Morgagni Hernia Repair in Adults: A Single-Center Experience in Spanish Population.

Introduction: Morgagni hernia (MH) is a rare congenital disorder, especially in adults, accounting for 2%-4% of all congenital diaphragmatic hernias. Materials and Methods: Retrospective review of all patients who underwent surgical repair of MH at our center from 1991 to 2022. A descriptive analysis was performed. Results: Eighteen patients presented with MH, of whom 11 (61.11%) were female, with a median age of 67.60 (IQR 50.25-84.50) years old. Six (33.33%) were asymptomatic and 12 (66.67%) presented with symptoms, being dyspnea (4; 33.33%) the most common. On the group of symptomatic patients, the computed tomography scan (8; 66.67%) was the most frequent diagnostic test. Whereas in the asymptomatic group, 5 patients (83.33%) were diagnosed intraoperatively, during surgery for other reasons. MH was mostly located on the right (16; 88.89%). Hernia contents included omentum and colon (10; 55.56%), omentum (5; 27.78%), and stomach (3; 16.67%). All patients underwent surgical repair, needing in 3 cases (16.67%) emergency surgery. Surgical approaches included 10 laparoscopies (55.56%), 7 laparotomies (38.89%), and 1 thoracotomy (5.55%). Repair was generally performed whether by primary closure in 8 patients (44.4%) or by mesh implantation in 10 (55.56%). The median hospital stay was 6 days (IQR 3-10). Three patients presented complications (17.65%): urinary tract infection (1 patient), intra-abdominal collection (1 patient), and the last 1 presented with renal failure and pneumonia. The median follow-up was 74 months (IQR 4.5-130). No recurrence was described. Conclusions: MH is a rare condition in the adult population. In our series most patients presented with symptoms. The gold standard treatment is surgical repair, being the laparoscopic approach the most frequent. The complications rate was relatively low and no recurrence was described in our study.

Early laparoscopic cholecystectomy in oldest-old patients: a propensity score matched analysis of a nationwide registry.

The role of early laparoscopic cholecystectomy (ELC) in "oldest-old" patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study is to assess the safety of ELC for ACC in ≥ 85-year-old patients. Multicentric retrospective study that analysed data of patients who underwent ELC for ACC between 2013 and 2018. Patients ≥ 85-year-old (oldest-old patients) were compared with younger patients, before and after propensity score matching (PSM). The main outcomes were mortality, post-operative complications, length of stay (LOS), and readmissions. The study included 1670 patients. The unmatched comparison revealed a selection bias towards the oldest-old group, which was associated with higher Charlson Comorbidity Index (5 vs 1, p < 0.001), more ASA III/IV subjects (54.2% vs 19.3%, p < 0.001), class II/III ACC (80.1% vs 69.1%, p = 0.016) and higher Chole-Risk Score (p > 0.001). The oldest-old also required more conversion to open surgery (20% vs 10.3%, p = 0.005). Postoperatively, they had a higher 90-day mortality rate (7.6% vs 1%, p < 0.001), more total complications (40.6% vs 17.7%, p < 0.001), complications ≥ IIIa Clavien-Dindo (14.4% vs 5.8%, p = 0.002), longer LOS (6 vs 5 days, p < 0.001), and more readmissions (6.6% vs 2.6%, p < 0.001). After PSM (n = 206), the two groups were comparable in terms of baseline characteristics and intraoperative outcomes. No differences were observed in post-operative complications; bile leak; incisional, intrabdominal, urinary or respiratory tract infections; LOS or readmissions. In the oldest-old, ELC for ACC is still associated with significant morbidity and mortality. However, it seems to be safe in selected patients. Therefore, age itself should not be regarded as a contraindication to ELC for ACC.

Myofibroblastoma of the male breast: A case report / Miofibroblastoma en la mama de un varón, descripción de un caso clínico

Myofibroblastoma (MFB) is a rare spindle stromal tumour of the breast that predominates in 60–80 years-old adult males. Its imaging features are nonspecific, leading to misdiagnosis. Thus, core biopsy is needed for definitive diagnosis. Macroscopically, MFB is usually a well-circumscribed, firm and rubbery, unencapsulated, pale white to grey round mass. Microscopically, it consists on spindle cells arranged in haphazardly intersecting fascicles or clusters, thick hyalinized collagen bundles and low mitotic activity with a lack of myoepithelial component and necrosis. Immunohistochemistry shows consistently positive immunoreactivity to vimentin and CD34, while expression of desmin, SMA, bcl-2 and CD99 varies. Oestrogen, progesterone and androgen receptors are usually expressed. They are constantly negative to cytokeratins, EMA, S100 protein, HMB-45 and c-kit (CD117). These differentiate them from fibroadenoma, phyllodes tumour, round pattern gynecomastia, carcinoma and sarcoma, since they present infiltrative growth and are negative to CD34. Wide local excision is curative, with no need of sentinel lymph node biopsy, since local recurrence is extremely low and has been reported to be less than 1.5%. No distant metastases have been described on the literature. We report a rare case MFB on a 73-year-old male attended at our institution presenting with a nodule on the right breast. (AU)

