Predictive Value of Antithrombin III and d -Dimer in the Development of Moderate-To-Severe Acute Pancreatitis : A Prospective, Observational Study (AT-PROPANC).

OBJECTIVES: To analyze if antithrombin III (AT-III) and d -dimer levels at admission and at 24 hours can predict acute pancreatitis (AP) progression to moderately severe AP (MSAP) to severe AP (SAP) and to determine their predictive value on the development of necrosis, infected necrosis, organ failure, and mortality. METHODS: Prospective observational study conducted in patients with mild AP in 2 tertiary hospitals (2015-2017). RESULTS: Three hundred forty-six patients with mild AP were included. Forty-four patients (12.7%) evolved to MSAP/SAP. Necrosis was detected in 36 patients (10.4%); in 10 (2.9%), infection was confirmed. Organ failure was recorded in 9 patients (2.6%), all of whom died. Those who progressed to MSAP/SAP showed lower AT-III levels; d -dimer and C-reactive protein (CRP) levels increased. The best individual marker for MSAP/SAP at 24 hours is CRP (area under the curve [AUC], 0.839). Antithrombin III (AUC, 0.641), d -dimer (AUC, 0.783), and creatinine added no benefit compared with CRP alone. Similar results were observed for patients who progressed to necrosis, infected necrosis, and organ failure/death. CONCLUSION: Low AT-III and high d -dimer plasma levels at 24 hours after admission were significantly associated with MSAP/SAP, although their predictive ability was low. C-reactive protein was the best marker tested. CLINICAL STUDY IDENTIFIER: ClinicalTrials.gov NCT02373293.

¿Es segura y eficaz la colecistostomía percutánea en la colecistitis aguda? Análisis de los efectos adversos asociados a la técnica / Is percutaneous cholecystostomy safe and effective in acute cholecystitis? Analysis of adverse effects associated with the technique

IntroducciónEl objetivo principal de nuestro estudio es valorar la seguridad y la eficacia de la colecistostomía percutánea para el tratamiento de la colecistitis aguda determinando la incidencia de efectos adversos que presentan los pacientes sometidos a este procedimiento.Material y métodoEstudio observacional con inclusión consecutiva de todos los pacientes con diagnóstico de colecistitis aguda durante 10 años. La variable principal estudiada ha sido la morbilidad (efectos adversos) recogida de forma prospectiva. Seguimiento mínimo de un año de los pacientes sometidos a colecistostomía percutánea.ResultadosDe 1.223 pacientes ingresados por colecistitis aguda, 66 pacientes han precisado colecistostomía percutánea. El 21% de estos han presentado algún efecto adverso, con un total de 22 efectos adversos. Tan solo 5 de estos efectos, presentados por 5 pacientes (7,6%), han podido ser atribuidos al propio drenaje vesicular. La mortalidad asociada a la técnica es del 1,5%. Tras la colecistostomía un tercio de los pacientes (22 pacientes) han sido sometidos a colecistectomía. Se ha realizado intervención quirúrgica urgente por fracaso del tratamiento percutáneo en 2 pacientes, y diferida en otros 2 pacientes por recidiva del proceso inflamatorio. El resto de los pacientes colecistectomizados han sido intervenidos de forma programada pudiéndose llevar a cabo el procedimiento de forma laparoscópica en 16 pacientes (72,7%) ConclusiónConsideramos la colecistostomía percutánea como técnica segura y eficaz por relacionarse con una baja incidencia de morbimortalidad, debiéndose considerar como alternativa puente o definitiva en aquellos pacientes no tributarios de colecistectomía urgente tras fracaso del tratamiento conservador con antibiótico (AU)

IntroductionThe main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure.Material and methodObservational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy.ResultsOf 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%).ConclusionWe consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment (AU)

Is percutaneous cholecystostomy safe and effective in acute cholecystitis? Analysis of adverse effects associated with the technique.

INTRODUCTION: The main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure. MATERIAL AND METHOD: Observational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy. RESULTS: Of 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%). CONCLUSION: We consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.

Is percutaneous cholecystostomy safe and effective in acute cholecystitis? Analysis of adverse effects associated with the technique. / ¿Es segura y eficaz la colecistostomía percutánea en la colecistitis aguda? Análisis de los efectos adversos asociados a la técnica.

INTRODUCTION: The main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure. MATERIAL AND METHOD: Observational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy. RESULTS: Of 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%). CONCLUSION: We consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.

