Anatomy variant symptomatic of the duplication of the common bile duct type IV.

INTRODUCTION: Duplicity of the common bile duct (BCBD) is an unusual congenital disorder. CASE REPORT: A 80-year-old woman with duplication of the common bile duct with retrograde endoscopic cholangiopancreatography (ERCP) who did not resolve the symptoms. DISCUSSION: Our case is a variant of type IV to the classification of DCBC. The MR cholangiography and presurgical ERCP allows assessment of the bile ducts, their caliber, and assessment of abnormalities. The treatment before DCBC will depend on the clinic and the type of opening of the CBCA. CONCLUSIONS: It is important to perform a pre-surgical study and during surgery with CIO.

INTRODUCCIÓN: La duplicidad del conducto biliar común (DCBC) es una alteración congénita insólita. CASO CLÍNICO: Mujer de 80 años con duplicación de la vía biliar común con colangiopancreatografía retrógrada endoscópica (CPRE) que no dilucida la clínica. DISCUSIÓN: Este caso es una variante del tipo IV de la clasificación de DCBC. La colangiorresonancia y la CPRE prequirúrgica permiten valorar las vías biliares, su calibre y las anormalidades. El tratamiento depende de la clínica y el tipo de apertura del conducto biliar común accesorio. CONCLUSIONES: Es importante realizar estudio prequirúrgico y durante la operación con colangiografía intraoperatoria.

The utility of hyperthermic intra-abdominal chemotherapy with gemcitabine for the inhibition of tumor progression in an experimental model of pancreatic peritoneal carcinomatosis, in relation to their behavior with pancreatic cancer stem cells CD133+ CXCR4.

OBJECTIVE: The origin of pancreatic cancer has been identified as a population of malignant pancreatic stem cells CD133+ CXCR4+ immunophenotype. These cells have high capacity for early locoregional invasion, being responsible for early recurrence and high mortality rates of pancreatic cancer. We propose a study for decreasing tumor progression of pancreatic cancer by reducing the volume and neoplastic subpopulation of pancreatic cancer stem cells CD133+ CXCR4+. Therefore, we develop a new therapeutic model, characterized by the application of HIPEC (Hyperthermic Intraperitoneal Chemotherapy) with gemcitabine. DESIGN: Pancreatic tumor cell line: human cell line BxPC-3. The animal model involved 18 immunosuppressed rats 5 weeks weighing 150-200 gr. The implantation of 13 × 10(6) cells/mL was performed with homogeneous distribution in the 13 abdominopelvic quadrants according to the peritoneal carcinomatosis index (PCI) and were randomized into three treatment groups. Group I (4 rats) received intravenous saline. Group II (6 rats) received intravenous gemcitabine. Group III (8 rats) received HIPEC at 41 °C for 30 min with gemcitabine + gemcitabine IV. A histological study confirmed pancreatic cancer and immunohistochemical quantification of pancreatic cancer stem cells CD133+ CXCR4+ tumor cells. RESULTS: There was a population decline of pancreatic cancer stem cells CD133+ CXCR4+ in the HIPEC group with respect to the other two groups (p < 0.001). There was a decrease in PCI between treatment groups (p < 0.05). CONCLUSION: The initial results are encouraging since there is a declining population of cancer stem cells CD133+ CXCR4+ in the HIPEC group and decreased tumor volume compared to the other two treatment groups. All the conclusions are only valid for BxPC3 cell line, and the effects HIPEC on Kras-driven pancreatic tumors remain to be determined.

[Axillary hidrosadenitis due to Leishmania: Case report and literature review]. / Hidrosadenitis axilar por Leishmania: presentación de un caso y revisión de la bibliografía.

BACKGROUND: Hidradenitis is a disorder where abscesses appear after the infection of the apocrine sweat glands. It is located normally in the axillae, groin, perineal region, and the scalp. CLINICAL CASE: A 37 year old male was referred by his GP to the General Surgery Department with axillary hidradenitis which had evolved over the years. The physical examination shows signs of hidradenitis in both axillae, with a noticeable suppurative hidradenitis in the right armpit. En bloc extirpation was performed to remove the whole affected area. The pathological examination revealed a cutaneous leishmaniasis. Subsequently, fucidin was administered topically, as well as local infiltrations of one millilitre of Glucantime™. DISCUSSION: Hidradenitis normally appears in intertriginous areas and its manifestation is accompanied by recurrent subcutaneous nodules. The incidence rate in females is three times higher than in males. The isolated Hidradenitis caused by Leishmania is a rare condition presented only in endemic areas or in immunocompromised patients, such as HIV-infected patients. Clinical manifestations can be different and the diagnosis can be confirmed through haematoxylin-eosin. The main pattern displays a disorganised granuloma without necrosis. Systemic or topical treatment can be applied. Immunotherapy treatment is the most common. CONCLUSIONS: Hidradenitis caused by Leishmania in HIV-negative patients is a rare condition. Therefore it is important to perform a good histological diagnosis and to administer the right treatment.

