[Splenectomy as definitive surgical treatment for hemophagocytic lymphohistiocytosis]. / Esplenectomía como tratamiento quirúrgico definitivo para linfohistiocitosis hemofagocítica.

Background: Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HL) is an immune hyperactivation of multifactorial etiology, characterized by excessive activation of lymphocytes and macrophages, as well as numerous pro-inflammatory cytokines. It has a non-specific and highly variable clinical presentation, with splenomegaly being one of the clinical manifestations. Due to its nature, it can manifest during childhood or adult life, which is why it is a disease of diagnostic and therapeutic complexity. Clinical case: 38-year-old male patient without comorbidities, who presented with abdominal pain, choluria, fever > 38 °C and diaphoresis of more than 10 days of evolution. A bone marrow aspirate was performed as part of the diagnostic approach with data compatible with hemophagocytosis and cytopenias. The immunosuppressive management did not show the expected response, which is why an open splenectomy was performed as the last therapeutic option with adequate hematological control. A documentary review of the disease was carried out, and of the therapeutic options, emphasizing surgical management in case of refractoriness to medical treatment. Conclusions: Splenectomy increases the overall survival rate and the time free of HL progression, even though there are still no studies to determine with certainty the ideal time to perform a splenectomy in patients with pancytopenia without splenomegaly who suffer from hemophagocytic syndrome.

Introducción: el síndrome hemofagocítico o linfohistiocitosis hemofagocítica (LH) es una hiperactivación inmune de etiología multifactorial, caracterizada por activación excesiva de linfocitos y macrófagos, así como por numerosas citocinas proinflamatorias. Tiene una presentación clínica poco específica y muy variable, y la esplenomegalia es una de las manifestaciones clínicas. Debido a su naturaleza puede manifestarse durante la infancia o la vida adulta, por lo que es una enfermedad de complejidad diagnóstica y terapéutica. Caso clínico: paciente del sexo masculino de 38 años sin comorbilidades, quien presentó dolor abdominal, coluria, fiebre > 38 °C y diaforesis de más de 10 días de evolución. Se le hizo aspirado de médula ósea como parte del abordaje diagnóstico con datos compatibles con hemofagocitosis y citopenias. El manejo inmunosupresor no mostró la respuesta esperada, por lo que se hizo esplenectomía abierta como última opción terapéutica con adecuado control hematológico. Se hizo una revisión documental de la enfermedad y de las opciones terapéuticas con énfasis en el manejo quirúrgico en caso de refractariedad al tratamiento médico. Conclusiones: la esplenectomía aumenta la tasa de supervivencia general y el tiempo libre de progresión de la LH, aunque no hay todavía estudios para determinar con certeza el tiempo ideal para hacer una esplenectomía en pacientes con pancitopenia sin esplenomegalia que padezcan síndrome hemofagocítico.

Characterization of a New Immunosuppressive and Antimicrobial Peptide, DRS-DA2, Isolated from the Mexican Frog, Pachymedusa dacnicolor.

Inflammatory and antimicrobial diseases constitute a major burden for society, and fighting them is a WHO strategic priority. Most of the treatments available to fight inflammatory diseases are anti-inflammatory drugs, such as corticosteroids or immunomodulators that lack cellular specificity and lead to numerous side effects. In addition to suppressing undesired inflammation and reducing disease progression, these drugs lessen the immune system protective functions. Furthermore, treating infectious diseases is more and more challenging due to the rise of microbial resistance to antimicrobial drugs. Thus, controlling the inflammatory process locally without compromising the ability to combat infections is an essential feature in the treatment of inflammatory diseases. We isolated three forms (DRS-DA2N, DRS-DA2NE, and DRS-DA2NEQ) of the same peptide, DRS-DA2, which belongs to the dermaseptin family, from the Mexican tree frog Pachymedusa dacnicolor. Interestingly, DRS-DA2N and DRS-DA2NEQ exhibit a dual activity by inducing the death of leukocytes as well as that of Gram-negative and Gram-positive bacteria, including multiresistant strains, without affecting other cells such as epithelial cells or erythrocytes. We showed that the death of both immune cells and bacteria is induced rapidly by DRS-DA2 and that the membrane is permeabilized, leading to the loss of membrane integrity. We also validated the capacity of DRS-DA2 to regulate the pool of inflammatory cells in vivo in a mouse model of noninfectious peritonitis. After the induction of peritonitis, a local injection of DRS-DA2N could decrease the number of inflammatory cells locally in the peritoneal cavity without inducing a systemic effect, as no changes in the number of inflammatory cells could be detected in blood or in the bone marrow. Collectively, these data suggest that this peptide could be a promising tool in the treatment of inflammatory diseases, such as inflammatory skin diseases, as it could reduce the number of inflammatory cells locally without suppressing the ability to combat infections.