Hemosuccus pancreático originado en la arteria gástrica izquierda: causa infrecuente de hemorragia digestiva / Hemosuccus pancreaticus originating from the left gastric artery: A rare cause of upper gastrointestinal bleeding

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Pancreatic non-functioning neuroendocrine tumor: a new entity genetically related to Lynch syndrome.

Some pancreatic neuroendocrine tumors (P-NETs) are associated with hereditary syndromes. An association between Lynch syndrome (LS) and P-NETs has been suggested, however it has not been confirmed to date. We describe the first case associating LS and P-NETs. Here we report a 65-year-old woman who in the past 20 years presented two colorectal carcinomas (CRC) endometrial carcinoma (EC), infiltrating ductal breast carcinoma, small intestine adenocarcinoma, two non-functioning P-NETs and sebomatricoma. With the exception of one P-NET, all these conditions were associated with LS, as confirmed by immunohistochemistry (IHC) and polymerase chain reaction (PCR). LS is caused by a mutation of a mismatch repair (MMR) gene which leads to a loss of expression of its protein. CRC is the most common tumor, followed by EC. Pancreatic tumors have also been associated with LS. Diagnosis of LS is based on clinical criteria (Amsterdam II and Bethesda) and genetic study (MMR gene mutation). The association between LS and our patient's tumors was confirmed by IHC (loss of expression of proteins MLH1 and its dimer PMS2) and the detection of microsatellite instability (MSI) using PCR.

Early discharge in Mild Acute Pancreatitis. Is it possible? Observational prospective study in a tertiary-level hospital.

BACKGROUND AND AIMS: In acute pancreatitis (AP), first 24 h are crucial as this is the period in which the greatest amount of patients presents an organ failure. This suggests patients with Mild AP (MAP) could be early identified and discharged. This is an observational prospective trial with the aim to demonstrate the safety of early discharge in Mild Acute Pancreatitis (MAP). METHODS: Observational prospective study in a third level single centre. Consecutive patients with AP from March 2012 to March 2014 were collected. INCLUSION CRITERIA: MAP, tolerance to oral intake, control of pain, C Reactive Protein <150 mg/dL and blood ureic nitrogen < 5 mg/dL in two samples. EXCLUSION CRITERIA: pregnant, lack of family support, active comorbidities, temperature and serum bilirubin elevation. Patients with MAP, who met the inclusion criteria, were discharged within the first 48 h. Readmissions within first week and first 30 days were recorded. Adverse effects related to readmissions were also collected. RESULTS: Three hundred and seventeen episodes were collected of whom 250 patients were diagnosed with MAP. From these, 105 were early discharged. Early discharged patients presented a 30-day readmission rate of 15.2% (16 patients out of 105) corresponding to the readmission rates in Acute Pancreatitis published to date. Any patient presented adverse effects related to readmissions. CONCLUSION: Early discharge in accurately selected patients with MAP is feasible, safe and efficient and leads to a decrease in median stay with the ensuing savings per process and with no increase in readmissions or inmorbi-mortality.

Cómo afecta el retraso de la colecistectomía tras la pancreatitis aguda litiásicaen la aparición de recidivas. Consecuencias de la falta de recursos / Influence of delayed cholecystectomy after acute gallstone pancreatitis on recurrence. Consequences of lack of resources

Introducción: la pancreatitis aguda es una enfermedad con tendencia a recurrir, sobre todo si persiste la causa que la desencadena. Nuestro objetivo es determinar la tasa de recurrencia de la pancreatitis aguda biliar tras un primer episodio y su intervalo de aparición, así como identificar los factores de riesgo de recidiva. Material y método: hemos incluido todos los pacientes ingresados por un primer episodio de pancreatitis aguda de origen litiásico durante cuatro años. Las variables principales estudiadas fueron reingreso por recurrencia e intervalo de tiempo de aparición del nuevo episodio. Resultados: hemos incluido 296 pacientes que han ingresado en un total de 386 ocasiones. La incidencia de la pancreatitis aguda biliar en nuestro medio es de 17,5/100.000 habitantes/año. El 19,6% de las pancreatitis han sido graves (22,6% de pancreatitis agudas graves en el primer episodio vs. 3,6% en las pancreatitis recurrentes) con una mortalidad global del 4,4%. La tasa global de recurrencia ha sido del 15,5%, con un intervalo de tiempo de 82 días de mediana. El 14,2% de los pacientes han presentado recurrencia después de un episodio de pancreatitis sin que se les hubiera realizado colecistectomía o colangio-pancreatografía retrógrada endoscópica. Las pancreatitis agudas graves recurren un 7,2% mientras que las leves lo hacen el 16,3%, siendo este el único factor de riesgo de recurrencia hallado. Conclusiones: los pacientes ingresados por pancreatitis deberían ser colecistectomizados a la mayor brevedad posible o ser priorizados en la lista de espera. En su defecto, una alternativa a la cirugía podría ser la colangio-pancreatografía retrógrada endoscópica con esfinterotomía en casos seleccionados (AU)

