Hematoma retroperitoneal espontáneo en pacientes con neumonía grave por SARS-CoV-2 / Spontaneous retroperitoneal hematoma in patients with severe SARS-CoV-2 pneumonia

Recientemente se han publicado varios casos de hematomas retroperitoneales espontáneos (Hre) en el contextode infección por SarS-CoV-2. este estudio presenta una revisión sistemática de la literatura con el objetivo deprofundizar en esta infrecuente asociación. Se identificaron 32 casos de Hre, el 28,1 % con enfermedad COVID-19 crítica. el 68,7 % recibió anticoagulacióncon HBpM y el 15,6 % con heparina sódica. La mediana de días hasta el diagnóstico fue de 10,5 (rango de 0-38).en el 31,2 % de los casos se optó por manejo conservador, mientras que otro 31,2 % requirió angioembolización. Se comunicaron 10 exitus (31,2 %), 6 probablemente relacionados con el Hre.existen hipótesis acerca de la relación entre la infección por SarS-CoV-2 y los fenómenos hemorrágicos. Se handescrito dos mecanismos que explicarían la coagulopatía: la unión al receptor aCe2 y la acción directa del virussobre el endotelio vascular. Por otra parte, la disfunción plaquetaria, la trombocitopenia inmune y la respuesta alSIrS, así como los microtraumas secundarios al esfuerzo tusígeno, la ventilación mecánica invasiva o los cambiosposturales, sugieren un origen multicausal del Hre.La literatura sobre esta asociación es escasa. Dado el exceso de morbimortalidad que supone, se considera nece-sario profundizar en su investigación.(AU)

Recently, cases of spontaneous retroperitoneal haematomas (SrH) in the context of SarS-CoV-2 infection havebeen published. this study presents a systematic review with the aim of further investigating this rare association. Thirty-two cases were identified, with a 28,1 % of critical patients. a total of 68,7 % received anticoagulation withLMWH, and a 15,6 % with UFH. the median number of days to diagnosis was 10,5 (0-38). Conservative manage-ment was chosen in 31,2 %, while another 31,2 % required angio-embolisation. ten exitus (31,2 %) were reported,6 related to SrH. There are hypotheses on the link between SarS-CoV-2 infection and haemorrhagic phenomena. two mechanismshave been described that would explain coagulopathy: the binding of SarS-CoV-2 to the aCe2 receptor and itsdirect action on the vascular endothelium. Furthermore, the platelet dysfunction, immune thrombocytopenia andSIrS, added to the endothelial disruption in retroperitoneal vessels, as well as microtrauma secondary to coughstress, invasive mechanical ventilation and/or postural changes, suggest a multicausal origin of SrH. The literature concerning this association is scarce. Given the excess morbidity and mortality involved, it is consid-ered necessary to investigate it further.(AU)

Valor pronóstico del ratio nodal en el cáncer gástrico: análisis unicéntrico de 199 pacientes / Prognostic value of the nodal ratio in gastric cancer: Unicentric analysis pf 199 patients

IntroducciónEl sistema de clasificación ganglionar más utilizado en el cáncer gástrico es el TNM. No obstante presenta limitaciones, como la «migración de estadificación» en los casos con linfadenectomías subóptimas, por ello se han planteado distintos sistemas. Asimismo, el objetivo fue valorar la influencia del ratio nodal medido en terciles [RNt] como factor pronóstico, y compararlo con los sistemas TNM (7.ª ed.) y log odds of positive lymph nodes [LODDS].Material y métodosSe trata de un estudio retrospectivo y unicéntrico sobre 199 pacientes con neoplasia gástrica intervenidos con intención curativa entre 2010 y 2014. Se realizó un análisis univariante y multivariante de cada sistema, y se compararon las tasas de supervivencia global [SG] obtenidas mediante test ROC.ResultadosLos factores pronóstico que mostraron significación estadística en el análisis multivariante fueron: RNt2 (HR 2,87) y RNt3 (HR 7,29); LODDS 2 (HR 1,55), LODDS3 (HR 2,6) y LODDS4 (HR 4,9); pN2 (HR 1,84) y pN3 (HR 2,91). La SG a 5 años fue del 75,8, 61,4, 25,8 y 3,84% para RNt0, RNt1, RNt2 y RNt3; 72,4, 60, 29,1 y 13,9% para LODDS1, LODDS2, LODDS3 y LODDS4; y 77,6, 59,4, 28,8 y 25,5% para pN0, pN1, pN2 y pN3, respectivamente. Los 3 sistemas se comportaron como buenos predictores, con áreas bajo la curva >0,75.ConclusiónEl RNt fue un factor pronóstico independiente para la estimación de la supervivencia en el cáncer gástrico. Además, la facilidad de su cálculo en la práctica clínica podría disminuir el efecto de migración de estadificación (AU)