Intraoperative complexity and risk factors associated with conversion to open surgery during laparoscopic cholecystectomy in eight hospitals in Mexico City.

BACKGROUND: The conversion to open surgery (COS) during the Laparoscopic Cholecystectomy (LC) is reported to occur at a rate of 10-15%. Some preoperative risk factors (RF) have been postulated; however, few studies have evaluated these factors and the intraoperative complexity with the COS rate. The aim of the study was to evaluate the preoperative RF and intraoperative complexity using the Parkland grading scale (PGS) with the COS rate in LC. METHODS: A retrospective study was done evaluating the demographic and surgical variables from the patients and LC videos from 8 different hospitals of Mexico City from December 2018 to January 2020. The evaluation of the PGS was done by 2 surgeons (one MI and one HPB surgeon); the PGS was also categorized as Non-Complex LC (nCLC, PGS1-2) and Complex LC (CLC, PGS 3-5). Logistic regression was used to evaluate the association of this factors with the COS rate. RESULTS: 430 LC were analyzed; 358 (78.61%) were women, 261 (60.7%) were elective and 169(39.3%) urgent LC, the mean age was 44.06 (SD ± 13.16) years. 21 (4.8%) LC were COS; the mean age of this group was 55 (SD ± 12.95), 3 (0.7%) were nCLC and 18 (4.19%) CLC, mean PGS of 3.76 (SD ± 1.09), the mean time to COS was 48.67 (SD ± 41.9), the estimated blood loss (EBL) was 258 (SD ± 260.22) and 6 (1.4%) intraoperative BDI were recognized on this group. Univariate analysis showed a significant association with the COS with male sex, older age, age > 45 years, presence of comorbidities, a higher PGS, a CLC, higher EBL and possible BDI; multivariate analysis produced a model using male sex, age, presence of comorbidities and a CLC with a 0.809 area under the ROC curve. CONCLUSION: The recognition of the associated RF and a CLC can guide the surgeon to establish preoperative and bailout strategies during the procedure, recognizing a higher risk of COS and its higher morbidity.

[Perforated metastatic primary fibromyxoid sarcoma of the transverse colon]. / Sarcoma fibromixoide primario de colon transverso metastásico perforado.

Background: Low grade fibromyxoid sarcoma (LGFMS) is considered a rare soft tissue tumor and has a tendency to arise from deep soft tissue of the trunk and lower extremities, the intraabdominal area is considered a rare location. Objective: To describe the first case of a LGFMS arising from the transverse colon with liver metastasis. Clinical case: We describe a 57-years-old male patient with abdominal pain of sudden onset; at surgery he was found to have an abscessed tumor in the transverse colon that infiltrated to mesentery root. An extended left hemicolectomy was performed with ascending colon colostomy. Later on, a postoperative scan he was found to have metastatic liver disease. Conclusions: This case is unique in terms of the location and presentation. It's a reminder of differential diagnosis of acute abdominal pain. To our knowledge is the first case of a LGFMS of the colon with synchronous liver metastasis.

