Solitary fibrous tumor of the parapharyngeal space: report of 2 cases and a literature review.

The solitary fibrous tumor (SFT) is usually described as a lesion arising from the pleura. Rarely, it has been described in the parapharyngeal space (PS). This study aims to report two cases of SFT in the PS and to perform a literature review on this topic. Two patients undergoing surgical resection of a SFT in the PS, were reported. A literature review on SFT of the PS, was also performed. Two patients were analyzed. Both patients underwent surgical resection, followed by adjuvant radiotherapy, for SFT arising from the PS. The postoperative course was uneventful and both patients recovered well after the procedure. No recurrences were diagnosed during the followup. SFT of the PS is an infrequent entity. Surgical resection is the most used treatment, and adjuvant radiation should be considered in patients with recurrence risk factors or distant metastases.

Is ERCP still the elective primary biliary drainage technique in patients with malignant distal biliary obstruction? Response to Garcia-Cano et al.

We have read the letter from García-Cano et al. regarding our Editorial and are very grateful for the response as it contributes to deepening the debate we aim to generate on the topic. We are aware that changing a paradigm is always difficult, takes years, and requires publication of good quality studies. However, the way to progress in medicine and provide the best for patients involves questioning existing paradigms and considering the possibility of changing them. Currently, the outcomes of endoscopic ultrasonography guided transmural biliary drainage (EUS-TBD) have been progressively improving and the rate of adverse events (AE) has considerably decreased. The data currently available suggest that primary EUS-TBD in a specific setting is not inferior to ERCP drainage and may even entail a lower rate of AE.

Plastic pigtail vs lumen-apposing metal stents for drainage of walled-off necrosis (PROMETHEUS study): an open-label, multicenter randomized trial.

BACKGROUND: Lumen-apposing metal stents (LAMS) have displaced double-pigtail plastic stents (DPS) as the standard treatment for walled-off necrosis (WON),ß but evidence for exclusively using LAMS is limited. We aimed to assess whether the theoretical benefit of LAMS was superior to DPS. METHODS: This multicenter, open-label, randomized trial was carried out in 9 tertiary hospitals. Between June 2017, and Oct 2020, we screened 99 patients with symptomatic WON, of whom 64 were enrolled and randomly assigned to the DPS group (n = 31) or the LAMS group (n = 33). The primary outcome was short-term (4-weeks) clinical success determined by the reduction of collection. Secondary endpoints included long-term clinical success, hospitalization, procedure duration, recurrence, safety, and costs. Analyses were by intention-to-treat. CLINICALTRIALS: gov, NCT03100578. RESULTS: A similar clinical success rate in the short term (RR, 1.41; 95% CI 0.88-2.25; p = 0.218) and in the long term (RR, 1.2; 95% CI 0.92-1.58; p = 0.291) was observed between both groups. Procedure duration was significantly shorter in the LAMS group (35 vs. 45-min, p = 0.003). The hospital admission after the index procedure (median difference, - 10 [95% CI - 17.5, - 1]; p = 0.077) and global hospitalization (median difference - 4 [95% CI - 33, 25.51]; p = 0.82) were similar between both groups. Reported stent-related adverse events were similar for the two groups (36 vs.45% in LAMS vs. DPS), except for de novo fever, which was significantly 26% lower in LAMS (RR, 0.26 [0.08-0.83], p = 0.015). CONCLUSIONS: The clinical superiority of LAMS over DPS for WON therapy was not proved, with similar clinical success, hospital stay and similar safety profile between both groups, yet a significant reduction in procedure time was observed. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT03100578.

Seguridad y factibilidad de la reconstrucción microquirúrgica en tumores de cabeza y cuello en pacientes mayores de 70 años / Safety and feasibility of free-flap reconstruction in head and neck tumors in patients aged 70 years or older

RESUMEN Antecedentes: debido al aumento en la expectativa de vida, se ha incrementado la incidencia de tumores de cabeza y cuello en pacientes añosos. Objetivo: evaluar los resultados de la reconstrucción con colgajos microquirúrgicos luego de la resección radical (RRMC) de tumores de cabeza y cuello en pacientes de 70 años o mayores. Material y métodos: se analizó una serie de pacientes sometidos a RRCM por tumores de cabeza y cuello en el período 2000-2020. Se dividió la muestra en dos grupos: G1: ≥ de 70 años y G2: < de 70 años. Se analizaron variables demográficas, quirúrgicas, posoperatorias y factores de riesgo de trombosis del colgajo en los pacientes ≥ de 70 años. Resultados: se incluyó un total de 178 pacientes, 61 en G1 y 117 en G2. Ambos grupos fueron homogéneos respecto del sexo, IMC (índice de masa corporal), alcoholismo, tabaquismo, tratamiento neoadyuvante e incidencia de HPV (virus del papiloma humano). Hubo mayor cantidad de pacientes con riesgo ASA ≥ III en G1 vs. G2; (p: 0,005). En G1, 33 (54%) correspondieron a estadio oncológico ≥ III vs. 99 (87%) en G2 (p: 0,001). Cuarenta y dos (69%) pacientes en G1 recibieron adyuvancia vs. 94 (83%) en G2 (p: 0,02) y no hubo diferencias en la morbimortalidad global y en fallas del colgajo. El sexo femenino fue el único factor de riesgo de trombosis del pedículo vascular (p: 0,05). Conclusión: la RRCM para tumores de cabeza y cuello es factible y segura en pacientes añosos, con una incidencia de morbimortalidad similar a la del resto de la población.

