[National survey on the treatment of acute appendicitis in Spain during the initial period of the COVID-19 pandemic]. / Encuesta nacional sobre el tratamiento de la apendicitis aguda en España durante la fase inicial de la pandemia por COVID-19.

INTRODUCTION: The COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected. METHODS: A national descriptive study was carried out by a online voluntary distribution of a specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons actually working in Spain (5203) opened from April 14th to April 24th. RESULTS: We received 337 responses from 170 centers. During the first month of the pandemic the incidence of acute appendicitis has decreased. Although conservative management has increased, surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period. CONCLUSION: Highlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

Liver abscess secondary to duodenal perforation by fishbone: Report of a case.

Liver abscesses usually arise from amoebian or bacterial origin, being rarely secondary to foreign bodies (1-3). We report the case of a 72-years-old female complaining from abdominal pain located in epoigastrium and right hypochondrium during the last 48 hours. Laboratory data revealed leukocytosis with neutrophilia and pain located in the mentioned locations at physical examination. Ultrasonography showed a liver abscess involving segments 2 and 3. CT scan revealed that the abscess was secondary to a fishbone perforating the duodenum and inlaid in the liver (Figure 1). The fishbone was surgically extracted from the hepatic lobe with hemostasia and a duodenal suture with epiploplastia was performed. Antibiotic was added to the treatment. The patient presented an uneventful postoperative course. The intake of foreign bodies is a frequent event, representing bones and fishbones the most frequent foreing bodies in the adults. Sometimes, the diagnosis may be difficult because the symptoms are not specific. Imaging test are very usefol for the diagnosis, as in the case we present.

Hemoperitoneum secondary to an spontaneous rupture of the spleen mimmicking a duodenal perforated ulcera: A case report.

Spontaneous rupture of the spleen without traumatic cause is an unfrequent entity, usually related with pathologic spleens. We present a case of spontaneous rupture of an histologically normal spleen with splenomegalia secondary to smoking habit. The hemoperitoneum caused by the spontaneous rupture of the spleen mimmicked a hollow viscera perforation.

Outpatient laparoscopic cholecystectomy and pain control: a series of 100 cases.

INTRODUCTION: We present our experience of 100 consecutive cases that underwent ambulatory cholecystectomy using a standard protocol of anesthesia and surgery. PATIENTS AND METHOD: Prospective study of 100 consecutive patients assessed in the surgery outpatient clinic in Torrevieja Hospital (September 2008-september 2009). Both anesthetic and surgical techniques were protocolized, standardized. The protocol included the use of intraperitoneal and parietal anesthesia. RESULTS: One hundred patients were included. Average age was 53 years and average surgical time was 29±12 min. Day-case surgery rate was 96%. Postoperative pain (VAS scale) was less than 4 in all cases. Six patients complained of nausea that eased with the administration of ev metoclopramide. Average length of stay in the day-case surgery unit was 7.4h (maximum 9.6, minimum 7). Morbidity and mortality rates were 0%. No re-admission was registered and conversion rate was 0%. Postoperative follow-up was 100%. A total of 97% of the cases were fully satisfied with the procedure. CONCLUSION: Ambulatory laparoscopic cholecystectomy is a feasible and safe technique. Postoperative pain has classically been the reason to not perform day-case surgery, but we achieved an excellent control by the combined use of local anesthetics and warm intraperitoneal saline solution.

[Analysis of the results [corrected] of survey on trauma systems: The neglected disease of the modern society]. / Análisis de los resultados de una encuesta sobre los sistemas de trauma en España: la enfermedad abandonada de la sociedad moderna.

BACKGROUND: Trauma injuries are the main cause of death in the world. The aim of this study is to determine how trauma patients are treated in Spain at an organizational level. MATERIAL AND METHODS: A questionnaire was prepared consisting of 14 questions regarding aspects of the trauma care organization and trauma education. It was posted on the web site of the Spanish College of Surgeons and all members were encouraged to participate. RESULTS: One hundred and ninety questionnaires from 110 different hospitals were received. More than two-thirds (67.3%) of the centers had protocols for treating trauma patients, with 81% of them based on ATLS guidelines. Almost three-quarters (72.6%) of the doctors had completed the ATLS course, and 38.9% the DSTC course. There was a specific education program in trauma in 24.5% of the centers, and 35.5% had a Trauma Committee. There was a rehabilitation program in 24.5% of the centers. CONCLUSION: Very few of the participating centers would fulfill the requirements of the American College of Surgeons accreditation for trauma centers. Trauma care in Spain has improved a lot in the recent years, but there is still a lot to do to reach the level of that in the United States of America.

[Spleen injuries in Spain: at what point are we?]. / Traumatismo esplénico en España: ¿en qué punto estamos?