Introducción: el sarcoma fibromixoide de bajo grado (LGFMS) se considera un tumor de tejidos blandos raro, que tiene tendencia a surgir del tronco y de las extremidades inferiores, su localización en el área intraabdominal se considera poco común. Objetivo: describir un caso de LGFMS primario de colon transverso perforado con metástasis hepática. Caso clínico: describimos el caso de un paciente masculino de 57 años con dolor abdominal de inicio súbito; en la cirugía se encontró un tumor con absceso y perforación en el colon transverso que infiltraba hasta la raíz del mesenterio. Se realizó hemicolectomía izquierda extendida con colostomía de colon ascendente. Más tarde, en una exploración posoperatoria, se encontró que tenía enfermedad hepática metastásica. Conclusiones: este caso es único en términos de ubicación y presentación. Es un recordatorio del diagnóstico diferencial del dolor abdominal agudo. Hasta donde sabemos, es el primer caso de LGFMS del colon con metástasis hepática sincrónica.

Sarcoma fibromixoide primario de colon transverso metastásico perforado / Perforated metastatic primary fibromyxoid sarcoma of the transverse colon

Introducción: el sarcoma fibromixoide de bajo grado (LGFMS) se considera un tumor de tejidos blandos raro, que tiene tendencia a surgir del tronco y de las extremidades inferiores, su localización en el área intraabdominal se considera poco común. Objetivo: describir un caso de LGFMS primario de colon transverso perforado con metástasis hepática. Caso clínico: describimos el caso de un paciente masculino de 57 años con dolor abdominal de inicio súbito; en la cirugía se encontró un tumor con absceso y perforación en el colon transverso que infiltraba hasta la raíz del mesenterio. Se realizó hemicolectomía izquierda extendida con colostomía de colon ascendente. Más tarde, en una exploración posoperatoria, se encontró que tenía enfermedad hepática metastásica. Conclusiones: este caso es único en términos de ubicación y presentación. Es un recordatorio del diagnóstico diferencial del dolor abdominal agudo. Hasta donde sabemos, es el primer caso de LGFMS del colon con metástasis hepática sincrónica.

Background: Low grade fibromyxoid sarcoma (LGFMS) is considered a rare soft tissue tumor and has a tendency to arise from deep soft tissue of the trunk and lower extremities, the intraabdominal area is considered a rare location. Objective: To describe the first case of a LGFMS arising from the transverse colon with liver metastasis Clinical case: We describe a 57-years-old male patient with abdominal pain of sudden onset; at surgery he was found to have an abscessed tumor in the transverse colon that infiltrated to mesentery root. An extended left hemicolectomy was performed with ascending colon colostomy. Later on, a postoperative scan he was found to have metastatic liver disease Conclusions: This case is unique in terms of the location and presentation. It's a reminder of differential diagnosis of acute abdominal pain. To our knowledge is the first case of a LGFMS of the colon with synchronous liver metastasis.

Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico.

BACKGROUND: Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources. METHODS: A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question. RESULTS: From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made. CONCLUSIONS: This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

Leptin receptor gene polymorphisms and morbid obesity in Mexican patients.

BACKGROUND: Human obesity is due to a complex interaction among environmental, behavioral, developmental and genetic factors, including the interaction of leptin (LEP) and leptin receptor (LEPR). Several LEPR mutations and polymorphisms have been described in patients with early onset severe obesity and hyperphagic eating behavior; however, some contradictory findings have also been reported. In the present study we explored the association of six LEPR gene polymorphisms in patients with morbid obesity. FINDINGS: Twenty eight patients with morbid obesity and 56 non-obese Mexican Mestizo individuals were included. Typing of rs1137100, rs1137101, rs1805134, Ser492Thr, rs1805094 and rs1805096 LEPR polymorphisms was performed by PCR and allele specific hybridization. The LEPR Ser492Thr polymorphism was monomorphic with the presence of only the Ser492Thr-G allele. Allele C and genotype T/C for rs1805134 polymorphism were associated with susceptibility to morbid obesity (p = 0.02 and p = 0.03, respectively). No association was observed with any haplotype. Linkage disequilibrium (LD) showed that five polymorphisms (rs1137100, rs1137101, rs1805134, rs1805094 and rs1805096) were in absolute (D' = 1) but none in perfect (r2 = 1) LD. CONCLUSIONS: Our results suggest that rs1805134 polymorphism could be involved in the development of morbid obesity, whilst none of the alleles of the LEPR gene, rs1137100, rs1137101, rs1805094 and rs1805096 were associated as risk factors. However, more studies are necessary to confirm or reject this hypothesis.