ABSTRACT Background: The higher life expectancy has increased the incidence of head and neck tumors in elder patients. Objective: the aim of this study was to evaluate the outcomes of free flap reconstructions after radical resection (FFRR) of head and neck tumors in patients aged 70 years or older. Material and methods: We analyzed a series of patients undergoing FFR due to head and neck tumors between 2000-2020. The patients were divided into two groups: G1: ≥ 70 years, and G2: < 70 years. The demographic, operative and postoperative variables and the risk factors for flap thrombosis in patients ≥ 70 years were analyzed. Results: A total of 178 patients were included, 61 in G1 and 117 in G2. Both groups were homogeneous regarding sex, BMI (body mass index), alcohol consumption, smoking habits, neoadjuvant treatment, and incidence of HPV (human papillomavirus). The incidence of ASA grade ≥ III was significantly higher in G1 vs. G2; (p: 0,005). In G1, 33 patients (54%) corresponded to cancer stage ≥ III vs. 99 (87%) in G2 (p: 0.001). Forty-two (69%) patients in G1 received adjuvant therapy vs. 94 (83%) in G2 (p = 0.02) and there were no differences in overall morbidity and mortality and in flap failure. Female sex was the only predictor of vascular flap thrombosis (p = 0.05). Conclusion: FFRR in head and neck tumors is feasible and safe in elderly patients, with morbidity and mortality rates similar to those of the general population.

El volumen de CPRE por endoscopista se asocia a mayor tasa de éxito y menor tasa de pancreatitis post-CPRE. Análisis de un registro prospectivo / The volume of ERCP per endoscopist is associated with a higher technical success and a lower post-ERCP pancreatitis rate. A prospective analysis

Introducción: la influencia del volumen anual de colangiopancreatografía retrógrada endoscópica (CPRE) en sus resultados ha sido analizada con resultados contradictorios.Objetivo: evaluar la influencia del volumen de CPRE en sus resultados. Material y métodos: análisis sobre base de datos prospectiva comparando los resultados de la CPRE en tres periodos definidos por el número de endoscopistas que la realizan: periodo I, con cinco endoscopistas; periodo II, con cuatro; y periodo III, con tres. Incluimos CPRE biliar en papila acce sible y virgen. Las variables principales fueron las tasas de canulación y los efectos adversos. Los grados de complejidad III y IV, según la clasificación de la Sociedad Americana de Endoscopia Digestiva (ASGE, por sus siglas en inglés), se consideraron procedimientos de alta complejidad. Resultados: fueron incluidos 2.561 pacientes: 727 (periodo I), 972 (periodo II) y 862 (periodo III). No hubo diferencias en edad y sexo entre grupos (p > 0,05). La tasa de canulación fue significativamente mayor en los periodos II y III: 92,4 % vs. 93,3 % vs. 93 % (p = 0,037). La tasa de efectos adver sos (EA) fue de 13,8 %, 12,6 % y 10,3 % (p > 0,05). La tasa de pancreatitis post-CPRE fue significativamente menor en el periodo III: 8,5 %, 7,3 % y 5 % (p = 0,01). El porcentaje de procedimientos de alta complejidad fue de 12 %, 14,8 % y 27 % (p < 0,0001), respectivamente. La regresión logística mostró tasas de canulación y pancreatitis post-CPRE significativamente mejores en el periodo III tras ajustar por sexo, complejidad y endoscopista. Conclusión: un mayor volumen anual de CPRE por endoscopista se asoció con mayor tasa de canulación y menor tasa de pancreatitis post-CPRE, a pesar de la mayor complejidad de los procedimientos. Estos efectos beneficiosos parecen diferir entre endoscopistas(AU)

Crisis hipercalcémica, presentación inusual de adenoma paratiroideo: reporte de 2 casos / Hypercalcemic crisis, unusual presentation of parathyroid adenoma

