Photodynamic Therapy for the Treatment of Complex Anal Fistula.

BACKGROUND AND OBJECTIVES: To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula. STUDY DESIGN/MATERIALS AND METHODS: This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J). RESULTS: In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively. CONCLUSION: i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

[Pylephlebitis: a rare but possible complication of intra-abdominal infections]. / Pileflebitis: una extraña pero posible complicación de las infecciones intraabdominales.

BACKGROUND: Pylephlebitis or septic thrombophlebitis of the portal venous system is a rare but serious complication of intra-abdominal infections which drain into the portal venous system. Its diagnosis is based on clinical suspicion and imaging tests, mainly a computed tomography scan, given the lack of specificity of the signs and symptoms. Spread of septic emboli is the major cause of morbidity and mortality. The aim of the study was to analyse patients diagnosed in our hospital. MATERIAL AND METHODS: Retrospective descriptive study of patients diagnosed with pylephlebitis in our hospital. CLINICAL CASES: Four patients were included, 3 men and one woman. In 3 cases it was acute cholecystitis that led to the diagnosis of pylephlebitis at the same time as the intra-abdominal infection. Emergency surgery was performed in one case, whilst the other 2 were treated conservatively. Blood cultures were performed in all cases, and empirical antibiotic treatment was used. In the only case of acute appendicitis, diagnosis of pylephlebitis was achieved during the study of postoperative fever, with empirical antibiotic treatment also being started. The haematologist was requested to start the required anticoagulation therapy in all cases. CONCLUSIONS: Pylephlebitis is a rare complication of intra-abdominal infections that may make lead to a worse outcome. A high level of suspicion is required as well as imaging tests to make an early diagnosis and appropriate treatment.

Biopsia del ganglio centinela en el melanoma. Análisis de nuestra experiencia (125 pacientes) / Sentinel node biopsy for melanoma. Analysis of our experience (125 patients)

INTRODUCCIÓN: El objetivo del estudio es analizar nuestra experiencia en el uso de la biopsia del ganglio centinela (BGC) en el melanoma y determinar la existencia de factores predictores de resultado positivo y de drenaje múltiple. MATERIAL Y MÉTODOS: Estudio retrospectivo y analítico de aquellos pacientes a los que se les realizó BGC por melanoma, en el período entre agosto de 2000 y febrero de 2013. RESULTADOS: Se incluyó a 125 pacientes con una media de edad de 55,6 (± 15) años. La distribución anatómica de los ganglios centinelas (GC) fue: 44 (35,2%) en miembros inferiores, 24 (19,2%) en miembros superiores, 53 (42,4%) en tronco y 3 (2,4%) en cabeza y cuello. La mediana del índice de Breslow fue de 1,81 (0,45-5). El número de ganglios aislados fue entre 1 y 6, siendo en 98 casos (78,4%) de localización única y en 27 (21,6%) múltiple, de los que 25 (92,6%) se localizaron en el tronco. El estudio definitivo de la BGC fue positivo en 18 casos (7,1%), siendo el factor predictivo relacionado el espesor tumoral (p = 0,01). CONCLUSIONES: La BGC seleccionó de forma adecuada a los candidatos a linfadenectomía. El melanoma de tronco fue la principal localización de drenaje múltiple. El único factor predictor de resultado positivo del GC fue el espesor tumoral

INTRODUCTION: The objective of this study is to analyze our experience in the use of sentinel node biopsy (SNB) in melanoma and identify the predictive factors of positive SNB and multiple drainage. MATERIAL AND METHODS: Retrospective study of patients who underwent SNB for melanoma between August of 2000 and February of 2013. RESULTS: SNB was performed in 125 patients with a median of age of 55,6 (±15) years. The anatomic distribution was: 44 (35,2%) in legs, 24 (19,2%) in arms, 53 (42,4%) trunk and 3 (2,4%) in head and neck. The median Breslow index was 1,81 (0,45-5). Between 1 and 6 nodes were isolated. The drainage was unique in 98 (78,4%) and multiple in 27 (21,6%). The trunk was the localization of 25 (92,6%) nodes with multiple drainage. The definitive result of sentinel node (SN) was positive in 18 cases (7,1%). Breslow thickness (p = 0,01) was statistically significant predictor of a positive SNB. CONCLUSIONS: The SNB allows patients to be selected for lymphadenectomy. Melanoma of the trunk was the principle location of multiple drainage. The only predictive factor of positive SNB was Breslow thickness