Uso del lipofilling en la mejora de los resultados de la cirugía de la mama. Nuestra experiencia / Use of lipofilling to improve the results of breast surgery: our experience

Objetivos. Presentar nuestra serie de pacientes en los que se ha llevado a cabo la técnica de lipofilling en el Hospital General Universitario de Ciudad Real. Material y métodos. Estudio descriptivo, retrospectivo de una serie de pacientes intervenidas quirúrgicamente por cáncer de mama y candidatas a reconstrucción mamaria mediante injerto autógeno de grasa, en el período de tiempo comprendido entre 2010 y 2012. Las variables analizadas fueron: edad, primera intervención quirúrgica realizada, tratamiento adyuvante, peso medio de grasa injertada, tiempo medio operatorio, tiempo de hospitalización, así como complicaciones a corto (en los primeros 7 días) y largo plazo (pasados los primeros 7 días). Resultados. Nuestra serie consta de un total de 40 pacientes mujeres, con una edad media de 44,9 años (40-54). El tiempo medio de hospitalización fue de 23 h, sin complicaciones a corto ni a largo plazo. Quince (37,5%) pacientes han referido pérdida de volumen con hundimiento del lecho quirúrgico durante el seguimiento. Seis casos se han sometido de nuevo al procedimiento. Conclusión. En nuestra experiencia durante 2 años, el autotrasplante de grasa puede ser una técnica conveniente que permita la regeneración de áreas afectadas, proporcionando elasticidad a los tejidos en pacientes con defectos estéticos tras cáncer de mama. En una tercera parte de las pacientes hubo pérdida de volumen durante el seguimiento (AU)

Objectives. To present our series of patients who underwent the lipofilling technique in the University General Hospital of Ciudad Real (Spain). Material and methods. A descriptive, retrospective study was carried out in series of patients who underwent surgery for breast cancer and who were candidates for breast reconstruction using autologous fat graft between 2010 and 2012. The variables analyzed were age, first surgery performed, adjuvant treatment, mean weight of grafted fat, mean operating time, length of hospital stay, and complications in the short-term (within 7 days) and long-term (past 7 days). Results. Our series consisted of 40 women with a mean age of 44.9 years (40-54). The mean length of hospital stay was 23 h without complications in the short- or long-term. Fifteen (37.5%) patients reported sinking volume loss. In 6 patients, the procedure was repeated. Conclusion. In our 2-year experience, autologous fat can be a useful technique to allow regeneration of affected areas, providing elasticity to tissues in patients with cosmetic defects after breast cancer. One-third of the patients experienced a loss of volume during follow-up (AU)

Endometriosis de localización extraovárica. Nuestra casuística en 10 años / Extraovarian endometriosis. Our 10-year casuistics

Introducción. La endometriosis es una enfermedad ginecológica cuya prevalencia oscila alrededor del 5-10% de las mujeres. La localización es pélvica en la mayoría de los casos; sin embargo, en un pequeño grupo de pacientes, puede presentarse en regiones diferentes de esta. Material y métodos. Estudio descriptivo, observacional y retrospectivo de las historias clínicas de 26 pacientes intervenidas quirúrgicamente de endometriosis de localización extraovárica en el Hospital General Universitario de Ciudad Real en el período comprendido entre enero del 2003 y enero del 2013. Resultados. Nuestra serie consta de 26 pacientes intervenidas de endometriosis de localización extraovárica. Las localizaciones, por orden de frecuencia, fueron: pared abdominal, ombligo, vulva, apéndice, íleon, saco herniario y colon. Discusión. La localización extrapélvica de la endometriosis se presenta con muy baja frecuencia. El tratamiento quirúrgico es la elección, llevando a cabo una resección con márgenes suficientes que permitirá reducir las posibilidades de recidiva (AU)

