Endoscopic treatment (endoscopic balloon dilation/self-expandable metal stent) vs surgical resection for the treatment of de novo stenosis in Crohn's disease (ENDOCIR study): an open-label, multicentre, randomized trial.

BACKGROUND: Stenosis is one of the most common complications in patients with Crohn's disease (CD). Endoscopic balloon dilation (EBD) is the treatment of choice for a short stenosis adjacent to the anastomosis from previous surgery. Self-expandable metal stents (SEMS) may be a suitable treatment option for longer stenoses. To date, however, there is no scientific evidence as to whether endoscopic (EBD/SEMS) or surgical treatment is the best approach for de novo or primary stenoses that are less than 10 cm in length. METHODS/DESIGN: Exploratory study as "proof-of-concept", multicentre, open-label, randomized trial of the treatment of de novo stenosis in the CD; endoscopic treatment (EBD/SEMS) vs surgical resection (SR). The type of endoscopic treatment will initially be with EDB; if a therapeutic failure occurs, then a SEMS will be placed. We estimate 2 years of recruitment and 1 year of follow-up for the assessment of quality of life, costs, complications, and clinical recurrence. After the end of the study, patients will be followed up for 3 years to re-evaluate the variables over the long term. Forty patients with de novo stenosis in CD will be recruited from 15 hospitals in Spain and will be randomly assigned to the endoscopic or surgical treatment groups. The primary aim will be the evaluation of the patient quality of life at 1 year follow-up (% of patients with an increase of 30 points in the 32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32). The secondary aim will be evaluation of the clinical recurrence rate, complications, and costs of both treatments at 1-year follow-up. DISCUSSION: The ENDOCIR trial has been designed to determine whether an endoscopic or surgical approach is therapeutically superior in the treatment of de novo stenosis in CD. TRIAL REGISTRATION: ClinicalTrials.gov NCT04330846. Registered on 1 April 1 2020. https://clinicaltrials.gov/ct2/home.

A randomized clinical trial comparing the initial vascular approach to the inferior mesenteric vein versus the inferior mesenteric artery in laparoscopic surgery of rectal cancer and sigmoid colon cancer.

BACKGROUND: The inferior mesenteric artery approach with a selective lateral splenic flexure mobilization is the most widely used initial step in laparoscopic rectal and left colon surgery. Surgery started through the inferior mesenteric vein (IMV) with systematic medial mobilization (MM) has some theoretical advantages that have never been analyzed in a clinical trial. The aim of this study was to compare the two techniques with regards to surgical technique variables (conversion, surgical time, bleeding, morbidity, and mortality) and pathological outcomes. METHODS: A single-blinded, randomized, controlled trial of patients operated electively by laparoscopic with curative intention for rectal or sigmoid cancer was performed at a single, specialized colorectal surgery department from April 2016 to October 2017. RESULTS: 49 patients were included in each group. There were no statistical differences in patient demographics between the two approaches. Pathological outcomes did not differ between the two groups. Intra-operative characteristics showed a higher conversion rate in patients in which the inferior mesenteric artery was dissected first (p = 0.031). The artery approach also increased intra-operative bleeding (p = 0.049), but there were no differences regarding operative time. On multivariate analysis, the artery approach was associated with a higher risk of conversion (OR 8.68; p = 0.050). Post-operatory complications did not differ between artery and vein dissection. CONCLUSIONS: In our study, the initial approach by the IMV with a systematic MM of the splenic flexure has allowed us to reduce the conversion rate without increasing complications or the surgical time. No differences were observed in the pathological results. Both approaches seem to be safe and effective and well-trained laparoscopic surgeons should have the two techniques available to them for use as needed.

Transthoracic migration of a Kirschner wire from the humerus to the abdomen.

Migration of Kirschner wires after fracture fixation is a rare complication. Several cases of intrathoracic migration after humeral or clavicle fixation with this technique have been reported though. We describe an even rarer case where a wire migrated from the proximal humerus to the abdomen perforating the left thoracic cavity and hemidiaphragm. The distal end of the wire was located next to the spleen and its proximal end at the fifth intercostal space. This particular case could be managed with a simple direct removal through an incision at the fifth intercostal space. The postoperative course was uneventful.

