[Massive cerebral air embolism following endoscopic retrograde cholangiopancreatography. A case report and review of the literature]. / Embolia aerea cerebral masiva tras colangiopancreatografia retrograda endoscopica. Presentacion de un caso y revision de la bibliografia.

INTRODUCTION: Cerebral air embolism following endoscopic processes is an infrequent complication, but can have catastrophic consequences. CASE REPORT: An 85-year-old male diagnosed with distal cholangiocarcinoma with criteria for unresectability who was submitted to placement of a biliary drainage prosthesis. Endoscopic retrograde cholangiopancreatography was performed to change the prosthesis. After the procedure, the patient's vital signs and level of consciousness underwent a decline, and orotracheal intubation was required. A computerised axial tomography scan of the head showed evidence of a massive air embolism with focal points of hyperacute ischaemia in both hemispheres. The patient later died. CONCLUSIONS: Cerebral air embolism following endoscopic retrograde cholangiopancreatography is infrequent, but potentially lethal. Manipulation of the bilio-intestinal wall in endoscopic examinations could give rise to communications between the lumen and the venous system. This, together with the high insufflation pressure used to conduct this test, would condition the passage of air to the portal venous system, and from there to the circulatory system. In the central nervous system, air bubbles would lead to a vascular obstruction, with the subsequent ischaemia and necrosis of tissues. An early diagnosis and life support therapy are essential. Its timely management can contribute to a better prognosis which, at least initially, is gloomy.

TITLE: Embolia aerea cerebral masiva tras colangiopancreatografia retrograda endoscopica. Presentacion de un caso y revision de la bibliografia.Introduccion. La embolia aerea cerebral tras procesos endoscopicos es una complicacion infrecuente, pero que puede tener consecuencias catastroficas. Caso clinico. Varon de 85 años, diagnosticado de colangiocarcinoma distal con criterios de irresecabilidad, al cual se coloca una protesis biliar de drenaje. Se realiza una colangiopancreatografia retrograda endoscopica para el cambio de protesis. Tras el procedimiento, el paciente sufre un deterioro de las constantes vitales y del nivel de consciencia, y requiere intubacion orotraqueal. En la tomografia axial computarizada craneal se evidencia una embolia aerea masiva con focos de isquemia hiperaguda en ambos hemisferios. El paciente fallece posteriormente. Conclusiones. El embolismo aereo cerebral tras una colangiopancreatografia retrograda endoscopica es infrecuente, pero potencialmente letal. La manipulacion de la pared biliointestinal en las exploraciones endoscopicas podria originar comunicaciones entre la luz y el sistema venoso. Esto, unido a la alta presion de insuflacion para la realizacion de la prueba, condicionaria el paso de aire al sistema venoso portal y, de ahi, al sistema circulatorio. En el sistema nervioso central, las burbujas de aire provocarian una obstruccion vascular, con la consiguiente isquemia y necrosis del tejido. Es fundamental un diagnostico precoz y una terapia de soporte vital. Su rapido manejo puede contribuir a un mejor pronostico, que en principio es sombrio.

Short- and mid-term outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer. Our experience after 198 consecutive cases.

BACKGROUND: Robot-assisted total mesorectal excision is a safe alternative for rectal cancer treatment. Nevertheless, substantial data is still missing. Our aim was to assess the perioperative and oncological outcomes of the routine use of the robotic-assisted approach for rectal cancer treatment. PATIENTS AND METHODS: 198 Consecutive robotic rectal resections were performed between January 2011 and April 2015 in patients with stage I-IV disease. We prospectively evaluated peri and postoperative data, pathological findings and mid-term oncological outcomes. RESULTS: 36 Abdominoperineal Amputations, 28 High Anterior Resections, 131 Low Anterior Resections and 3 Hartmann operations were performed. Mean age, ASA, BMI and distance form anal verge were respectively 67.5 years, ASA II, 26.95 kg/m(2) and 5.9 cm. 71.2% Patients received neoadjuvant therapy. Mean OR time was 294 minutes. Conversion occurred in 4.5%. Mean postoperative stay was 8 days. 36 Patients required blood transfusion with a mean of 162 ml. Complications Clavien III-IV were 12.1%. 8 complete responses were observed, 50 UICC class I, 84 class II, 51 class III and 13 class IV. Mean lymph node harvested were 11.7. Mean distal margin was 3.3 cm. 11 Circumferential margins were affected in UICC class III-IV patients. Postoperative mortality was 0.5%. Local recurrence was observed in 5% patients. Median follow-up was 27.6 months. LIMITATIONS: Single institution descriptive study. CONCLUSIONS: The routine use of robotic assisted laparoscopic surgery may help to achieve lower conversion rates with lower ventral hernia rates and similar oncological outcomes using a minimally invasive approach in a non-selected group of patients with non-selected rectal tumours.