Introduction: Acute pancreatitis is often a relapsing condition, particularly when its triggering factor persists. Our goal is to determine the recurrence rate of acute biliary pancreatitis after an initial episode, and the time to relapse, as well as to identify the risk factors for recurrence. Material and method: We included all patients admitted for a first acute gallstone pancreatitis event during four years. Primary endpoints included readmission for recurrence and time to relapse. Results: We included 296 patients admitted on a total of 386 occasions. The incidence of acute biliary pancreatitis in our setting is 17.5/100,000 population/year. In all, 19.6% of pancreatitis were severe (22.6% of severe acute pancreatitis for first episodes versus 3.6% for recurring pancreatitis), with an overall mortality of 4.4%. Overall recurrence rate was 15.5%, with a median time to relapse of 82 days. In total, 14.2% of patients relapsed after an acute pancreatitis event without cholecystectomy or endoscopic retrograde cholangio-pancreatography. Severe acute pancreatitis recur in 7.2% of patients, whereas mild cases do so in 16.3%, this being the only risk factor for recurrence thus far identified. Conclusions: Patients admitted for pancreatitis should undergo cholecystectomy as soon as possible or be guaranteed priority on the waiting list. Otherwise, endoscopic retrograde cholangio-pancreatography with sphincterotomy may be an alternative to surgery for selected patients (AU)

Influence of delayed cholecystectomy after acute gallstone pancreatitis on recurrence. Consequences of lack of resources.

INTRODUCTION: Acute pancreatitis is often a relapsing condition, particularly when its triggering factor persists. Our goal is to determine the recurrence rate of acute biliary pancreatitis after an initial episode, and the time to relapse, as well as to identify the risk factors for recurrence. MATERIAL AND METHOD: We included all patients admitted for a first acute gallstone pancreatitis event during four years. Primary endpoints included readmission for recurrence and time to relapse. RESULTS: We included 296 patients admitted on a total of 386 occasions. The incidence of acute biliary pancreatitis in our setting is 17.5/100,000 population/year. In all, 19.6% of pancreatitis were severe (22.6% of severe acute pancreatitis for first episodes versus 3.6% for recurring pancreatitis), with an overall mortality of 4.4%. Overall recurrence rate was 15.5%, with a median time to relapse of 82 days. In total, 14.2% of patients relapsed after an acute pancreatitis event without cholecystectomy or endoscopic retrograde cholangio-pancreatography. Severe acute pancreatitis recur in 7.2% of patients, whereas mild cases do so in 16.3%, this being the only risk factor for recurrence thus far identified. CONCLUSIONS: Patients admitted for pancreatitis should undergo cholecystectomy as soon as possible or be guaranteed priority on the waiting list. Otherwise, endoscopic retrograde cholangio-pancreatography with sphincterotomy may be an alternative to surgery for selected patients.

Solitary fibrous tumor of the liver. Case report and review of the literature.

Solitary fibrous tumor (SFT) is a rare mesenchymal tumor. Given its origin, it can appear in almost any location. In the literature, only 50 cases of SFT in the liver parenchyma have been reported. Despite its rarity, this entity should be included in the differential diagnosis of liver masses. We report the first case with imaging data from five years prior to diagnosis, which was treated by right portal embolization and arterial tumor embolization, and subsequent liver resection. We also present an exhaustive review of the cases described to date.

Tumor fibroso solitario hepático. Descripción de un caso y revisión de la literatura / Solitary fibrous tumor of the liver. Case report and review of the literature

El tumor fibroso solitario (TFS) es una neoplasia mesenquimal infrecuente. Dado su origen, puede aparecer en prácticamente cualquier localización. En la literatura sólo hay 50 casos descritos de TFS localizado en el parénquima hepático. A pesar de su rareza, debe ser considerada dentro del diagnóstico diferencial de una masa hepática. Presentamos el primer caso con seguimiento por imagen desde 5 años antes del diagnóstico, tratado mediante embolización portal derecha y embolización arterial tumoral con posterior resección hepática, así como una revisión exhaustiva de los casos descritos hasta la actualidad

Solitary fibrous tumor (SFT) is a rare mesenchymal tumor. Given its origin, it can appear in almost any location. In the literature, only 50 cases of SFT in the liver parenchyma have been reported. Despite its rarity, this entity should be included in the differential diagnosis of liver masses. We report the first case with imaging data from five years prior to diagnosis, which was treated by right portal embolization and arterial tumor embolization, and subsequent liver resection. We also present an exhaustive review of the cases described to date

Abscesos esplénicos múltiples / Multiple splenic abscesses

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A randomized study of the safety of outpatient care for patients with bleeding peptic ulcer treated by endoscopic injection.

