in elderly people, with a very low incidence of complications. However, as we report, they are possible.It is advisable that conventional stemmed implants could be available when RRH is performed.

Perioperative fracture-dislocation of the humeral head during a resurfacing hemiarthroplasty

We report a case of perioperative fracture-dislocation of the humeral head produced during the reaming for a resurfacing replacement hemiarthroplasty (RRH) in a 79-year old woman. This is a surgical complication not previously described in the literature for this type of prosthesis design. Resurfacing humeral head implant has been noted as a useful treatment for glenohumeral arthropathies; also in elderly people; with a very low incidence of complications. However; as we report; they are possible. It is advisable that conven- tional stemmed implants could be available when RRH is performed