Cocoa as immunomodulatory agent: an update.

Cocoa is rich in polyphenols, mainly flavonoids, which correlate with several health benefits mediated by their antioxidant, anti-inflammatory and immunomodulatory properties. Cocoa and chocolate consumption have been reported to impact the regulation of the immune system, both in preclinical studies and in human trials. The mechanisms for immunomodulation can involve different effects of cocoa polyphenols on the immune system, acting as anti-inflammatory, antioxidant and anti-allergic agents, as well as the direct influence of cocoa on innate and acquired immunity, with cytokines production and activation of both lymphocyte-dependent and -independent pathways. Cocoa intake has been also correlated to changes in gut microbiota ecology and composition, also affecting the intestinal immune system. This review summarises the updates of the last two decades on cocoa as immunomodulatory agent and explores the health-related benefits of cocoa and chocolate intake.

Efectividad de la analgesia controlada por el paciente en el dolor agudo y crónico después de cirugía cardiaca: estudio prospectivo / Effectiveness of patient-controlled analgesia in acute and chronic pain after cardiac surgery: a prospective study

INTRODUCCIÓN: La intensidad del dolor postoperatorio moderado-intenso después de una cirugía cardiaca (CC) varía, según los estudios, de un 45 a un 85 %. No existe evidencia sobre cuál es la pauta analgésica óptima en el postoperatorio de estos pacientes. El objetivo de este estudio es evaluar la efectividad de la aplicación de un protocolo analgésico multimodal, basado en la analgesia controlada por el paciente (PCA) con morfina, en pacientes sometidos a CC con circulación extracorpórea (CEC). PACIENTES Y MÉTODOS: Estudio prospectivo de todos los pacientes sometidos a CC con CEC, durante los primeros 3 días del postoperatorio (DPO). Se incluyeron 102 pacientes en dos periodos, noviembre de 2016, con analgesia convencional (AC) y enero-febrero de 2017 con PCA. RESULTADOS: El dolor en reposo se mantuvo controlado (mediana escala numérica < 3). Se registró un 27 % de pacientes con dolor moderado e intenso. No hubo diferencias en la intensidad del dolor entre los pacientes con AC y los de PCA. El grupo de PCA precisó menos analgesia de rescate (63 vs. 44 %, p = 0,0487). La incidencia de dolor crónico postquirúrgico fue de un 39 % a los tres meses y un 3 % al año. El dolor y la ansiedad preoperatorios se correlacionaron con la intensidad del dolor dinámico (r = 0,287, p = 0,03). CONCLUSIONES: La PCA con opioides a demanda y analgesia multimodal es una alternativa efectiva después de la CC. Se obtiene un buen control del dolor postoperatorio sin incrementar los efectos adversos y precisando menos analgesia de rescate administrada por enfermería

INTRODUCTION: The intensity of postoperative moderate/intense pain after cardiac surgery (CC), varies according to the different studies, from 45 % to 85 %. There is no evidence about which is the optimal analgesic regimen in the postoperative period. The main objective of this study is to evaluate the effectiveness of the application of a multimodal analgesic protocol, based on patient-controlled analgesia (PCA) with morphine, in patients undergoing cardiac surgery with extracorporeal circulation (ECC). PATIENTS AND METHODS: Prospective observational study of all patients undergoing CS with ECC, during the first 3 days postoperatively. There were included 102 patients in two periods, first, in November 2016 with conventional analgesia and second, in January - February 2017 with PCA. RESULTS: The pain at rest was controlled (median numerical scale <3). An average of 27 % of moderate and intense pain was recorded. There was no difference in pain intensity between patients with CA and those with PCA. The PCA group required less rescue analgesia in the first postoperative days (63 % vs. 44 % p = 0.0487). The incidence of Post-surgical Chronic Pain was 39 % at three months, and 3 % at one year. There was a correlation between preoperative pain and anxiety with the intensity of the dynamic pain (r = 0.287, p = 0.03). CONCLUSIONS: PCA with on-demand opioids and multimodal analgesia is an effective alternative after cardiac surgery. Good control of postoperative pain is obtained without increasing adverse effects, and requiring less rescue analgesia administered by the nursing staff