INTRODUCTION: Management of spleen trauma has changed over last decades, although there is no data on its treatment in Spain. The aim of this study is to determine the characteristics of spleen injuries in adults with severe abdominal injuries and how we manage them. METHODS: A prospective study using the databases of six Spanish hospitals: Gregorio Marañón Hospital, Virgen de la Vega Hospital, Torrevieja Hospital, Getafe Hospital, Doce de Octubre Hospital and Corporació Sanitària Parc Taulí. RESULTS: A total of 566 patients who had sustained spleen injuries were analyzed (448 males and 118 females), most of them were due to blunt trauma (94%), and the most frequent mechanism of injury was motor vehicle accident. The mean Injury Severity Score (ISS) was 25.2. The initial treatment was surgical in 56.6% of the patients (85.3% total splenectomy and 14.7% other conservative surgical procedures, of which 4.6% finally failed and required total splenectomy). The remaining 43.4% were initially managed conservatively, but 6.5% of them finally required surgical splenectomy, and in 8.8% angio-embolization was performed. CONCLUSION: In Spain, management of spleen trauma is mainly surgical (particularly splenectomy). Angio-embolization and conservative surgical procedures are now hardly used.

Under the Hood: Understanding the Features of Mucin in Pseudomyxoma Peritonei.

Pseudomyxoma peritonei (PMP) is a rare malignant growth characterized by the production of mucin and the potential for peritoneal relapse. This study aimed to investigate the immunohistochemical and biological characteristics of mucin in patients with cellular and acellular PMP. We prospectively analyzed mucin specimens obtained from our patient cohort and described the composition and type of mucin present in each sample. A metagenomic analysis of the samples was performed to investigate the bacterial composition of the PMP microbiome. Secreted mucins 2 and 5AC and membrane-associated mucin-1 were the primary components of mucin in both cellular and acellular tumor specimens. The metagenomic study revealed a predominance of the phylum Proteobacteria and the genus Pseudomonas. Notably, Pseudomonas plecoglossicida, a species not previously reported in the human microbiome, was found to be the most abundant organism in the mucin of pseudomyxoma peritonei. Our findings suggest that the presence of MUC-2 and mucin colonization by Pseudomonas are characteristic features of both cellular and acellular disease. These results may have significant implications for the diagnosis and treatment of this rare entity.

Resection and primary anastomosis without diverting ileostomy for left colon emergencies: is it a safe procedure?

INTRODUCTION: Large-bowel obstruction and perforation are still frequently occurring entities for the acute care surgeon. In these cases, Hartmann's procedure is the most commonly used surgical technique. However, recent papers demonstrate that colon resection and primary anastomosis (RPA) in the emergency setting is a safe and feasible procedure. We present our series of left colon resection and primary anastomosis procedures from Torrevieja Hospital (Alicante, Spain), performed without bowel irrigation or a diverting ileostomy. MATERIALS AND METHODS: Thirty-two RPA procedures were performed in emergency settings for perforation or obstruction, or both, during an 18-month period. The following data were prospectively collected: age, gender, nationality, diagnoses, ASA score, body mass index (BMI), POSSUM score (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity), and the score according to the Hinchey classification. Furthermore, duration of the operation, length of postoperative hospital stay, and mortality and morbidity data were recorded. RESULTS: Sixteen of these patients were diagnosed with acute diverticulitis, 14 patients with neoplasm (of which 9 cases had obstruction, 2 cases had perforation, and 3 cases had both), and foreign body perforation in the remaining 2 cases. The mean hospital stay was 7.8 (range, 4-10) days. The physiological POSSUM score was 24.4 (range, 15-39), and the surgical POSSUM score was 19.8 (range, 16-24). None of the patients died (0% mortality). Seven patients developed some kind of complication (21.9%), all of which were managed conservatively. CONCLUSIONS: The results of this study suggest that RPA for left colon obstruction and perforation in emergency settings can be safely performed in certain surgical conditions.

Effects of negative-pressure therapy with and without ropivacaine instillation in the early evolution of severe peritonitis in pigs.

PURPOSE: The abdomen is the second most common source of sepsis and secondary peritonitis, which likely lead to death. In the present study, we hypothesized that instillation of local anesthetics into the peritoneum might mitigate the systemic inflammatory response syndrome (SIRS) in the open abdomen when combined with negative-pressure therapy (NPT) to treat severe peritonitis. METHODS: We performed a study in 21 pigs applying a model of sepsis based on ischemia/reperfusion and fecal spread into the peritoneum. The pigs were randomized into three groups, and treated for 6 h as follows: Group A: temporary abdominal closure with ABTHERA™ Open Abdomen Negative-Pressure Therapy; Group B: temporary abdominal closure with ABTHERA™ Open Abdomen Negative-Pressure Therapy plus abdominal instillation with physiological saline solution (PSS); and Group C: temporary abdominal closure with ABTHERA™ Open Abdomen Negative-Pressure Therapy plus peritoneal instillation with a solution of ropivacaine in PPS. RESULTS: A comparison between the three groups revealed no statistically significant difference for any of the parameters registered (p > 0.05), i.e., intra-abdominal pressure, blood pressure, heart rate, O2 saturation, diuresis, body temperature, and blood levels of interleukin 6 (IL-6), tumor necrosis factor alpha (TNFα), and c-reactive protein (CRP). In addition, histological studies of the liver, ileum, kidney and lung showed no difference between groups. CONCLUSIONS: The use of abdominal instillation (with or without ropivacaine) did not change the effect of 6 h of NPT after sepsis in animals with open abdomen. The absence of adverse effects suggests that longer treatments should be tested.