La crisis hipercalcémica (CH) es una emergencia endocrina inusual, definida por la presencia de calcemia > 14 mg/dl asociada a disfunción renal, alteraciones cardiovasculares, gastrointestinales y del sensorio; también podría considerarse en pacientes con síntomas graves y calcemia menor. El hiperparatiroidismo primario (HPTP) y las neoplasias malignas son las etiologías más comunes de la hipercalcemia (90% de los casos); sin embargo, rara vez el primero se presenta como CH. Debido a la alta mortalidad asociada a esta entidad, es de gran importancia establecer diagnóstico y tratamiento precoces. Presentamos dos pacientes con crisis hipercalcémica como primera manifestación del HPTP, el 1.° con bloqueo auriculoventricular (AV) completo y el 2.° con pancreatitis aguda. La anatomía patológica (AP) reveló adenoma oxifílico en ambos casos, que es una variante histológica poco frecuente y puede manifestarse clínicamente de forma grave. Conclusiones: los adenomas paratiroideos son causa poco frecuente de CH. Consideramos el tipo histológico observado (adenoma oxifílico) como probable factor condicionante. La pancreatitis y especialmente el bloqueo AV son manifestaciones poco frecuentes de la CH. Resaltamos la importancia de la determinación de los niveles de calcio dentro de la evaluación inicial de todo paciente con bloqueo AV. (AU)

Hypercalcemic crisis (HC) is an unusual endocrine emergency, defined as the presence of serum calcium > 14 mg/dl related to kidney dysfunction, cardiovascular, gastrointestinal and sensory disturbances. It could also be considered in patients with severe symptoms and lower serum calcium levels. Primary hyperparathyroidism (PHPT) and malignant neoplasms are the most common hypercalcemia etiologies (90% of cases), nevertheless, the former hardly ever occurs as HC. Due to the high mortality associated with HC, it is crucial to establish early diagnosis and treatment.We report two patients with HC as the first manifestation of PHPT; the former with atrioventricular (AV) block and the latter with acute pancreatitis. Pathology revealed oxyphilic adenoma in both cases, which is an infrequent histological variant that can have a severe clinical manifestation. Conclusions: parathyroid adenomas are a rare cause of HC. We consider the histological type observed (oxyphilic adenoma) as a probable conditioning factor. Pancreatitis and especially AV block are rare manifestations of HC. We emphasize the importance of determining calcium levels in the initial evaluation of all patients with AV block. (AU)

Estudios preoperatorios coincidentes para el diagnóstico de hiperparatiroidismo primario por adenoma simple: ¿podemos evitar la PTH intraoperatoria? / Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring?

Introducción: La causa más frecuente de hiperparatiroidismo primario (HPP) es el adenoma paratiroideo (único en el 80 a 85% de los casos y doble en un 4%, aproximadamente). El resto de los casos obedece a una hiperplasia de las glándulas paratiroides, o de forma más infrecuente, a un carcinoma paratiroideo. Nuestro objetivo es determinar la utilidad de la hormona paratiroidea intraoperatoria (PTHio) en pacientes con ecografía cervical y centellograma coincidentes preoperatorios, en el HPP por un adenoma simple. Métodos: Se realizó un estudio retrospectivo, unicéntrico, incluyendo a todos los pacientes sometidos a paratiroidectomía mini-invasiva (PMI) por HPP, por adenoma simple. Definimos estudios coincidentes cuando ambos localizaron el adenoma. La PTHio fue medida en tres ocasiones: en la inducción anestésica, inmediatamente antes y a los 15 minutos de la escisión de la glándula. El éxito se definió como la caída de al menos el 50% del valor máximo de la hormona paratiroidea (PTH) luego de remover la glándula. Se analizaron variables demográficas, intraoperatorias, postoperatorias y la utilidad de la PTHio. Resultados: Se realizaron un total de 499 paratiroidectomías, de estas, 218 presentaron un adenoma localizado en la ecografía y gammagrafía. La edad fue de 60,1 años y 85% eran mujeres. Luego de 15 minutos de la escisión del adenoma, la PTHio no descendió en nueve pacientes (4,2% OR 1,9 a 7,69%); todos ellos fueron a una exploración cervical bilateral. El valor agregado de la PTHio para la cura de la enfermedad fue de 3,6%. Hubo un 99% de curación de enfermedad. El tiempo operatorio fue de 66,4 minutos y el de espera de la PTHio fue de 31 minutos. La PTHio encareció el procedimiento al doble. Conclusiones: La ecografía y el centellograma preoperatorios coincidentes para la localización de un adenoma en HPP podrían evitar la medición de la PTHio durante las PMI. (AU)

Introduction: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. Methods: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 minutes after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50%compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. Results: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 minutes after its excision, IOPTH did not decrease in 9 patients (4.2% OR 1.9% - 7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 minutes and the waiting time for the third IOPTH result was 31minutes. Performing IOPTH monitoring made the surgery about twice more expensive. Conclusions: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies. (AU)

Factores de riesgo de hipocalcemia severa postiroidectomía total / Risk factors for severe hypocalcemia after total thyroidectomy