Papel de la cirugía en el manejo de las complicaciones biliares tras el trasplante hepático / Role of surgery in the management of biliary complications after liver transplantation

Resumen El manejo de las complicaciones biliares (CB) postrasplante hepático ha evolucionado en los últimos años. Resumen Los objetivos de este estudio fueron, analizar la incidencia y el manejo de las CB en nuestro centro en 1.000 transplantes hepáticos; y estudiar específicamente el manejo de las estenosis anastomóticas (EA). Resultados la incidencia de CB fue del 23%. Se dieron 76 casos de fístula biliar, 106 casos de estenosis anastomóticas, 46 casos de estenosis no-anastomóticas, 42 coledocolitiasis y 19 otras complicaciones. Resultados De los 106 casos de estenosis anastomóticas, se indicó tratamiento radiológico (CPRE o CTPH) en 62 casos. En 38 casos (33%), la estenosis anastomótica se resolvió mediante tratamiento quirúrgico, en 18 tras previo tratamiento radiológico. La morbilidad y mortalidad relacionada con el tratamiento radiológico de las CB fue discretamente superior (morbilidad: Quir: 4 (18%) vs Radiol: 20 (32%); p=0,2 y mortalidad: Quir: 0% vs Radiol: 8 (11%); p=0,23).Resultados De los 46 pacientes con estenosis no anastomóticas, 29 (63%) fueron tratados mediante retrasplante. Conclusión El tratamiento quirúrgico tiene un papel relevante en el manejo de las CB postrasplante hepático, y es el tratamiento de elección en algunos casos de estenosis anastomóticas. El retrasplante, sin manipulación previa, es el tratamiento de elección en los pacientes con estenosis no anastomóticas (AU)

Abstract Management of biliary tract complications (BTC) after liver transplantation (LT) has progressed in recent years. The aims of this study were, to analyse the incidence and management in our institution of BTC after 1000LT; and to study the management of patients with anastomotic strictures (AS). Results The incidence of BTC was 23%. There were 76 cases of bile leak, 106 cases of anastomotic strictures, 46 non-anastomotic strictures, 42 choledocolithiasis and 19 other complications. Results Among 106 cases of anastomotic strictures, radiological treatment, either PTC or ERCP, was initially indicated in 62. The AS of 38 patients (33%) were resolved with surgical treatment, 18 of them after a previous attempt at radiological treatment. Patients who were treated initially by radiologically required more procedures. Morbidity and mortality related to BTC were slightly higher in the group of patients treated by radiology (morbidity: surgical: 4 (18%) vs. radiological: 20 (32%); p=0.2 and mortality: surgical: 0% vs. radiological: 8 (11%); p=0.23).Results Among 46 patients with non-anastomotic strictures, 29 were resolved with retransplantation (63%). Conclusions Surgery has a significant role in the management of BTC, and is the treatment of choice in some cases of anastomotic strictures. Retransplantation may be the preferred option in patients with non-anastomotic strictures (AU)

[Role of surgery in the management of biliary complications after liver transplantation]. / Papel de la cirugía en el manejo de las complicaciones biliares tras el trasplante hepático.

UNLABELLED: Management of biliary tract complications (BTC) after liver transplantation (LT) has progressed in recent years. The aims of this study were, to analyse the incidence and management in our institution of BTC after 1000 LT; and to study the management of patients with anastomotic strictures (AS). RESULTS: The incidence of BTC was 23%. There were 76 cases of bile leak, 106 cases of anastomotic strictures, 46 non-anastomotic strictures, 42 choledocolithiasis and 19 other complications. Among 106 cases of anastomotic strictures, radiological treatment, either PTC or ERCP, was initially indicated in 62. The AS of 38 patients (33%) were resolved with surgical treatment, 18 of them after a previous attempt at radiological treatment. Patients who were treated initially by radiologically required more procedures. Morbidity and mortality related to BTC were slightly higher in the group of patients treated by radiology (morbidity: surgical: 4 (18%) vs. radiological: 20 (32%); p=0.2 and mortality: surgical: 0% vs. radiological: 8 (11%); p=0.23). Among 46 patients with non-anastomotic strictures, 29 were resolved with retransplantation (63%). CONCLUSIONS: Surgery has a significant role in the management of BTC, and is the treatment of choice in some cases of anastomotic strictures. Retransplantation may be the preferred option in patients with non-anastomotic strictures.

[Radical resection of a hilar cholangiocarcinoma. Indications and results]. / Resección radical del colangiocarcinoma hiliar. Indicaciones y resultados.

OBJECTIVE: The objective of the study is to review our experience in the surgical treatment of Klatskin tumours, after the systematic application of the current concepts of radicalism. Sixty-one patients resected using these criteria are presented. PATIENTS AND METHOD: We have studied 154 patients. Surgery was ruled out in 59 (41%) of them, and a liver transplant was performed on 9; of the 86 patients operated on, 25 were resectable. Resectability was 71% (of the 86 patients operated on) and was 39% of the total patients. The results during two periods are compared, 1989-1998 (pre-99) and 1999-2007 (post-99). RESULTS: On comparing the two periods, resectability increased from 26% to 53% (p = 0.01), the percentage of exploratory laparotomies decreasing (pre: 45% vs post: 22%; p = 0.04). Hepatectomy was performed in 53 cases (87%), being most frequent post-99 (pre: 66% vs post: 91%; p = 0.02). Resection of the caudate was performed in 48 cases (90%), being most frequent in the post-99 period (pre: 40% vs pos: 89%; p = 0.005). Post-operative morbidity was 77%, with 28% the patients being re-operated on, and the post-operative mortality was 16.4%, with no significant differences between the periods. Actuarial survival at 5 years increases in the post-99 period (pre: 26% vs post: 51%; p = 0.06). CONCLUSIONS: Adequate staging, associated with an aggressive surgical strategy can achieve a greater than 50% resectability rate. The post-operative morbidity and mortality of this strategy is high, but the survival that it achieves justifies this.