Introduction. Endometriosis is a gynecological disease with a prevalence of about 5% to 10% of women. Localization is usually pelvic but in a small group of patients the disease can be localized elsewhere. Material and methods. We performed a descriptive, observational and retrospective study of the medical records of 26 patients treated surgically for extraovarian endometriosis at the University General Hospital of Ciudad Real between January 2003 and January 2013. Results. Our series included 26 patients who underwent surgery for extraovarian endometriosis. In order of frequency, the locations were the abdominal wall, umbilicus, vulva, appendix, ileum, hernia sac and colon. Discussion. The frequency of extrapelvic endometriosis is very low. The treatment of choice is surgery. Resection with adequate margins reduces the chances of recurrence (AU)

Determinación rápida intraoperatoria de la paratirina intacta en la cirugía del hiperparatiroidismo primario. La experiencia en nuestro centro / Rapid intraoperative determination of intact parathyroid hormone during surgery for primary hyperparathyroidism. Experience at our center

INTRODUCCIÓN: El hiperparatiroidismo primario (HPTP) se debe a un adenoma único en el 85-95% de las ocasiones, lográndose frecuentemente la curación con la extirpación del mismo. La determinación rápida intraoperatoria de la paratirina intacta (PTHio) puede constituir una herramienta para el control de la efectividad de la cirugía del HPTP. El objetivo principal de nuestro estudio fue evaluar la determinación de PTHio y objetivar si su implementación colaboraba en lograr la aplicación de una cirugía mínimamente invasiva (CMI) y en régimen de cirugía mayor ambulatoria (CMA) en el tratamiento del HPTP. MATERIAL Y MÉTODOS: Estudio retrospectivo de una serie consecutiva de pacientes diagnosticados e intervenidos quirúrgicamente de HPTP en el Hospital General Universitario de Ciudad Real entre enero de 2005 y enero de 2012. RESULTADOS: En el periodo estudiado, se intervinieron 91 pacientes. 39 (42,9%) fueron intervenidos bajo anestesia general y 52 (57,1%) fueron candidatos a anestesia locorregional mediante bloqueo cervical. Del total, 76 (83,5%) fueron subsidiarios de CMI con abordaje unilateral. En el resto se realizó cervicotomía clásica. En 75 pacientes se realizó la determinación de PTHio, de los cuales, en 68 se demostró curación en el mismo acto quirúrgico. El 70,3% (64) de los pacientes fueron intervenidos en régimen de CMA. CONCLUSIONES: La determinación de PTHio puede permitir modificar la estrategia quirúrgica del HPTP en nuestro servicio, colaborando en la realización de una CMI en un porcentaje importante de pacientes, de forma ambulatoria, con alguna mejora estética, probablemente menor dolor, menor ingreso y con menos complicaciones potenciales que en la exploración cervical bilateral

INTRODUCTION: Primary hyperparathyroidism (PHPT) is due to a single adenoma in 85%-95% of cases, and is often cured after adenoma removal. Intraoperative rapid determination of intact parathyroid hormone (PTHio) may be a tool for monitoring the effectiveness of PHPT surgery. The main objective of our study was to evaluate PTHio determination and to establish whether its successful implementation contributed to achieve minimally invasive surgery (MIS) and major ambulatory surgery (MAS) in the treatment of PHPT. MATERIAL AND METHODS: Retrospective study of a consecutive series of patients diagnosed and operated on for PHPT at the University General Hospital of Ciudad Real between January 2005 and January 2012.RESULTS: In the study period, 91 patients underwent surgery. 39 (42.9%) under general anesthesia, while 52 (57.1%) were candidates for regional anesthesia by cervical block. Seventy-six of all patients (83.5%) were amenable to MIS using a unilateral approach. Classical cervicotomy was performed in all other patients. PTHio determination was done in 75 patients, showing cure in the same surgery in 68 of them. MAS was performed in 70.3% (64) of patients. CONCLUSIONS: Determination of PTHio may allow for changing the surgical approach to PHPT at our department, allowing for performance of MIS on an outpatient basis in a significant proportion of patients with some cosmetic improvement, probably less pain, shorter hospital stay, and less potential complications than bilateral cervical exploration