Antecedentes: la hipocalcemia es la complicación más frecuente luego de una tiroidectomía total y puede manifestarse de manera bioquímica, o con síntomas leves o severos. Objetivos: analizar factores de riesgo asociados al desarrollo de hipocalcemia severa postiroidectomía total. Material y métodos: se incluyeron pacientes en los que se realizó tiroidectomía total primaria, analizando factores de riesgo asociados al desarrollo de hipocalcemia severa (signos y síntomas que requirieron internación y tratamiento con calcio intravenoso o persistencia de signosintomatología luego de 48 horas de haber recibido tratamiento inicial vía oral). Se analizaron variables demográficas, clínico-quirúrgicas e histopatológicas. Resultados: se realizaron un total de 1665 tiroidectomías entre 2007 y 2018 y, de estas, 918 fueron tiroidectomías totales primarias. Un total de 203 (22%) pacientes desarrollaron hipocalcemia. De ellos, 183 (20%) presentaron hipocalcemia leve y 20 (2%) hipocalcemia severa. En el análisis univariado, la edad, la intervención por cirujano especialista en cabeza y cuello, el peso de la glándula tiroides mayor de 30 gramos, la resección paratiroidea y la patología maligna se vieron asociados al desarrollo de hipocalcemia severa. En el análisis multivariado, los últimos tres fueron factores de riesgo asociados a esta complicación, con significancia estadística. Conclusiones: en nuestra serie, los factores de riesgo asociados al desarrollo de hipocalcemia severa postiroidectomía total fueron la resección, advertida o inadvertida de las glándulas paratiroides, el peso de la glándula tiroides mayor de 30 gramos y la patología maligna. Por lo tanto, en estos pacientes debemos prestar especial atención al desarrollo de dicha complicación en el posoperatorio.

Background: Hypocalcemia is the most common complication after a total thyroidectomy. It may occur as biochemical hypocalcemia, or with mild or severe symptoms. Objectives: The aim of this study was to analyze the risk factors associated with the development of severe hypocalcemia after total thyroidectomy. Material and methods: Patients undergoing primary total thyroidectomy were included. The risk factors for the development of severe hypocalcemia (signs and symptoms requiring hospitalization and treatment with intravenous calcium or persistence of signs and symptoms after 48 hours of initial oral treatment) were analyzed. The evaluation included analysis of the demographic, clinical, surgical and histopathological variables. Results: Of 1665 thyroid resections performed between 2007 and 2018, 918 corresponded to primary total thyroidectomies; 203 (22%) of these patients developed hypocalcemia. Mild hypocalcemia occurred in 183 (20%) cases and sever hypocalcemia in 20 (2%) patients, The univariate analysis showed that a procedure performed by head and neck surgeons, thyroid gland weight > 30 g, resection of the parathyroid glands and thyroid cancer were associated with the development of severe hypocalcemia. On multivariate analysis, the last three variables were risk factors significantly associated with this complication. Conclusions: In our series, noticed or inadvertent resection of the parathyroid glands with subsequent reimplantation, high weight of the thyroid gland and malignancy were identified as risk factors for the development of severe hypocalcemia after total thyroidectomy. Therefore, we should pay special attention to the development of such complication in the postoperative period.

Endoscopic ultrasound cytologic brushing vs endoscopic ultrasound - fine needle aspiration for cytological diagnosis of cystic pancreatic lesions. A multicenter, randomized open-label trial

Introduction: the incidence of cystic pancreatic lesions (CPL) in the asymptomatic population is increasing. Achieving a preoperative diagnosis of CPL still remains a challenge. Objectives: to evaluate the diagnostic accuracy of the cytological diagnosis of CPL from samples obtained by cytology brush versus standard endoscopic ultrasound fine needle aspiration (EUS-FNA). Methods: a multicenter, randomized, open-label trial was performed of EUS-cytology brush (EUS-EB) versus EUS-FNA for the cytological diagnosis of CPL. Patients that underwent EUS-FNA with a CPL > 15 mm were included and randomized into two groups: group I, EUS-EB; group II, EUS-FNA. The final diagnosis was based on the histological evaluation of surgical specimens and clinical parameters, imaging and a five year follow-up in non-operated patients. The main outcome was the diagnostic accuracy of both methods. Secondary outcomes were the diagnostic adequacy of specimens and the rate of adverse events. Data were compared using the Chi-squared test. An intention to treat (ITT) and per-protocol (PP) analysis were performed. Results: sixty-five patients were included in the study, 31 in group I and 34 in group II. Three patients initially randomized to group I were changed to group II as it was impossible to obtain a sample using the brush. The mean size of the CPL was 28.2 mm (range 16-60 mm). The diagnostic accuracy of EUS-EB was not superior to EUS-FNA, neither in the ITT nor the PP analysis (44.8% vs 41.1%, p = 0.77 and 38.4% vs 45.9%, p = 0.55). Conclusions: EUS-EB does not improve the diagnostic accuracy of CPL in comparison with EUS-FNA

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Efficacy of peroral endoscopic myotomy compared with other invasive treatment options for the different esophageal motor disorders