[Thyroglossal cyst and papillary carcinoma. Management proposals]. / Quiste tirogloso con carcinoma papilar de tiroides. Propuestas de manejo.

The thyroid descends through the foramen cecum leaving the thyroglossal duct, which disappears between the fifth and the tenth week of pregnancy. The lack of involution of any part of this duct results in thyroglossal cyst formation. Its diagnostic approach is made by cervical ultrasound, computed tomography and magnetic resonance imaging. Approximately 1 % of the thyroglossal cyst formation contains malignant elements, and the most reported primary tumor has been papillary carcinoma. The recommended treatment for these carcinomas is controversial and it has evolved as time goes by. From Sistrunk procedure to neck dissection with total thyroidectomy and complementary therapies, such as iodine ablation and thyroid supplements, yet there is still no consensus as to the type of surgery and postoperative management it should be used to treat this carcinoma. Therapy should be applied according to each specific case, and it should be based on histological diagnosis, the invasive character of the tumor, and the lymph node affectation. In this paper we review the literature published so far with regards to the treatment of this carcinoma.

La tiroides hace su descenso a través del foramen cecum y deja el conducto tirogloso, el cual desaparece entre la quinta y la décima semana de gestación. La falta de involución de cualquier parte de este conducto da lugar a la formación de quistes tiroglosos. Su evaluación se realiza por medio de ecografía cervical, tomografía computada y resonancia magnética. Aproximadamente el 1 % de los quistes tiroglosos contiene elementos malignos y el tumor primario que se ha documentado más ha sido el carcinoma papilar. El tratamiento recomendado para estos carcinomas es objeto de discusión; se ha usado desde la operación de Sistrunk hasta la disección cervical con tiroidectomía total y terapias complementarias como la ablación con yodo y los suplementos tiroideos; sin embargo, todavía no existe un consenso dominante en cuanto al tipo de intervención quirúrgica y su manejo postoperatorio. La terapia debe ser adaptada a cada caso, sobre el diagnóstico histológico, el carácter invasivo del tumor y la afectación de los ganglios linfáticos. En el presente escrito hemos realizado una revisión de la literatura respecto al tratamiento.

[Vaginal evisceration. Report of a case and a literature review]. / Evisceración vaginal. Informe de un caso y revisión de la bibliografía.

BACKGROUND: Vaginal evisceration is a rare event associated to be associated with several factors. In premenopausal women it is often associated with trauma during intercourse, rape, iatrogenic injury and introduction of foreign objects. In postmenopausal women 73% of cases are associated with previous vaginal surgery or hysterectomy. CASE REPORT: Here we present the case of a female patient who had a vaginal evisceration six days after an abdominal hysterectomy. The patient underwent an abdominal reduction of the small bowel, but due to irreversible vascular compromise it was resected. The vaginal cuff was closed with interrupted non-absorbable sutures. CONCLUSION: Vaginal evisceration is a rare disease associated with pelvic surgery. When it happens, it should be addressed as an emergency. The abdominal approach is the choice when there is trauma or intestinal ischemia, while the combined vaginal with laparoscopic approach is a good option in selected patients.

[Adenocarcinoid neoplasm of the colon. Case report]. / Tumor adenocarcinoide de colon. Informe de un caso.

BACKGROUND: adenocarcinoid tumor is a rare malignancy that combines clinical and histological features of epithelial origin (adenocarcinoma) and neuroendocrine (carcinoid), occupies less than 1 % of all colorectal cancer histology, occurring mainly in the appendix and its presence in the colon is rare. CLINICAL CASE: we present a case of a 41-year-old female with sigmoid colon tumor, who underwent an extended left hemicolectomy and anastomosis; having a good postoperative evolution, with hospital stay of seventh days. The final histopathological study reported was adenocarcinoid colon tumor with free margins of injuries and four positive nodes of adenocarcinoma. CONCLUSIONS: adenocarcinoid tumors are present in the appendix in 85 to 95 % of all cases and only 6 % are located in the colon (13 % in sigmoid). Early diagnosis is certainly the most important determinant of good prognosis, in these cases the five-year survival is 80 to 84 %, and 15 years of 60 %.