Rapid intraoperative determination of intact parathyroid hormone during surgery for primary hyperparathyroidism. Experience at our center.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is due to a single adenoma in 85%-95% of cases, and is often cured after adenoma removal. Intraoperative rapid determination of intact parathyroid hormone (PTHio) may be a tool for monitoring the effectiveness of PHPT surgery. The main objective of our study was to evaluate PTHio determination and to establish whether its successful implementation contributed to achieve minimally invasive surgery (MIS) and major ambulatory surgery (MAS) in the treatment of PHPT. MATERIAL AND METHODS: Retrospective study of a consecutive series of patients diagnosed and operated on for PHPT at the University General Hospital of Ciudad Real between January 2005 and January 2012. RESULTS: In the study period, 91 patients underwent surgery. 39 (42.9%) under general anesthesia, while 52 (57.1%) were candidates for regional anesthesia by cervical block. Seventy-six of all patients (83.5%) were amenable to MIS using a unilateral approach. Classical cervicotomy was performed in all other patients. PTHio determination was done in 75 patients, showing cure in the same surgery in 68 of them. MAS was performed in 70.3% (64) of patients. CONCLUSIONS: Determination of PTHio may allow for changing the surgical approach to PHPT at our department, allowing for performance of MIS on an outpatient basis in a significant proportion of patients with some cosmetic improvement, probably less pain, shorter hospital stay, and less potential complications than bilateral cervical exploration.

Nesidioblastosis. A case of hyperplasia of the islets of Langerhans in the adult.

INTRODUCTION: Nesidioblastosis is a rare disease caused by hyperplasia of pancreatic islets, developing a state of hypoglycemia due to an increase in the insulin production. It is the leading cause of hyperinsulinic hypoglycemia in childhood, whereas in adults it only represents the 0.5-5% of cases. The pathogenesis is still unknown. We have studied several genetic mutations associated with dependent potassium channel of ATP present in the beta cells of the pancreas, as well as in patients underwent bariatric surgery because of the metabolic changes involved. REPORT: Woman (38 years old) attends consultation of General Surgery derived from Endocrinology before symptoms of persistent hypoglycemia. Factitious hypoglycemia and syndromes of neuroendocrine origin were ruled out. Imaging tests failed to identify space-occupying lesions. The medical treatment failed, persisting hypoglycemia symptoms. Before the given analytical and radiological findings obtained, and the persistence of symptoms affecting the quality of life of the patient, we opted for surgical treatment performing a pancreatectomy of the 80% of the gland. The final pathologic diagnosis was nesidioblastosis. DISCUSSION: Nesidioblastosis is a rare pathology, but it must be present in the differential diagnosis of hypoglycemia symptoms with endogenous hyperinsulinism in adults, once the intake of sulfonylureas and possible pancreatic neoformations have been ruled out.

Histiocitoma fibroso maligno. Un sarcoma excepcional en la glándula mamaria / Malignant fibrous histiocytoma. An exceptional sarcoma in the mammary gland

Introducción. El histiocitoma fibroso maligno constituye la neoplasia sarcomatosa más frecuente en los adultos, pero la mama es una localización excepcional. Presentamos el caso de una mujer que comenzó con una tumoración de crecimiento progresivo en la mama derecha. Caso clínico. Mujer de 68 años que consulta por autopalpación de un nódulo en la mama derecha que ha crecido de forma progresiva en los últimos meses. La mamografía y la ecografía muestran una imagen nodular con bordes bien definidos, situada en intercuadrantes superiores de mama derecha, sin adenopatías axilares. Se decidió intervención quirúrgica y el estudio histológico definitivo fue informado como neoformación mesenquimal fusocelular con patrón estoriforme. El estudio inmunohistoquímico fue compatible con un histiocitoma fibroso maligno. Conclusión. Es primordial el diagnóstico diferencial de esta entidad clínica debido a la variabilidad histológica de los tumores sarcomatosos. Sus características clínicas y radiológicas pueden hacerlo pasar desapercibido, pero su comportamiento agresivo hace necesario un diagnóstico precoz, lo cual permitirá un tratamiento adecuado para lograr el aumento en la supervivencia(AU)

Introduction. Malignant fibrous histiocytoma is the most common sarcomatous neoplasm in adults. Localization in the breast, however, is exceptional. We report the case of a woman who presented with progressive tumoral growth in the right breast. Case report. A 68-year-old woman consulted for a self-palpated nodule in the right breast that had grown steadily in the last few months. Mammography and ultrasound showed a nodule with well-defined borders, located in the upper inner quadrant of the right breast. There was no axillary lymphadenopathy. Surgery was performed and the histological examination gave a definitive diagnosis of mesenchymal spindle cell neoplasm with storiform pattern. Immunohistochemical analysis was compatible with a diagnosis of malignant fibrous histiocytoma. Conclusion. Due to the histological variability of sarcomatous tumors, differential diagnosis is paramount in malignant fibrous histiocytoma. Because of their clinical and radiological features, malignant fibrous histiocytoma can be overlooked. Because these tumors are aggressive, an early diagnosis is essential to allow appropriate treatment and to increase survival(AU)