Introduction: Peroral endoscopic myotomy (POEM) has been performed since 2008 on more than 5,000 patients. It has proven to be highly effective in the treatment of achalasia and has shown promising outcomes for other esophageal motility spastic disorders. Methods: A literature review of the efficacy of POEM compared to the previous invasive treatments for different esophageal motility disorders was performed. The application in the pediatric and elderly populations and its role as a rescue therapy after other procedures are also outlined. Results: Short-term outcomes are similar to laparoscopic Heller myotomy (LHM) and pneumatic endoscopic dilation (PD) (clinical success > 90%) for achalasia subtypes I and II. Mid-term outcomes are comparable to LHM and overcome results obtained after PD (> 90% vs ~50%). With regard to type III achalasia, POEM efficacy is 98% compared to 80.8% for LHM and the PD success remains at 40%. With regard to spastic esophageal disorders (SED), POEM has an effectiveness of 88% and 70% for distal esophageal spasm (DES) and jackhammer esophagus (JE) respectively. A response of 95% in patients with sigmoid esophagus has been reported. POEM has been performed in pediatric and elderly populations and has obtained a higher efficacy than PD in pediatric series (100% vs 33%) without greater adverse events. Previous treatments do not seem to hinder POEM results with excellent response rates, including 97% in post LHM and 100% in a re-POEM series. Final considerations: POEM has shown excellent short and mid-term results for all subtypes of achalasia but long-term results are not yet available. The promising results in SED may make POEM the first-line treatment for SED. A high-safety profile and efficacy have been shown in elderly and pediatric populations. Previous treatments do not seem to diminish the success rate of POEM. Core tip: POEM has emerged as an efficient treatment option for all subtypes of achalasia and other scenarios (including previous treatments and elderly and pediatric populations). Short and midterm results are comparable to LHM and are better than PD data. The clinical response rate of DES and JE may make POEM the first-line treatment for SED (AU)

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Carcinoma escamoso primario de órbita / Primary orbital squamous cell carcinoma

El carcinoma escamoso primario de órbita es una entidad poco frecuente. Hay escasa literatura publicada al respecto. Presentamos un caso de carcinoma escamoso primario de los tejidos blandos de la órbita. La resección quirúrgica ofrecía el mejor tratamiento para esta paciente. Se realizó un abordaje cráneo-facial y se logró la resección completa de la lesión. La paciente recibió radioterapia adyuvante debido a la proximidad de la lesión a los márgenes quirúrgicos. El tratamiento quirúrgico es factible y debe ser considerado como parte del arsenal del cirujano. Sin embargo, las decisiones terapéuticas deben tomarse teniendo en cuenta las particularidades de cada caso.

Primary orbital squamous cell carcinoma is a rare entity. There is little published literature. We report a case of primary squamous cell carcinoma of the orbital soft tissues. Surgical resection offered the best treatment for the patient. Complete resection of the lesion was achieved. The patient received adjuvant radiotherapy due to the proximity of the lesion to the surgical margins. Surgical treatment is feasible and should be considered as part of the surgeon´s arsenal. However, therapeutic decisions must be made on a case-by-case basis.

Valor predictivo pretratamiento del cociente neutrófilos/linfocitos circulantes sobre la posibilidad de resección R0 en el cáncer gástrico / Pretreatment predictive value of blood neutrophil/lymphocyte ratio in R0 gastric cancer resectability

INTRODUCCIÓN: Se necesitan nuevos parámetros, complementarios al TNM clínico, para orientar preoperatoriamente acerca de la resecabilidad R0 del cáncer gástrico. Analizaremos el posible valor predictivo del cociente neutrófilos/linfocitos (N/L) circulantes sobre dicha resecabilidad. MÉTODOS: Estudiamos retrospectivamente 257 carcinomas gástricos, diagnosticados consecutivamente y sin tratamiento neoadyuvante. Realizamos un análisis univariante y multivariante de la frecuencia de casos con resección R0 entre los grupos con cociente N/L «normal» (< 5) y «patológico» (≥ 5). Adicionalmente, estudiamos el subgrupo de pacientes operados (n = < 5 o ≥ 5. RESULTADOS: Fueron operados 156 casos, con 139 resecciones R0. Registramos un cociente N/L elevado en 46 casos (17,9%). Globalmente, la resecabilidad R0 fue superior en los pacientes con cociente N/L < 5: 59,7% frente al cociente ≥ 5: 28,6% (p < 0,001; OR = 3,76; IC 95% = 1,78-8,04). En el análisis multivariante se confirma la relación entre cociente N/L < 5 y resección R0 (p = 0,006; OR = 3,86; IC 95% = 1,46-10,22). En el subgrupo de pacientes operados se mantiene la mayor frecuencia de resección R0 en los casos con cociente < 5: 91,3% frente a 72,2% (p = 0,015; OR = 4,04; IC 95% = 1,23-13,26). CONCLUSIONES: De modo global, un cociente N/L < 5 en el momento del diagnóstico del cáncer gástrico se relaciona de modo significativo e independiente con una mayor frecuencia de resección tumoral R0. En el subgrupo de pacientes operados se confirma esta mayor proporción de resección R0 en los casos con cociente N/L < 5