Influence of simultaneous liver and peritoneal resection on postoperative morbi-mortality and survival in patients with colon cancer treated with surgical cytoreduction and intraperitoneal hyperthermic chemotherapy. / Influencia de la resección hepática y peritoneal simultánea, en la morbimortalidad y supervivencia de los pacientes con cáncer de colon intervenidos mediante cirugía citorreductora con quimioterapia intraperitoneal hipertérmica.

INTRODUCTION: Cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy (HIPEC) has recently been established as the treatment of choice for selected patients with peritoneal carcinomatosis of colonic origin. Until recently, the simultaneous presence of peritoneal and hepatic dissemination has been considered a contraindication for surgery. The aim of this paper is to analyze the morbidity, mortality and survival of patients with simultaneous peritoneal and hepatic resection with HIPEC for peritoneal carcinomatosis secondary to colon cancer. METHODS: Between January 2010 and January 2015, 61 patients were operated on, 16 had simultaneous peritoneal and hepatic dissemination (group RH+), and 45 presented only peritoneal dissemination (group RH-). RESULTS: There were no differences between the groups in terms of demographic data, length of surgery and extension of peritoneal disease. Postoperative grade III-V complications were significantly higher in the RH+ group (56.3 vs. 26.6%; P=.032). For the whole group, mortality rate was 3.2% (two patients in group RH-, and none in group RH+). Patients with liver resection had a longer postoperative stay (14.4 vs. 23.1 days) (P=.027). Median overall survival was 33 months for RH-, and 36 for RH+ group. Median disease-free survival was 16 months for RH-, and 24 months for RH+ group. CONCLUSIONS: Simultaneous peritoneal cytoreduction and hepatic resection resulted in a significantly higher Clavien grade III-V morbidity and a longer hospital stay, although the results are similar to other major abdominal interventions. The application of multimodal oncological and surgical treatment may obtain similar long-term survival results in both groups.

Influencia de la resección hepática y peritoneal simultánea, en la morbimortalidad y supervivencia de los pacientes con cáncer de colon intervenidos mediante cirugía citorreductora con quimioterapia intraperitoneal hipertérmica / Influence of simultaneous liver and peritoneal resection on postoperative morbi-mortality and survival in patients with colon cancer treated with surgical cytoreduction and intraperitoneal hyperthermic chemotherapy

INTRODUCCIÓN: La citorreducción con quimioterapia intraperitoneal hipertérmica (HIPEC) se ha postulado como tratamiento de elección en pacientes seleccionados con carcinomatosis peritoneal por cáncer de colon. La presencia simultánea de diseminación peritoneal y hepática ha sido considerada una contraindicación para esta cirugía. El objetivo del presente estudio es analizar la morbimortalidad y supervivencia de los pacientes con carcinomatosis peritoneal por cáncer de colon, intervenidos mediante una citorreducción peritoneal y resección hepática simultánea con HIPEC. MÉTODOS: Entre enero de 2010 y enero de 2015 se intervinieron 61 pacientes, 45 pacientes con carcinomatosis peritoneal (grupo RH−) y 16 con carcinomatosis peritoneal y metástasis hepáticas (grupo RH+). RESULTADOS: No hubo diferencias significativas entre los 2grupos en los datos demográficos, ASA, duración de la intervención, ni extensión de la enfermedad peritoneal. Las complicaciones postoperatorias Clavien III-V fueron significativamente superiores en el grupo RH+ (56,3 vs. 26,6%; p = 0,03). La mortalidad global de la serie fue del 3,2% (2 pacientes en el grupo RH− y ninguno en el grupo RH+). Los pacientes con resección hepática presentaron una estancia hospitalaria significativamente más larga (14,4 vs. 23,1 días; p = 0,027). La mediana estimada de supervivencia global fue de 33 meses para RH− y de 36 meses para RH+, y la de supervivencia libre de enfermedad fue de 16 meses para RH− y de 24 para RH+. CONCLUSIONES: La citorreducción peritoneal con resección hepática simultánea presenta una morbilidad postoperatoria y una estancia hospitalaria significativamente mayores, aunque las cifras son similares a las de otras cirugías abdominales mayores. La aplicación de un tratamiento oncológico y quirúrgico multimodal permite obtener resultados de supervivencia similares en ambos grupos