[Epiploic appendagitis: a rare cause of abdominal pain]. / Apendagitis epiploica, causa poco frecuente de dolor abdominal.

BACKGROUND: Epiploic appendagitis is an atypical cause of abdominal pain whose knowledge could avoid diagnostic or treatment errors. Diagnosis has been performed with abdominal ultrasound or tomography with the only treatment being nonsteroidal anti-inflammatory drugs. OBJECTIVE: To analyze patients diagnosed in our hospital. METHODS: We performed a 4-year retrospective and descriptive study (March 2009-March 2013) of patients diagnosed with epiploic appendagitis in our hospital. RESULTS: Seventeen patients were included, 14 females and three males with a median age of 57 years. Symptom delay was 72 h. Abdominal pains were located in the left lower quadrant in 64.7% and right lower quadrant in 35.3% of patients. Blood test demonstrated leukocytes 6,300 (5,000-9,500), neutrophils 61.6% (57-65.8), and C reactive protein 1.5 (0.85-2.92). Diagnosis was confirmed with abdominal ultrasound or tomography in 88.2% and intraoperatively in 11.8%. CONCLUSIONS: Epiploic appendagitis was more frequent in women. Abdominal pain was located in the lower quadrant, more predominant in left than right. Blood tests were normal except for increased levels of C-reactive protein. Diagnosis was made mostly preoperatively due to imaging tests, avoiding unnecessary surgical intervention.

ANTECEDENTES: la apendagitis epiploica es una causa poco frecuente de dolor abdominal cuyo conocimiento podría evitar errores diagnósticos y terapéuticos. El diagnóstico suele establecerse mediante ecografía o tomografía abdominal; el tratamiento es sintomático, con antiinflamatorios. OBJETIVO: analizar los casos diagnosticados en nuestro centro. MATERIAL Y MÉTODOS: estudio retrospectivo y descriptivo de pacientes con diagnóstico de apendagitis epiploica durante 4 años (marzo 2009 a marzo 2013). RESULTADOS: se incluyeron 17 pacientes, 14 mujeres y 3 hombres, con una mediana de edad de 57 años. El periodo de latencia de los síntomas fue 72 horas. En 64.7% de los pacientes el dolor abdominal se localizó en el cuadrante inferior izquierdo y en 35.3% en el derecho. Laboratorio: leucocitos 6,300 (5,000-9,500), neutrófilos 61.6% (57- 65.8), proteína C reactiva 1.5 (0.85-2.92). El diagnóstico se confirmó mediante ecografía o tomografía abdominal en 88.2%, e intraoperatorio en 11.8%. CONCLUSIONES: la apendagitis epiploica fue más frecuente en mujeres. La clínica fue dolor abdominal en los cuadrantes inferiores, más frecuente en el lado izquierdo, con RESULTADOS de laboratorio normales, excepto la elevación de la proteína C reactiva. En la mayoría de los casos el diagnóstico se estableció preoperatoriomente, gracias al uso de pruebas radiológicas que evitó las intervenciones quirúrgicas innecesarias.

[Appendiceal diverticulitis: comparative study of 7 cases versus 442 acute appendicitis]. / Diverticulitis apendicular: Estudio comparativo de 7 casos versus 442 apendicitis agudas.