IntroductionIn the gastric cancer the most widely used classification is the AJCC TNM system. However, it presents limitations, such as staging migration in cases with suboptimal lymphadenectomies. The nodal ratio has been proposed as an alternative system, proving to be a good prognostic predictor of survival. The aim was to assess the influence of the nodal ratio measured in tertiles [tNR] as a prognostic factor and compare with the TNM systems (7th ed.) and log odds of positive lymph nodes [LODDS].Material and methodsRetrospective and single-center study on 199 patients operated on with curative intent between 2010 and 2014. For each system an univariate and multivariate analysis was performed and the overall survival rates [OS] were compared by the ROC test.ResultsThe prognostic factors that showed statistical significance in the multivariate analysis were: tNR2 (HR 2.87) and tNR 3 (HR 7.29); LODDS 2 (HR 1.55), LODDS3 (HR 2.6) and LODDS4 (HR 4.9); pN2 (HR 1.84) and pN3 (HR 2.91). The 5-year OS was 75.8, 61.4, 25.8 and 3.84% for tNR0, tNR1, tNR2 and tNR3; 72.4, 60, 29.1 and 13.9% for LODDS1, LODDS2, LODDS3 and LODDS4; and 77.6, 59.4, 28.8 and 25.5% for pN0, pN1, pN2 and pN3, respectively. The three systems behaved as good predictors, with areas under the curve >0.75.ConclusiontNR was an independent prognostic factor for estimating survival in gastric cancer. Furthermore, the ease of its calculation in clinical practice could reduce the effect of staging migration (AU)

Prognostic value of the nodal ratio in gastric cancer: unicentric analysis of 199 patients.

INTRODUCTION: In the gastric cancer the most widely used classification is the AJCC TNM system. However, it presents limitations, such as staging migration in cases with suboptimal lymphadenectomies. The nodal ratio has been proposed as an alternative system, proving to be a good prognostic predictor of survival. The aim was to assess the influence of the nodal ratio measured in tertiles [tNR] as a prognostic factor and compare with the TNM systems (7th ed.) and log odds of positive lymph nodes [LODDS]. MATERIAL AND METHODS: Retrospective and single-center study on 199 patients operated on with curative intent between 2010 and 2014. For each system an univariate and multivariate analysis was performed and the overall survival rates [OS] were compared by the ROC test. RESULTS: The prognostic factors that showed statistical significance in the multivariate analysis were: tRN2 (HR2.87) and tRN3 (HR7.29); LODDS 2 (HR1.55), LODDS3 (HR2.6) and LODDS4 (HR4.9); pN2 (HR1.84) and pN3 (HR2.91). The 5-year OS was 75.8%, 61.4%, 25.8%, and 3.84% for tRN0, tRN1, tRN2 and tRN3; 72.4%, 60%, 29.1% and 13.9% for LODDS1, LODDS2, LODDS3 and LODDS4; and 77.6%, 59.4%, 28.8% and 25.5% for pN0, pN1, pN2 and pN3, respectively. The three systems behaved as good predictors, with areas under the curve >0.75. CONCLUSION: tNR was an independent prognostic factor for estimating survival in gastric cancer. Furthermore, the ease of its calculation in clinical practice could reduce the effect of staging migration.

Early laparoscopic cholecystectomy in oldest-old patients: a propensity score matched analysis of a nationwide registry.

The role of early laparoscopic cholecystectomy (ELC) in "oldest-old" patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study is to assess the safety of ELC for ACC in ≥ 85-year-old patients. Multicentric retrospective study that analysed data of patients who underwent ELC for ACC between 2013 and 2018. Patients ≥ 85-year-old (oldest-old patients) were compared with younger patients, before and after propensity score matching (PSM). The main outcomes were mortality, post-operative complications, length of stay (LOS), and readmissions. The study included 1670 patients. The unmatched comparison revealed a selection bias towards the oldest-old group, which was associated with higher Charlson Comorbidity Index (5 vs 1, p < 0.001), more ASA III/IV subjects (54.2% vs 19.3%, p < 0.001), class II/III ACC (80.1% vs 69.1%, p = 0.016) and higher Chole-Risk Score (p > 0.001). The oldest-old also required more conversion to open surgery (20% vs 10.3%, p = 0.005). Postoperatively, they had a higher 90-day mortality rate (7.6% vs 1%, p < 0.001), more total complications (40.6% vs 17.7%, p < 0.001), complications ≥ IIIa Clavien-Dindo (14.4% vs 5.8%, p = 0.002), longer LOS (6 vs 5 days, p < 0.001), and more readmissions (6.6% vs 2.6%, p < 0.001). After PSM (n = 206), the two groups were comparable in terms of baseline characteristics and intraoperative outcomes. No differences were observed in post-operative complications; bile leak; incisional, intrabdominal, urinary or respiratory tract infections; LOS or readmissions. In the oldest-old, ELC for ACC is still associated with significant morbidity and mortality. However, it seems to be safe in selected patients. Therefore, age itself should not be regarded as a contraindication to ELC for ACC.