INTRODUCTION: New parameters complementary to clinical TNM classification are needed, to orient preoperative on the possibility of a R0 gastric cancer resection. We analysed the possible predictive value of blood neutrophil/lymphocytic ratio (N/L) in relation to resectability. METHODS: Two hundred and fifty-seven gastric cancers consecutively diagnosed and without neoadjuvant treatment were retrospectively studied. Univariate and multivariate analysis of the frequency of R0 cases was performed between groups with a normal N/L ratio (< 5) and pathological N/L ratio (≥ 5). Furthermore, we studied the subgroup of operated patients (n = 156) analysing the frequency of R0 resection according to N/L ratio < 5 or ≥ 5. RESULTS: One hundred and fifty-six patients underwent surgical intervention, of which 139 had R0 resections. A high N/L ratio was registered in 46 cases (17.9%). Globally, resectability was higher in patients with a N/L ratio < 5: 59.7% vs. N/L ratio ≥ 5: 28.6% (P < .001; OR = 3.76; 95% C = 1.78-8.04). The relation between N/L ratio < 5 and R0 resection was confirmed in the multivariate (P = .006; OR = 3.86; 95% CI = 1.46-10.22). In the operated subgroup, the higher frequency of R0 resection achievement is maintained in cases with N/L ratio < 5: 91.3% vs. 72.2% (P = .015; OR =4.04; 95% CI = 1.23-13.26). CONCLUSIONS: The presence of a N/L ratio < 5 at the diagnosis of a gastric carcinoma is related in a significant and independent way with a higher frequency of R0 tumoral resection, globally. This higher proportion of R0 resection cases in patients with a N/L < 5 ratio is confirmed in the subgroup of operated patients

Mielolipoma adrenal gigante: Adrenalectomía derecha laparoscópica / Giant adrenal myelolipoma. Right laparoscopic adrenalectomy

El mielolipoma es un tumor adrenal poco frecuente. Se trata de un tumor benigno no funcionante compuesto por tejido adiposo y hematopoyético. Presentamos el caso de una paciente de 33 años de edad con diagnóstico de incidentaloma adrenal de 14 cm de diámetro no funcionante. Los estudios imagenológicos presentaban características sugestivas de mielolipoma. Debido a la naturaleza benigna del tumor se decidió el abordaje laparoscópico. La anatomía patológica informó un mielolipoma de 444 gramos. La paciente evolucionó favorablemente en el postoperatorio. El abordaje laparoscópico para la resección del mielolipoma gigante fue factible y exitoso.

Adrenal myelolipoma is a rare, benign, non-functioning tumor. It is composed by fat and hematopoietic tissues. We present the case of a 33-year-old woman with diagnosis of a 14 cm diameter non-functioning right adrenal incidentaloma, with imaging features suggestive of myelolipoma. Based on the benign nature of the tumor, laparoscopic resection was performed. Histopathology showed a myelolipoma, weighting 444 grams. The patient evolved with an uneventful postoperative period. Laparoscopic adrenalectomy for a giant myelolipoma was feasible and successful.

Valor pronóstico pretratamiento del antígeno carcinoembrionario en el cáncer colorrectal operado. ¿Es útil en todos los estadios del tumor? / Prognostic value of preoperative carcinoembryogenic antigen: Is it useful in all stages of colorectal cancer?

INTRODUCCIÓN: Publicaciones recientes han reactivado la discusión sobre el valor pronóstico de la elevación pretratamiento del antígeno carcinoembrionario (CEA) en el cáncer colorrectal. Debido a los resultados discordantes comunicados, pretendemos analizar en nuestro medio esta posible capacidad predictiva, globalmente y en los diferentes estadios tumorales. PACIENTES Y MÉTODOS: Estudiamos retrospectivamente 303 cánceres colorrectales resecados consecutivamente con intención curativa, analizando la mortalidad debida al tumor. Determinamos la frecuencia de casos con CEA pretratamiento patológico (>5 mg/l). Comparamos mediante análisis univariante y multivariante las curvas de supervivencia entre los casos con CEA normal y patológico, tanto en el global de la serie como en los diferentes estadios pTNM. RESULTADOS: La frecuencia de pacientes con CEA > 5 mg/l fue del 31%. La mediana de seguimiento clínico alcanzó los 83 meses. En el análisis multivariante de la serie global, la supervivencia fue desfavorable para los casos con CEA elevado: hazard ratio (HR) = 1,89; intervalo de confianza al 95% (IC 95%) = (1,15-3,10); p = 0,012. Al efectuar el análisis de supervivencia en los diversos estadios, únicamente se mantiene el valor predictivo en el estadio II (n = 104): HR = 3,02; IC 95% = (1,22-7,45); p = 0,017. CONCLUSIONES: Antes del inicio del tratamiento, un 31% de nuestros cánceres colorrectales resecados con intención curativa presentaron unos valores patológicos de CEA. Considerando la serie globalmente, la elevación del CEA pretratamiento presenta, de modo independiente, un valor pronóstico desfavorable sobre la supervivencia, pero al analizar su valor predictivo según los diferentes estadios, solo mantiene su significación en el estadio pTNM II