BACKGROUND: Appendiceal diverticulitis (AD) is a rare cause of acute appendicitis (AA) which is most frequently diagnosed after appendectomy in pathological study. OBJECTIVE: To compare AA versus AD. METHODS: Retrospective analytic study in avperiod of 51 months fom January 2009 to March 2013 in the Hospital Universitario San Juan de Alicante (Spain), including patients with clinical or radiological suspicious of acute appendicitis which was confirmed intraoperatively and with the pathological study. RESULTS: We included 449 patients, 442 typical AA (98.5%) and 7AD (1.5%). DA was more frequent in women (57%) with a median age of 44 years old (range 37 to 57 years old), whereas AA was more frequent in men (61%) with a median age of 28 years old (range 15 to 46 years old). Leukocyte count, neutrophils and C-reactive protein were respectively 13,300 per mm3 (range 10,700 to 15,700 per mm3), 87.1% (range 84.6 to 89.6%) and 1.82 mg/dL (range 0.59 to 5.31 mg/dL) in AD versus 14,700 per mm3 (range 12,300 to 17,600 per mm), 81.6% (range 75.1 to 86.4%) and 2.71 mg/dL (range 0.67 to 75 mg/dL) in AA. Alvarado score and appendicitis diagnostic score were respectively 7 (range 6 to 8) and 6 (range 5 to 7) in AD and 7 (range 5 to 7) and 6 (range 5 to 6) in AA. An appendiceal perforation was seen in 3 AD (43%) and 80 AA (18%). CONCLUSION: AD appeared in older patients with a clinical and blood test profile similar to AA but with a higher perforation rate.

Sentinel node biopsy for melanoma. Analysis of our experience (125 patients).

INTRODUCTION: The objective of this study is to analyze our experience in the use of sentinel node biopsy (SNB) in melanoma and identify the predictive factors of positive SNB and multiple drainage. MATERIAL AND METHODS: Retrospective study of patients who underwent SNB for melanoma between August of 2000 and February of 2013. RESULTS: SNB was performed in 125 patients with a median of age of 55,6 (±15) years. The anatomic distribution was: 44 (35,2%) in legs, 24 (19,2%) in arms, 53 (42,4%) trunk and 3 (2,4%) in head and neck. The median Breslow index was 1,81 (0,45-5). Between 1 and 6 nodes were isolated. The drainage was unique in 98 (78,4%) and multiple in 27 (21,6%). The trunk was the localization of 25 (92,6%) nodes with multiple drainage. The definitive result of sentinel node (SN) was positive in 18 cases (7,1%). Breslow thickness (p=0,01) was statistically significant predictor of a positive SNB. CONCLUSIONS: The SNB allows patients to be selected for lymphadenectomy. Melanoma of the trunk was the principle location of multiple drainage. The only predictive factor of positive SNB was Breslow thickness.

Diverticulitis apendicular: Estudio comparativo de 7 casos versus 442 apendicitis agudas. / [Appendiceal diverticulitis: comparative study of 7 cases versus 442 acute appendicitis].

BACKGROUND: Appendiceal diverticulitis (AD) is a rare cause of acute appendicitis (AA) which is most frequently diagnosed after appendectomy in pathological study. OBJECTIVE: To compare AA versus AD. METHODS: Retrospective analytic study in avperiod of 51 months fom January 2009 to March 2013 in the Hospital Universitario San Juan de Alicante (Spain), including patients with clinical or radiological suspicious of acute appendicitis which was confirmed intraoperatively and with the pathological study. RESULTS: We included 449 patients, 442 typical AA (98.5

) and 7AD (1.5

). DA was more frequent in women (57

) with a median age of 44 years old (range 37 to 57 years old), whereas AA was more frequent in men (61

) with a median age of 28 years old (range 15 to 46 years old). Leukocyte count, neutrophils and C-reactive protein were respectively 13,300 per mm3 (range 10,700 to 15,700 per mm3), 87.1

(range 84.6 to 89.6

) and 1.82 mg/dL (range 0.59 to 5.31 mg/dL) in AD versus 14,700 per mm3 (range 12,300 to 17,600 per mm), 81.6

(range 75.1 to 86.4

) and 2.71 mg/dL (range 0.67 to 75 mg/dL) in AA. Alvarado score and appendicitis diagnostic score were respectively 7 (range 6 to 8) and 6 (range 5 to 7) in AD and 7 (range 5 to 7) and 6 (range 5 to 6) in AA. An appendiceal perforation was seen in 3 AD (43

) and 80 AA (18

). CONCLUSION: AD appeared in older patients with a clinical and blood test profile similar to AA but with a higher perforation rate.