Linitis plastica: current prognostic implication of a classic concept.

BACKGROUND: Despite having been described for several centuries linitis plastica's (LP) prognostic implication remain unclear. OBJECTIVE: To analyze the impact of LP on the survival of patients undergoing gastrectomy for gastric adenocarcinoma. METHOD: A single-center retrospective study of cases of LP diagnosed and confirmed by pathological anatomy has been carried out in a third-level center for 5 years. RESULTS: They were grouped into Linitis Plastica (LP), diffuse non-LP carcinomas (DNLP) and other adenocarcinomas (ADC). 199 gastrectomies performed in the same period of time were included in the comparative analysis. With a median follow-up of 54.5 months (95% CI: 37.0-65.0), the median survival of LP was 14 months (95% CI: 9-27) significantly lower (p = 0.002) compared to DNLP 51.5 months (95% CI: 25-70) and the rest of ADC 62 months (95% CI: 43-68). The OS at 1, 3 and 5 years was statistically worse in the LP group (69, 15, 8%) compared to DNLP (82, 54, 44%) and ADC (89, 63, 54%) (p = 0.073, p <0.001, p <0.001). In the multivariate analysis, LP was identified as an independent risk factor for OS with an HR of 3.26 (p = 0.001). CONCLUSIONS: LP is an independent prognostic factor associated with higher mortality in gastric cancer.

ANTECEDENTES: A pesar de haber sido descrita hace varios siglos, sigue sin estar clara la implicación pronóstica de la linitis plástica (LP). OBJETIVO: Analizar el impacto de la LP en la supervivencia de los pacientes intervenidos de gastrectomía por adenocarcinoma gástrico. MÉTODO: Estudio retrospectivo unicéntrico de los casos de LP diagnosticados en nuestro centro durante 5 años. RESULTADOS: Se agruparon en LP, carcinomas difusos no LP (DNLP) y resto de adenocarcinomas (ADC). En el análisis comparativo se incluyeron 199 gastrectomías realizadas en el mismo periodo de tiempo. Con una mediana de seguimiento de 54.5 meses (intervalo de confianza del 95% [IC 95%]: 37.0-65.0), la supervivencia mediana de la LP fue de 14 meses (IC 95%: 9-27), significativamente menor (p = 0.002) que en los DNLP, que fue de 51.5 meses (IC 95%: 25-70), y que en el resto de los ADC, en los que fue de 62 meses (IC 95%: 43-68). La supervivencia global a 1, 3 y 5 años fue estadísticamente peor en el grupo de LP (69, 15 y 8%) comparado con los grupos de DNLP (82, 54 y 44%) y ADC (89, 63 y 54%) (p = 0.073, p < 0.001 y p < 0.001, respectivamente). En el análisis multivariante se identificó la LP como un factor de riesgo independiente de supervivencia (hazard ratio: 3.26; p = 0.001). CONCLUSIONES: La LP es un factor pronóstico independiente asociado a mayor mortalidad por cáncer gástrico.

Prognostic value of the nodal ratio in gastric cancer: Unicentric analysis pf 199 patients. / Valor pronóstico del ratio nodal en el cáncer gástrico: análisis unicéntrico de 199 pacientes.