INTRODUCTION: Cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy (HIPEC) has recently been established as the treatment of choice for selected patients with peritoneal carcinomatosis of colonic origin. Until recently, the simultaneous presence of peritoneal and hepatic dissemination has been considered a contraindication for surgery. The aim of this paper is to analyze the morbidity, mortality and survival of patients with simultaneous peritoneal and hepatic resection with HIPEC for peritoneal carcinomatosis secondary to colon cancer. METHODS: Between January 2010 and January 2015, 61 patients were operated on, 16 had simultaneous peritoneal and hepatic dissemination (group RH+), and 45 presented only peritoneal dissemination (group RH−). RESULTS: There were no differences between the groups in terms of demographic data, length of surgery and extension of peritoneal disease. Postoperative grade III-V complications were significantly higher in the RH+ group (56.3 vs. 26.6%; P=.032). For the whole group, mortality rate was 3.2% (two patients in group RH−, and none in group RH+). Patients with liver resection had a longer postoperative stay (14.4 vs. 23.1 days) (P=.027). Median overall survival was 33 months for RH−, and 36 for RH+ group. Median disease-free survival was 16 months for RH−, and 24 months for RH+ group. CONCLUSIONS: Simultaneous peritoneal cytoreduction and hepatic resection resulted in a significantly higher Clavien grade III-V morbidity and a longer hospital stay, although the results are similar to other major abdominal interventions. The application of multimodal oncological and surgical treatment may obtain similar long-term survival results in both groups

Resultados de la rehabilitación multimodal en la duodenopancreatectomía cefálica / Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy

INTRODUCCIÓN: La rehabilitación multimodal precoz (RMP) ha demostrado en la cirugía colorrectal una reducción de la morbilidad y de la hospitalización sin comprometer la seguridad de los pacientes. La experiencia de la RMP en la duodenopancreatectomía cefálica (DPC) es más limitada. Los objetivos de este estudio fueron analizar la aplicabilidad de un programa RMP en los pacientes intervenidos mediante una DPC en nuestro medio y evaluar los resultados postoperatorios. MÉTODOS: Estudio retrospectivo utilizando una base de datos prospectiva de 41 pacientes a los que se realizó DPC y fueron incluidos en un programa de RMP. Se evaluaron 3 elementos clave: retirada precoz de sondas y drenajes, ingesta oral y movilización precoz. Las variables analizadas fueron la mortalidad, morbilidad, datos perioperatorios, estancia hospitalaria, reintervenciones y reingresos. Este grupo de pacientes fue comparado con un grupo control de 44 pacientes consecutivos, en los que se realizó una DPC con manejo postoperatorio estándar. RESULTADOS: Se estudió a 85 pacientes intervenidos con DPC (41 pacientes en el grupo RMP y 44 pacientes en el grupo control). La mortalidad global fue del 2,4%: 2 pacientes pertenecientes al grupo control. No encontramos diferencias significativas en la mortalidad, ingreso en Reanimación, reintervenciones ni reingresos. El grupo RMP presentó una morbilidad menor que el grupo control (32 vs. 48%; p = 0,072), y una estancia hospitalaria menor (14,2 vs. 18,7 días; p = 0,014). Todos los elementos clave propuestos fueron conseguidos. CONCLUSIONES: La RMP en la DPC puede implantarse con seguridad en nuestro medio. Permite unificar los cuidados perioperatorios, disminuir la variabilidad clínica y la estancia media y como consecuencia, el coste hospitalario

BACKGROUND: Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results. METHODS: A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management. RESULTS: A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved. CONCLUSIONS: ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs

Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results. METHODS: A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management. RESULTS: A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved. CONCLUSIONS: ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs.