National survey on the treatment of acute appendicitis in Spain during the initial period of the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected. METHOD: A national descriptive study was carried out by an online voluntary specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons currently working in Spain (5203), opened from April 14th to April 24th. RESULTS: We received 337 responses from 170 centers. During the first month of the pandemic, the incidence of acute appendicitis decreased. Although conservative management increased, the surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period. CONCLUSION: Highlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

Incisional Surgical Site Infection after Abdominal Fascial Closure with Triclosan-Coated Barbed Suture vs Triclosan-Coated Polydioxanone Loop Suture vs Polydioxanone Loop Suture in Emergent Abdominal Surgery: A Randomized Clinical Trial.

BACKGROUND: Triclosan-coated sutures have been shown to reduce surgical-site infection (SSI) in emergent operation for fecal peritonitis. Barbed sutures provoke a homogeneous distribution of tension throughout the suture, implying better blood supply to the wound edges and healing. The aim of this study was to evaluate the effect, on SSI and evisceration, of using triclosan-coated and barbed sutures for fascial closure in patients undergoing emergent surgery. STUDY DESIGN: A prospective, randomized clinical trial was performed. Patients were randomized into 3 groups: those undergoing aponeurotic closure with triclosan-coated barbed suture (Stratafix Symmetric [Johnson & Johnson]), patients undergoing closure with triclosan-coated polydioxanone loop suture (PDS plus [Johnson & Johnson]), and patients undergoing closure with polydioxanone loop suture (PDS [Johnson & Johnson]). Primary investigated outcomes were SSI and evisceration rates during a follow-up period of 30 days. The primary analysis plan was based on a per-protocol approach. RESULTS: Incisional SSI was 6.4% (3 of 47) in the Stratafix Symmetric group, 8.9% (4 of 45) in the PDS plus group, and 23.4% (11 of 47) in PDS group (p = 0.03). The evisceration rate was 0% in Stratafix Symmetric, 8.9% (4 of 45) in PDS plus, and 12.8% (6 of 47) in PDS (p = 0.05). Median hospital stay was 4 days (range 2 to 14 days) in Stratafix Symmetric, 5 days (range 2 to 21 days) in PDS plus, and 8 days (range 2 to 60 days) in PDS (p = 0.012). The use of triclosan-coated sutures (Stratafix Symmetric and PDS plus) was associated with a lower risk of incisional SSI (p = 0.009), and the use of barbed suture was associated with a lower risk of evisceration (p = 0.019). Comparing Stratafix Symmetric with PDS plus, there were no significant differences in SSIs, but the evisceration rate was significantly higher in the PDS plus group (p = 0.036). CONCLUSIONS: The use of triclosan-coated sutures (Stratafix Symmetric and PDS plus) in emergent surgery reduces the incidence of incisional SSIs. The use of barbed sutures reduces the incidence of evisceration.

[Síndrome de compresión del ligamento arcuato medio en el adulto: a propósito de dos casos]. / Median arcuate ligament syndrome in adults with laparoscopic treatment: report of two cases.

The medium arcuate ligament syndrome is a rare disorder that results from luminal narrowing of the celiac artery by the insertion of diaphragmatic muscle or the celiac nerve plexus. The syndrome is characterized by weight loss, postprandial abdominal pain, nausea, vomiting and an epigastric murmur. Surgical management involves the complete division of the medial arcuate ligament. We present two cases satisfactorily treated by laparoscopic surgery. The role of minimally invasive surgery in the treatment of this syndrome is a safe alternative approach to open surgery.

El síndrome de ligamento arcuato medio es un trastorno poco frecuente que resulta del estrechamiento luminal de la arteria celíaca por la inserción de fibras musculares diafragmáticas o bandas fibrosas del plexo nervioso celíaco. El síndrome se caracteriza por pérdida de peso, dolor abdominal posprandial, náuseas, vómitos y un soplo epigástrico. El manejo quirúrgico implica la división completa del ligamento arqueado mediano. Presentamos dos casos tratados satisfactoriamente mediante cirugía laparoscópica. El papel de la cirugía mínimamente invasiva en el tratamiento de este síndrome es una vía de abordaje segura alternativa a la cirugía abierta.

[Hepatic undifferentiated (embryonal) sarcoma in an adult: a case report and literature review]. / Sarcoma indiferenciado (embrionario) de hígado del adulto: informe de un caso y revisión de la literatura médica.

Undifferentiated (embryonal) sarcoma of the liver (USL) is a rare malignant hepatic tumor in adults. We report the case of a 40-year-old man with USL who was successfully treated with surgical resection and chemotherapy using ifosfamide and adriamycin. To our knowledge, only 70 cases of USL in adults have been reported worldwide in the 40 years since this clinicopathological entity was defined. Although the prognosis of the disease remains generally poor, long term survival has been achieved in patients with a combination of surgery and chemotherapy.