INTRODUCTION: In the gastric cancer the most widely used classification is the AJCC TNM system. However, it presents limitations, such as staging migration in cases with suboptimal lymphadenectomies. The nodal ratio has been proposed as an alternative system, proving to be a good prognostic predictor of survival. The aim was to assess the influence of the nodal ratio measured in tertiles [tNR] as a prognostic factor and compare with the TNM systems (7th ed.) and log odds of positive lymph nodes [LODDS]. MATERIAL AND METHODS: Retrospective and single-center study on 199 patients operated on with curative intent between 2010 and 2014. For each system an univariate and multivariate analysis was performed and the overall survival rates [OS] were compared by the ROC test. RESULTS: The prognostic factors that showed statistical significance in the multivariate analysis were: tNR2 (HR 2.87) and tNR 3 (HR 7.29); LODDS 2 (HR 1.55), LODDS3 (HR 2.6) and LODDS4 (HR 4.9); pN2 (HR 1.84) and pN3 (HR 2.91). The 5-year OS was 75.8, 61.4, 25.8 and 3.84% for tNR0, tNR1, tNR2 and tNR3; 72.4, 60, 29.1 and 13.9% for LODDS1, LODDS2, LODDS3 and LODDS4; and 77.6, 59.4, 28.8 and 25.5% for pN0, pN1, pN2 and pN3, respectively. The three systems behaved as good predictors, with areas under the curve >0.75. CONCLUSION: tNR was an independent prognostic factor for estimating survival in gastric cancer. Furthermore, the ease of its calculation in clinical practice could reduce the effect of staging migration.

Esophageal perforation secondary to an arterial embolization device in scimitar syndrome.

Scimitar syndrome is a congenital malformation that is usually associated with hypoplasia of the right lung with an abnormal blood supply by direct branches of the aorta. These branches normally require embolization.

Escudo de Blumer: signo diagnóstico de la diseminación a distancia del cáncer gástrico difuso / Blumer ́s shelf: diagnostic sign of distant spread of diffuse gastric cancer

Introducción. Se conoce como escudo de Blumer al engrosamiento neoplásico del fondo de saco de Douglas, palpable al tacto rectal como una protrusión en forma de resalte, presente en pacientes afectados por carcinomas con infiltración difusa. A pesar de haber sido descrito hace más de un siglo, se trata de un proceso diagnosticado infrecuentemente y con escasa mención en la literatura científica. Es preciso tener un alto nivel de sospecha clínica para correlacionar los síntomas pélvicos con la presencia de un tumor, habitualmente gástrico. Casos clínicos. Presentamos dos pacientes con hallazgo de escudo de Blumer, asociado a cáncer gástrico difuso, uno como diagnóstico primario de enfermedad metastásica y otro como recidiva de la enfermedad, meses después de ser operado. Ambos casos presentan un complejo proceso diagnóstico, en el que prima la sospecha clínica, apoyado sobre pruebas de imagen como tomografía computarizada y resonancia nuclear magnética, ya que tanto las biopsias obtenidas por endoscopia, como las biopsias intraoperatorias fueron negativas. Discusión. En el escudo de Blumer, las células tumorales infiltran el fondo de saco de Douglas de forma difusa por debajo de la serosa, sin necesidad de que existan implantes macroscópicamente visibles en el peritoneo visceral. La infiltración tumoral puede afectar extrínsecamente al recto, causando una estenosis del mismo, lo que produce sintomatología pélvica inespecífica, como tenesmo rectal y proctalgia. Por lo tanto, este ominoso proceso debe ser sospechado en pacientes con sintomatología pélvica, que presenten o hayan presentado cáncer gástrico

Introduction. The neoplastic thickening of the cul-de-sac of Douglas is known as "Blumer's shelf". It is palpable on rectal examination as a protrusion in the form of a projection, and it presents in patients affected by carcinomas with diffuse infiltration. Despite being described more than a century ago, it is a rare process with little mention in the scientific literature. A high level of clinical suspicion is required to correlate pelvic symptoms with the presence of a typically gastric tumor.Clinical cases. We present two patients with a Blumer's shelf finding associated with diffuse gastric cancer, one as a primary diagnosis of metastatic disease and the other as a recurrence of the disease, months after being operated on. Both cases present a complex diagnostic process, in which clinical suspicion prevails, supported by imaging tests such as computed tomography and magnetic resonance imaging, since both endoscopic biopsies and intraoperative biopsies were negative.Discussion. In Blumer's shelf, tumor cells infiltrate the cul-de-sac of Douglas in a diffuse and subserous manner, without the need for macroscopically visible implants in the visceral peritoneum. Tumor infiltration can extrinsically affect the rectum, causing its stenosis, which produces nonspecific pelvic symptoms such as rectal tenesmus and proctalgia. Therefore, this ominous process should be suspected in patients with pelvic symptoms, who present or have presented gastric cancer

Laparoscopic cholecystectomy for acute cholecystitis: is the surgery still safe beyond the 7-day barrier? A multicentric observational study.

Timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. This study assesses ELC for ACC with delayed presentation, according to hospital volume. Multicentric retrospective analysis of 1868 ELC. Patients were classified into two groups according to the timing of surgery from clinical onset and centre volume. Group 1 (G1) within the first 7 days, group 2 (G2) beyond that. Then centres were classified in low volume centres (LVC) and higher volume centres (HVC) according to the number of ELC performed per year. Overall, G2 showed increased conversion rate (17.7% vs 10.7%; p = 0.004), intraoperative complications (7.3% vs 2.9%; p = 0.001); postoperative haemorrhage (3.6% vs 0.8%; p < 0.001), infections (16.6% vs 9.3%; p = 0.003) and global complications (27.6% vs 19.8%; p = 0.011). HVC in comparison with LVC presented decreased conversion rate (17.1% vs 7.6%; p < 0.001), intraoperative bleeding (2.1% vs 1%; p = 0.047), postoperative bile leakage (4.1% vs 2.1%; p = 0.011), infectious (13.7% vs 7.5%; p < 0.001) and global complications (25.7% vs 17.1%; p < 0.001). HVC did not show an increase in any of the above-mentioned outcomes when G1 and G2 were compared. ELC must be indicated cautiously in patients with ACC and more than 1 week of symptom duration. It should be performed in centres with sufficient experience in the management of this disease.

From Lauren's diffuse gastric cancer to WHO's poorly cohesive carcinoma. Clinicopathological and prognostic characteristics.

INTRODUCTION: since Lauren classified gastric cancer into intestinal-type adenocarcinoma and diffuse gastric carcinoma back in 1965, countless categorizations have been published that attempt to elucidate the clinicopathological and prognostic differences between histological subtypes. OBJECTIVE: a retrospective study was performed of gastric cancer cases managed in a third-level site over ten years in order to compare subtypes between the most widely used classifications (Lauren and World Health Organization [WHO]). METHODS: a comparative study of the most relevant clinicopathological characteristics and a multivariate survival analysis were performed. RESULTS: significant differences exist between histological subtypes in terms of age, gender, location, extension, stage and treatment received. A univariate overall survival analysis revealed better survival rates for intestinal-type adenocarcinoma as compared to diffuse carcinoma (hazard ratio [HR]: 1.405 [1.024-1.927]) according to the Lauren's classification. Furthermore, there was a better prognosis of mucinous carcinoma (HR: 0.378 [0.164-0.868]), though failing to prove a poorer prognosis of poorly cohesive (HR: 1.242 [0.878-1.757]) and signet cell (HR: 1.354 [0.792-2.314]) carcinomas, according to the WHO classification. In the multivariate overall survival analysis, the following poor prognosis factors were identified: male gender, local infiltration (T), nodal invasion (N) and received adjuvant therapy. CONCLUSION: although the various histological subtypes show significant clinicopathological differences, further studies are needed to compare them and clarify the prognostic relevance of each one.

Migración de clip al coledoco tras colecistectomía laparoscópica / Migration of a clip to the common bile duct after laparoscopic cholecystectomy

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Intususcepción ileocólica en el adulto como presentación de un linfoma no Hodgkin de intestino delgado / Ileocolic Intussusception in Adults due to Small-Bowel Non-Hodgkin's Lymphoma

La intususcepción intestinal, definida como la penetración de un segmento intestinal en otro adyacente, es una causa infrecuente de obstrucción intestinal en el adulto. El objetivo de este trabajo es presentar el caso de un paciente adulto con intususcepción ileocólica como presentación de un linfoma no Hodgkin de intestino delgado. Este paciente presenta una causa poco frecuente de intususcepción intestinal. Dada lo inespecífico de la clínica, el diagnóstico etiológico suele ser intraoperatorio, precisando resección de la lesión causante y, en el caso de nuestro paciente, quimioterapia adyuvante(AU)

Intestinal intussusception, defined as penetration of an intestinal segment into an adjacent, is a rare cause of intestinal obstruction in adults. The aim of this paper is to present the case of an adult patient with ileocolic intussusception as presenting a non-Hodgkin lymphoma of the small intestine. This patient has a rare cause of intestinal intussusception. Because of its non-specific clinical, etiologic diagnosis is usually intraoperative, requiring resection of the culprit lesion and, in the case of our patient, adjuvant chemotherapy(AU)

Pneumomediastino y enfisema subcutáneo cervical por diverticulitis aguda perforada colónica / Pneumomediastinum and cervical subcutaneous emphysema caused by a perforated acute colonic diverticulitis

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