BACKGROUND: Outpatient management is safe for patients with non-variceal upper-GI bleeding who are at low risk of recurrent bleeding and death. However, outpatient care cannot be offered to many patients because of the presence of risk factors (severe comorbid disorders, major endoscopic stigmata of bleeding, significant hemorrhage). The present study assessed the safety of outpatient management for selected high-risk patients with bleeding peptic ulcer. METHODS: Patients hospitalized with upper-GI bleeding because of peptic ulcer with a non-bleeding vessel were eligible for inclusion in the study. Inclusion criteria were the following: ulcer size less than 15 mm, absence of hypovolemia, no associated severe disease, and appropriate family support. After endoscopic therapy (injection of epinephrine and polidocanol), patients were randomized to outpatient or hospital care. Patients remained in the emergency ward for a minimum of 6 hours before discharge, during which time omeprazole was administered intravenously. Outpatients were contacted by telephone daily during the first 3 days; a 24-hour telephone hotline was provided for any queries. For both groups, outpatient visits were scheduled at 7 to 10 and 30 days after discharge. RESULTS: A total of 82 patients were included: 40 were randomized to outpatient care and 42 to hospital care. Clinical and endoscopic variables were similar in both groups. The rate of recurrent bleeding was similar in both groups (4.8% outpatient, 5% hospital). There was no morbidity or mortality in either group at 30 days. Seven patients (17%) randomized to outpatient care received blood transfusion compared with 14 (38%) in the hospital care group (p=0.06). Mean cost of care per patient was significantly lower for the outpatient vs. the hospital group (970 US dollars vs. 1595 US dollars; p < 0.001). CONCLUSIONS: Selected patients with bleeding peptic ulcer can be safely managed as outpatients after endoscopic therapy. This policy conserves health care resources without compromising standards of care.

¿Es útil un robot en cirugía? A propósito del uso del soporte de la cámara de videoendoscopia en la colecistectomía / Are robots useful in surgery? Apropos of the use of a robotic videoendoscopy camera holder in cholecystectomy. A randomized trial

Objetivo. El diseño de un brazo motorizado para llevar la cámara de videoendoscopia de forma inteligente nos ha llevado a determinar sus funciones y su aplicabilidad. En este contexto, hemos llevado a cabo un estudio en pacientes sometidos a colecistectomía en el que hemos comparado la utilidad de un soporte mecánico fijo con la manera tradicional de llevar la videocámara manualmente por un ayudante. Pacientes y método. Estudio unicéntrico aleatorizado, abierto y controlado, realizado en paralelo en 2 grupos de pacientes sometidos a una colecistectomia laparoscópica. Se ha incluido a 95 pacientes adultos ASA I-III, de ambos sexos, afectados de colelitiasis sintomática. Durante la intervención quirúrgica, en el grupo A un ayudante conducía la cámara manualmente y en el grupo B se empleó un brazo mecánico no motorizado. En cada intervención se valoraron la duración total y de la colecistectomía propiamente dicha, el número de encuadres del campo quirúrgico, y las veces que fue necesario limpiar la óptica por haberse ensuciado accidentalmente. Resultados. El tiempo operatorio de la colecistectomía fue menor en el grupo B, lo que repercutió de manera significativa en el tiempo operatorio total. El número de veces que hubo que limpiar la óptica, así como la media de cambios de encuadre, fue significativamente menor al utilizar el soporte mecánico. Conclusiones. Sustituir a un ayudante por un soporte mecanizado acorta el tiempo de intervención y no conlleva inconvenientes sustanciales. La reducción del número de maniobras de encuadre y de lavado de la óptica durante la operación parece que haría de éste un elemento facilitador en operaciones de larga duración que, además, supondría un ahorro económico en personal. Ante estos resultados, hoy día no parece justificado incorporar otro aparato más complejo que un soporte mecanizado en el quirófano, con la única finalidad de aguantar la cámara de videoendoscopia (AU)