Diverticulitis apendicular: Estudio comparativo de 7 casos versus 442 apendicitis agudas / [Appendiceal diverticulitis: comparative study of 7 cases versus 442 acute appendicitis].

BACKGROUND: Appendiceal diverticulitis (AD) is a rare cause of acute appendicitis (AA) which is most frequently diagnosed after appendectomy in pathological study. OBJECTIVE: To compare AA versus AD. METHODS: Retrospective analytic study in avperiod of 51 months fom January 2009 to March 2013 in the Hospital Universitario San Juan de Alicante (Spain), including patients with clinical or radiological suspicious of acute appendicitis which was confirmed intraoperatively and with the pathological study. RESULTS: We included 449 patients, 442 typical AA (98.5

) and 7AD (1.5

). DA was more frequent in women (57

) with a median age of 44 years old (range 37 to 57 years old), whereas AA was more frequent in men (61

) with a median age of 28 years old (range 15 to 46 years old). Leukocyte count, neutrophils and C-reactive protein were respectively 13,300 per mm3 (range 10,700 to 15,700 per mm3), 87.1

(range 84.6 to 89.6

) and 1.82 mg/dL (range 0.59 to 5.31 mg/dL) in AD versus 14,700 per mm3 (range 12,300 to 17,600 per mm), 81.6

(range 75.1 to 86.4

) and 2.71 mg/dL (range 0.67 to 75 mg/dL) in AA. Alvarado score and appendicitis diagnostic score were respectively 7 (range 6 to 8) and 6 (range 5 to 7) in AD and 7 (range 5 to 7) and 6 (range 5 to 6) in AA. An appendiceal perforation was seen in 3 AD (43

) and 80 AA (18

). CONCLUSION: AD appeared in older patients with a clinical and blood test profile similar to AA but with a higher perforation rate.

[Acute abdomen due to perforated appendicular mucocele]. / Abdomen agudo por mucocele apendicular perforado.

Primary neoplasms of the appendix are present in approximately 0.2% to 0.3% of appendectomy specimens. Generally affect middle-age adults and elderly people. Approximately 30% to 50% of appendiceal neoplasms manifest with acute appendicitis by luminal obstruction. The definitive diagnosis is histological. We must avoid simple laparoscopic appendectomy and adopt an open procedure with a laparotomy appendectomy for a bening process. Right hemicolectomy is indicated when a malignant condition is suspected Follow-up is recommended in this pathology due to the risk of associated malignant neoplasms. We report a case of perforated appendiceal mucocele in a 84-year-old man presented as an acute abdomen.

[Leiomyomatosis peritonealis disseminata]. / Leiomiomatosis peritoneal difusa.

Leiomyomatosis peritonealis disseminata (LPD) is a rare, benign proliferative process characterized by multiple smooth muscle nodules throughout the peritoneum. Predominantly affects women in their reproductive years. The cause of LPD is unknown although it may be associated with high estrogen state. The clinical appearance mimics a peritoneal carcinomatosis and the radiologic findings are unspecific. So, the definitive diagnosis is histological. Treatment must be individualized depending on age, hormonal status and symptomatology. To date, less than 140 cases have been reported. We report a case of LPD in a 50-year-old woman presented as an intestinal obstruction.

[Thoracic empyema due to subphrenic appendicitis: an infrequent presentation]. / Empiema pleural secundario a apendicitis subdiafragmática: una extraña presentación.

Acute appendicitis is the most common abdominal surgical emergency. Atypical presentations lead to a late diagnosis with a higher complication rate. Given its rarity, we report a case of a thoracic empyema due to subphrenic appendicitis.