Resección radical del colangiocarcinoma hiliar. Indicaciones y resultados / Radical resection of a hilar cholangiocarcinoma. Indications and results

Objetivo. El objetivo del estudio es la revisión de nuestra experiencia en el tratamiento quirúrgico del tumor de Klatskin, tras la aplicación sistemática de los conceptos actuales de radicalidad. Se presentan 61 casos de resección con estos criterios. Pacientes y método. Hemos estudiado a 154 pacientes. Se descartó cirugía en 59 (41%), y se realizó trasplante hepático en 9; de los 86 pacientes operados, 25 fueron irresecables. La resecabilidad fue del 71% (de 86 pacientes operados) y del 39% del total de pacientes. Se comparan los resultados según dos períodos, 1989-1998 (pre99) y 1999-2007 (pos99). Resultados. Comparando ambos períodos, la resecabilidad aumentó del 26 al 53% (p = 0,01) y disminuyó el porcentaje de laparotomías exploradoras (el 45% pre99, frente al 22% pos99; p = 0,04). Se realizó hepatectomía en 53 casos (87%), que fue más frecuente en pos99 (el 66% pre99 frente al 91% pos99; p = 0,02). La resección del caudado se llevó a cabo en 48 casos (90%), que fue más frecuente en el período pos99 (el 40% pre99 frente al 89% pos99; p = 0,005). La morbilidad postoperatoria fue del 77%, se reintervino al 28% de los pacientes, y la mortalidad postoperatoria fue del 16,4%, sin diferencias significativas entre períodos. La supervivencia actuarial a 5 años aumentó en el período pos99 (el 26% pre99 frente al 51% pos99; p = 0,06). Conclusiones. Una adecuada estadificación, asociada a una estrategia quirúrgica agresiva, permite alcanzar un índice de resecabilidad mayor que el 50%. La morbimortalidad postoperatoria de esta estrategia es elevada, pero la supervivencia que se alcanza la justifica (AU)

Objective. The objective of the study is to review our experience in the surgical treatment of Klatskin tumours, after the systematic application of the current concepts of radicalism. Sixty-one patients resected using these criteria are presented. Patients and method, We have studied 154 patients. Surgery was ruled out in 59 (41%) of them, and a liver transplant was performed on 9; of the 86 patients operated on, 25 were resectable. Resectability was 71% (of the 86 patients operated on) and was 39% of the total patients. The results during two periods are compared, 1989-1998 (pre-99) and 1999-2007 (post-99). Results. On comparing the two periods, resectability increased from 26% to 53% (p = 0.01), the percentage of exploratory laparotomies decreasing (pre: 45% vs post: 22%; p = 0.04). Hepatectomy was performed in 53 cases (87%), being most frequent post-99 (pre: 66% vs post: 91%; p = 0.02). Resection of the caudate was performed in 48 cases (90%), being most frequent in the post-99 period (pre: 40% vs pos: 89%; p = 0.005). Post-operative morbidity was 77%, with 28% the patients being re-operated on, and the post-operative mortality was 16.4%, with no significant differences between the periods. Actuarial survival at 5 years increases in the post-99 period (pre: 26% vs post: 51%; p = 0.06). Conclusions. Adequate staging, associated with an aggressive surgical strategy can achieve a greater than 50% resectability rate. The post-operative morbidity and mortality of this strategy is high, but the survival that it achieves justifies this (AU)

Successful reuse of liver grafts after death of the first recipient.

Brain death secondary to cerebrovascular disease is a possible early complication of orthotopic liver transplantation. If liver graft continues to function normally, the reuse of liver for another patient may be considered. We report three cases of successful reuse of liver grafts after death of the first recipient. In our experience, liver graft can be reused in the first weeks after a previous transplantation provided that liver function is good, in the absence of systemic uncontrolled infection, graft rejection and after gross graft examination at laparotomy.