INTRODUCTION: Recent reports have reopened discussion of the prognostic value of elevated pre-treatment carcinoembryonic antigen (CEA) levels in colorectal cancer. Due to the discrepancies in the published results, we aimed to analyze the possible predictive value of CEA, both overall and in different tumoral stages in our environment. PATIENTS AND METHODS: We retrospectively studied 303 consecutive patients with colorectal cancer resected with curative intent by analysing tumor-related mortality. The frequency of patients with increased CEA levels (> 5 mg/l) was registered. Univariate and multivariate analyses of survival curves were performed, comparing patients with increased CEA levels and those with CEA levels within normal limits, both in the overall series and in the different pTNM tumoral stages. RESULTS: Frequency of patients with CEA > 5 mg/l was 31%. The median clinical follow-up was 83 months. A poor survival rate was registered in the multivariate analysis of the whole series in patients with high CEA levels: hazard ratio (HR) = 1.81; 95% confidence interval (95% CI) = (1.15-3.10); P=.012. This predictive value was only maintained in stage II in the survival analysis of the distinct tumoral stages (n = 104): HR = 3.02; 95% CI = (1.22-7.45); P=.017. CONCLUSIONS: Before treatment, 31% of our patients with colorectal cancer resected with curative intent had pathological CEA values. In the overall series, a high pretreatment CEA level showed an independent prognostic value for poor survival. When pTNM tumoral stages were analyzed separately, CEA level had predictive value only in pTNM II tumors

Predictores de metástasis de ganglio centinela en melanoma cutáneo / Predictors for sentinel lymph node metastasis of cutaneous melanoma

Antecedentes: se han descripto múltiples factores de riesgo para el compromiso del ganglio centinela en melanoma cutáneo, pero existe discrepancia en cuanto a la importancia de cada uno de ellos. El objetivo de este estudio fue identificar factores predictores de metástasis del ganglio centinela en pacientes con melanoma cutáneo. Material y métodos: se incluyeron los mapeos linfáticos realizados en pacientes con melanoma cutáneo entre 2001 y 2013. Se evaluaron variables demográficas y características del tumor primario. Se realizaron análisis univariado y multivariado en busca de factores predictivos del compromiso del ganglio centinela. Resultados: en el período citado se efectuaron 117 mapeos linfáticos; 25 pacientes (21,3%) presentaron ganglio centinela positivo. La edad y la localización de la lesión primaria no se asociaron con riesgo de metástasis linfática. Los melanomas con espesor de 1 a 4 mm se asociaron con mayor compromiso ganglionar que aquellos con espesor menor de 1 mm, y aquellos con espesor mayor de 4 mm tuvieron aún mayor tasa de ganglio centinela positivo. La presencia de ulceración y el tipo histológico nodular tuvieron mayor compromiso del ganglio centinela. La regresión tumoral y el número de mitosis no se relacionaron con la positividad del ganglio centinela. En el análisis multivariado solo el índice de Bres-low mayor de 4 mm y el tipo histológico nodular presentaron significación estadística. Conclusiones: la ulceración, el índice de Breslow y el tipo histológico nodular se asocian a mayor compromiso del ganglio centinela. El índice de Breslow y el tipo histológico nodular serían predictores independientes de compromiso ganglionar en melanoma cutáneo.

Background: multiple risk factors have been described in order to predict sentinel lymph node (SLN) compromise in patents with cutaneous melanoma. However, there is no agreement as to the impor-tance of each of those factors. The aim of this study was to identify risk factors of SLN metastasis. Methods: consecutive SLN biopsies in patents with cutaneous melanoma in the period 2001-2013 were included. Demographic factors and primary tumor characteristics were evaluated and univariate and multivariate analyses were performed. Results: of 117 SLN biopsies, 25 patents (21.3%) had a positive SLN. Age and tumor locaton were not associated with risk of lymphatic metastasis. Patents with Breslow thickness 1-4 mm were associated with more nodal involvement than those with thickness < 1mm and those with > 4mm had even higher rate of positive SLN. Ulceraton and nodular histology showed higher SLN compromise. Tumor regres-sion and number of mitoses were not associated with positive SLN. In the multivariate analysis Breslow thickness > 4mm and nodular histologic type showed statstical significance. Conclusions: ulceraton, Breslow thickness and nodular histologic type are associated with the SLN status. Furthermore, Breslow thickness and nodular histologic type could be independent predictor factors of SLN involvement.