Histological differences between various methods of hemiepiphysiodesis: is guided growth really different?

Traditional systems of hemiepiphysiodesis are based on the application of asymmetrical compression to the physis to correct angular deformities. The guided growth method claims to act as a tension plate avoiding compression. The aim of this study was to confirm or refute this claim. Twenty-four White New Zealand rabbits were subjected to a proximal tibial hemiepiphysiodesis using either staples or a plate and two-screws method. Both methods succeeded in producing deformity. The initial existent histological differences between systems became less apparent after 6 weeks of hemiepiphysiodesis, when histological results were very similar. The findings suggest that the eight-plate system produces, like staples, compression of the physis, but the forces are applied more gradually.

Guided growth: the importance of a single tether. An experimental study.

BACKGROUND: During the last few years, the use of the 8-plate as a technique for hemiepiphysiodesis has gained wide acceptance, as it has been shown that it works in a more physiological way than other methods such as staples or transphyseal screws. It has mechanically been compared with a tension band plate, and for this reason, only a single plate is needed. The following study was undertaken to test the 8-plate against the staples and assess factors that can influence the difference in results. METHODS: A prospective experimental study was designed to compare the ability of 2 hemiepiphysiodesis methods, the 8-plate and the double staple, to produce angular deformity in the rabbit's tibia (group I). The variable studied was the variations in the articular line-diaphysis angle at 6 weeks. As the results showed that the 8-plate produced a bigger deformity, a second group was designed (group II) comparing single against double staple, under the hypothesis that the differences observed in the first group could be related to the number of anchors put across the physis and consequently depend on the volume of physis involved by the staples. RESULTS: In group I, the 8-plate produced a bigger angulation at 6 weeks' time than the 2 staples (a difference of 6.5 degrees, P = 0.03). Similarly, in group II, the single staple produced a greater angulation than the 2 staples (difference 6 degrees, P = 0.08). When both groups were compared, no differences in the angulation produced by the 8-plate and the single staple with respect to the 2 staples were found. CONCLUSIONS: These results suggest that one of the reasons why the 8-plate may act in a more "physiological way" (vs. the traditional 2-staple or 3-staple hemiepiphysiodesis) could be the fact that the growth plate is tethered only at a single point. Therefore, the physis retains a major potential for growth and deformity. CLINICAL RELEVANCE: The 8-plate is superior in producing/correcting angular deformity when compared with the traditionally used staples (2 or more) but not when compared with a single staple.

Screw length in the guided growth method.

BACKGROUND: The appearance of the 8-plate as a method for hemiepiphysiodesis has renewed the interest for the use of this technique. However, many questions remain unanswered about the way of action of the guided growth method. Although screw length has been said to play no role, to our knowledge, no clinical or experimental evidence exists. METHODS: An experimental prospective randomized study with 40 WNZ Rabbits aged 8 weeks was conducted. Four experimental groups were established. Each tibia was randomly allocated to one of the following groups: Staples (group 1), 8-plate either using self-taping screws of 9 mm (group 2), or 5 mm lengths (groups 3) and control (group 4). Radiological assessment of the tibial deformity was done in a weekly fashion, and ALDA (articular line-diaphyseal angle) variations at 6 weeks were used as the control variable. RESULTS: The 8-plate as a whole produced a significant bigger deformity than the staples (10°). No significant differences between the two models of the 8-plate were found along the study (3.7°). CONCLUSIONS: The 8-plate has shown to be more efficient in producing angular deformity than staples. However, the length of the screw has showed no role in the 8-plate function.