Resultados y factores pronósticos de mortalidad en la intervención de Hartmann / Results and prognostic factors in the Hartmann procedure

Introducción. La introducción, hace ya muchos años, de la cirugía cólica urgente en un tiempo ha relegado la intervención de Hartmann para los pacientes más graves. Este hecho ha conducido a que las tasas de morbimortalidad asociadas a la técnica de Hartmann sean elevadas. El objetivo de nuestro estudio fue analizar los resultados obtenidos con la intervención de Hartmann en el período de estudio y analizar los factores pronósticos de mortalidad postoperatoria en este grupo de pacientes. Pacientes y métodos. Durante el período comprendido entre enero de 1995 y diciembre de 2000 se intervino quirúrgicamente a 79 pacientes (34 varones y 45 mujeres), con una edad media de 71,5 años, a los que se les realizó una intervención de Hartmann. Casi la totalidad de los pacientes (91,1%) tenía una o más enfermedades asociadas. En este grupo de pacientes se analizaron retrospectivamente los resultados de morbimortalidad y, mediante un estudio de regresión logística multivariable, los factores pronósticos de mortalidad postoperatoria. Resultados. En toda la serie, la indicación de cirugía fue: peritonitis aguda (77,2%), oclusión intestinal (18,9%) y hemorragia digestiva baja (3,7%). La causa etiológica más frecuente fue la diverticulitis aguda complicada (36 casos) y el cáncer colorrectal complicado (18 casos). El 70,9% de los pacientes (56 casos) presentó 1 o más complicaciones durante el postoperatorio;15 casos fueron reintervenidos (18,9%), y la mortalidad postoperatoria fue del 45,5%. La insuficiencia renal (creatinina ≥ 120 µmol/l) y el riesgo quirúrgico ASA avanzado (III o IV) alcanzaron significación estadística cómo factores predictivos de mortalidad en estos pacientes (p = 0,001 y 0,005, respectivamente). Conclusión. Los pacientes a los que se les practicó una intervención de Hartmann y que tenían un mayor riesgo quirúrgico anestésico (ASA) y/o una alteración de la función renal tuvieron un riesgo de mortalidad significativamente más elevado (AU)

Introduction. The introduction of one-stage procedures in emergency colonic surgery many years ago has relegated the use of the Hartmann procedure to the most seriously-ill patients, which has led to the high morbidity and mortality rates associated with this surgical technique. The aim of our study was to investigate our results using Hartmann’s procedure and to evaluate several prognostic factors of postoperative mortality in this group of patients. Patients and methods. From January 1995 to December2000, 79 patients (34 men and 45 women) with a mean age of 71.5 years underwent Hartman’s operation. Almost all the series (91.1%) had comorbidities. In this group of patients, morbidity and mortality were analyzed retrospectively, and a multivariate logistic regression analysis was performed to study prognostic factors of postoperative mortality. Results. The indications for surgery were acute peritonitis(77.2%), intestinal obstruction (18.9%), and lower gastrointestinal hemorrhage (3.7%). The most frequent etiology was acute diverticulitis (36 patients),followed by complicated colorectal carcinoma (18 patients). In 70.9% of the patients (56 patients) one or more postoperative complications was observed. Reoperation was performed in 15 patients (18.9%) and overall postoperative mortality was 45.5%. Renal failure (creatinine ≥ 120 µmol/l) and high surgical ASA score (III or IV) reached statistical significance as predictive factors of mortality in these patients(p=.001 and p=.005, respectively). Conclusion. The patients who underwent Hart-mann’s procedure with high surgical ASA score and/or renal failure were at significantly higher risk of mortality (AU)

[Results and prognostic factors in the Hartmann procedure]. / Resultados y factores pronósticos de mortalidad en la intervención de Hartmann.

INTRODUCTION: The introduction of one-stage procedures in emergency colonic surgery many years ago has relegated the use of the Hartmann procedure to the most seriously-ill patients, which has led to the high morbidity and mortality rates associated with this surgical technique. The aim of our study was to investigate our results using Hartmanns procedure and to evaluate several prognostic factors of postoperative mortality in this group of patients. PATIENTS AND METHODS: From January 1995 to December 2000, 79 patients (34 men and 45 women) with a mean age of 71.5 years underwent Hartmanns operation. Almost all the series (91.1%) had comorbidities. In this group of patients, morbidity and mortality were analyzed retrospectively, and a multivariate logistic regression analysis was performed to study prognostic factors of postoperative mortality. RESULTS: The indications for surgery were acute peritonitis (77.2%), intestinal obstruction (18.9%), and lower gastrointestinal hemorrhage (3.7%). The most frequent etiology was acute diverticulitis (36 patients), followed by complicated colorectal carcinoma (18 patients). In 70.9% of the patients (56 patients) one or more postoperative complications was observed. Reoperation was performed in 15 patients (18.9%) and overall postoperative mortality was 45.5%. Renal failure (creatinine > or = 120 micromol/l) and high surgical ASA score (III or IV) reached statistical significance as predictive factors of mortality in these patients (p=.001 and p=.005, respectively). CONCLUSION: The patients who underwent Hartmanns procedure with high surgical ASA score and/or renal failure were at significantly higher risk of mortality.