Experimental study of hybrid-knife endoscopic submucosal dissection (ESD) versus standard ESD in a Western country / Estudio experimental sobre disección submucosa endoscópica con bisturí híbrido frente a la ESD estándar en un país occidental

Background: Endoscopic submucosal dissection (ESD) is an effective but time-consuming treatment for early neoplasia that requires a high level of expertise. Objective: The objective of this study was to assess the efficacy and learning curve of gastric ESD with a hybrid knife with highpressure water jet and to compare with standard ESD. Material and methods: We performed a prospective nonsurvival animal study comparing hybrid-knife and standard gastric ESD. Variables recorded were: Number of en-bloc ESD, number of ESD with all marks included (R0), size of specimens, time and speed of dissection and adverse events. Ten endoscopists performed atotal of 50 gastric ESD (30 hybrid-knife and 20 standard). Results: Forty-six (92 %) ESD were en-bloc and 25 (50 %) R0 (hybrid-knife: n = 13, 44 %; standard: n = 16, 80 %; p = 0.04).Hybrid-knife ESD was faster than standard (time: 44.6 ± 21.4 minutes vs. 68.7 ± 33.5 minutes; p = 0.009 and velocity: 20.8 ± 9.2 mm2/ min vs. 14.3 ± 9.3 mm2/min (p = 0.079). Adverse events were not different. There was no change in speed with any of two techniques (hybrid-knife: From 20.33 ± 15.68 to 28.18 ± 20.07 mm2/min; p= 0.615 and standard: From 6.4 ± 0.3 to 19.48 ± 19.21 mm2/min; p = 0.607). The learning curve showed a significant improvement in R0 rate in the hybrid-knife group (from 30 % to 100 %). Conclusion: despite the initial performance of hybrid-knife ESD is worse than standard ESD, the learning curve with hybridknife ESD is short and is associated with a rapid improvement. The introduction of new tools to facilitate ESD should be implemented with caution in order to avoid a negative impact on the results (AU)

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Disección submucosa endoscópica. Guía de práctica clínica de la SEED / Endoscopic submucosal dissection. Sociedad Española de Endoscopia Digestiva (SEED) clinical guideline

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¿Influye el posible cansancio del endoscopista en la frecuencia de colonoscopias incompletas y de las lesiones polipoideas diagnosticadas? / Does endoscopist fatigue play a role in incomplete colonoscopies and detection of polypoid lesions?

INTRODUCCIÓN: Actualmente sigue discutiéndose el posible efecto del cansancio del explorador sobre los resultados de las colonoscopias. Pretendemos analizar posibles diferencias en cuanto a exploraciones completas e índice de pólipos y adenomas diagnosticados en las endoscopias, según fueran efectuadas al principio o al final de cada sesión de trabajo continuado, y valorar la influencia del número de orden de realización de la colonoscopia (queue position) sobre los índices de lesiones detectadas. PACIENTES Y MÉTODOS: Estudio retrospectivo de 1.000 colonoscopias ambulatorias, sucesivas y divididas en 2 grupos: «inicial» y «final». Tras excluir 95 exploraciones mal preparadas y comprobar la homogeneidad de los grupos en cuanto a características y antecedentes de los pacientes, comparamos la frecuencia de exploraciones completas y el índice de pólipos y adenomas entre ambos bloques. Analizamos posibles diferencias en la frecuencia de lesiones polipoideas, según el número de orden de realización de la colonoscopia. RESULTADOS: Los índices globales de pólipos y adenomas fueron 44,2 y 30,5%, respectivamente, sin diferencias significativas entre los 13 exploradores; pólipos: p = 0,21, y adenomas: p = 0,63. Comparando los grupos «inicial» (n = 532) y «final» (n = 373), no encontramos diferencias en cuanto a exploraciones completas (97,2 versus 99,4% [p = 0,92]), ni índice de pólipos (45,9 versus 41,8% [p = 0,23], ni adenomas (30,8 versus 30% [p = 0,80] o adenomas serrados (2,1 versus 1,6% [p = 0,62]). El índice de lesiones detectadas no varió en relación con la queue position: pólipos, p = 0,60, y adenomas, p = 0,83. CONCLUSIONES: En nuestro medio, el posible cansancio del explorador al final de la agenda de trabajo no influyó en el porcentaje de colonoscopias completas, ni en los índices de pólipos o adenomas diagnosticados. Tampoco registramos diferencias en cuanto a lesiones polipoideas detectadas en relación con el número de orden de realización de la colonoscopia

INTRODUCTION: Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate. PATIENTS AND METHODS: A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early» and «late» procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed. RESULTS: The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p = 0.63. No significant differences were found between the «early group» (n = 532) and the «late group» (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p = 0.92)], the polyp detection rate [45.9 vs 41.8% (p = 0.23)], the adenoma detection rate [30.8 vs 30% (p = 0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p = 0.62)]. The lesion detection rate did not vary in relation to the «queue position»: polyps [p = 0.60, and adenomas: p = 0.83. CONCLUSIONS: In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy Schedule