El miofibroblastoma (MFB) es un tumour estromal de células fusiformes que aparece en varones de 60-80 años. Las características radiológicas son inespecíficas, por lo que es necesaria la realización de biopsia para el diagnóstico definitivo. Macroscópicamente se trata de una lesión bien circunscrita, firme, no encapsulada. Microscópicamente consiste en células fusiformes organizadas en fascículos entremezclados con bandas de colágeno hialino, con baja actividad mitótica y ausencia de componente mioepitelial y necrosis. La inmunohistoquímica muestra la expresión constante de vimentina y CD34, con expresión variable de desmina, AML, bcl-2 y CD99. Los receptores de estrógenos, progesterona y andrógenos normalmente son positivos, mientras que la expresión de citoqueratinas, EMA, S100, HMB-45 y c-kit (CD117) es negativa. Estas características lo diferencian del fibroadenoma, tumour filodes, ginecomastia, carcinoma y sarcoma, ya que la mayoría de ellos se caracterizan por ser negativos para CD34 y presentar crecimiento infiltrativo. La tumorectomía es considerada curativa, sin necesidad de realizar biopsia selectiva de ganglio centinela, dado que la recurrencia local es baja (menos del 1,5%). No se ha descrito la presencia de metástasis a distancia en la literatura. Presentamos el caso de MFB en un varón de 73 años que debutó con un nódulo en la mama derecha. (AU)

Multicentre cohort study of acute cholecystitis management during the COVID-19 pandemic.

PURPOSE: To analyse acute cholecystitis (AC) management during the first pandemic outbreak after the recommendations given by the surgical societies estimating: morbidity, length of hospital stay, mortality and hospital-acquired SARS-CoV-2 infection rate. METHODS: Multicentre-combined (retrospective-prospective) cohort study with AC patients in the Community of Madrid between 1st March and 30th May 2020. 257 AC patients were involved in 16 public hospital. Multivariant binomial logistic regression (MBLR) was applied to mortality. RESULTS: Of COVID-19 patients, 30 were diagnosed at admission and 12 patients were diagnosed during de admission or 30 days after discharge. In non-COVID-19 patients, antibiotic therapy was received in 61.3% of grade I AC and 40.6% of grade II AC. 52.4% of grade III AC were treated with percutaneous drainage (PD). Median hospital stay was 5 [3-8] days, which was higher in the non-surgical treatment group with 7.51 days (p < 0.001) and a 3.25% of mortality rate (p < 0.21). 93.3% of patients with SARS-CoV-2 infection at admission were treated with non-surgical treatment (p = 0.03), median hospital stay was 11.0 [7.5-27.5] days (p < 0.001) with a 7.5% of mortality rate (p > 0.05). In patients with hospital-acquired SARS-CoV-2 infection, 91.7% of grade I-II AC were treated with non-surgical treatment (p = 0.037), with a median hospital stay of 16 [4-21] days and a 18.2% mortality rate (p > 0.05). Hospital-acquired infection risk when hospital stay is > 7 days is OR 4.7, CI 95% (1.3-16.6), p = 0.009. COVID-19 mortality rate was 11.9%, AC severity adjusted OR 5.64 (CI 95% 1.417-22.64). In MBLR analysis, age (OR 1.15, CI 95% 1.02-1.31), SARS-CoV-2 infection (OR 14.49, CI 95% 1.33-157.81), conservative treatment failure (OR 8.2, CI 95% 1.34-50.49) and AC severity were associated with an increased odd of mortality. CONCLUSION: In our population, during COVID-19 pandemic, there was an increase of non-surgical treatment which was accompanied by an increase of conservative treatment failure, morbidity and hospital stay length which may have led to an increased risk hospital-acquired SARS-CoV-2 infection. Age, SARS-CoV-2 infection, AC severity and conservative treatment failure were mortality risk factors.

Laparoscopic cholecystectomy for acute cholecystitis: is the surgery still safe beyond the 7-day barrier? A multicentric observational study.

Timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. This study assesses ELC for ACC with delayed presentation, according to hospital volume. Multicentric retrospective analysis of 1868 ELC. Patients were classified into two groups according to the timing of surgery from clinical onset and centre volume. Group 1 (G1) within the first 7 days, group 2 (G2) beyond that. Then centres were classified in low volume centres (LVC) and higher volume centres (HVC) according to the number of ELC performed per year. Overall, G2 showed increased conversion rate (17.7% vs 10.7%; p = 0.004), intraoperative complications (7.3% vs 2.9%; p = 0.001); postoperative haemorrhage (3.6% vs 0.8%; p < 0.001), infections (16.6% vs 9.3%; p = 0.003) and global complications (27.6% vs 19.8%; p = 0.011). HVC in comparison with LVC presented decreased conversion rate (17.1% vs 7.6%; p < 0.001), intraoperative bleeding (2.1% vs 1%; p = 0.047), postoperative bile leakage (4.1% vs 2.1%; p = 0.011), infectious (13.7% vs 7.5%; p < 0.001) and global complications (25.7% vs 17.1%; p < 0.001). HVC did not show an increase in any of the above-mentioned outcomes when G1 and G2 were compared. ELC must be indicated cautiously in patients with ACC and more than 1 week of symptom duration. It should be performed in centres with sufficient experience in the management of this disease.