Onyx®, A New Tool for Intraoperative Localization of Liver Lesions.

BACKGROUND: Precise preoperative localization of liver tumors facilitates successful surgical procedures, Intraoperative ultrasonography is a sensitive imaging modality. However, the presence of small non-palpable isoechoic intraparenchymal lesions may be challenging intraoperatively. METHODOLOGY AND MATERIAL DESCRIPTION: Onyx® is a non-adhesive liquid agent comprised of ethylene-vinyl alcohol usually used dissolved in dimethyl-sulfoxide and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy and ultrasonography and a macroscopic black shape. This embolization material has been increasingly used for the embolization of intracranial arteriovenous malformations. We present the novel application of Onyx® on liver surgery. CURRENT STATUS: We present the case of a female, 55 years-old, whose medical history revealed an elective sigmoidectomy (pT3N1a). After 17 months of follow up, by PET-CT scan, the patient was diagnosed of a small intraparenchymal hypo-attenuated 13 mm tumor located at segment V consistent with metachronous colorectal liver metastasis. Open metastasectomy was performed, ultrasonography-guided Onyx® infusion was delivered the day after, intraoperative ultrasonography showed a palpable hyperechoic material with a posterior acoustic shadowing artifact around the lesion. Onyx® is a promising new tool, without any previous application on liver surgery, feasible with advantages in small not palpable intraparenchymal liver lesions.

Textbook outcome in colon carcinoma: implications for overall survival and disease-free survival.

BACKGROUND: Textbook outcome (TO) is a multidimensional quality management tool that uses a set of traditional surgical measures to reflect an "ideal" surgical result for a particular pathology. The aim of the present study is to record the rate of TO in patients undergoing elective surgery for colon cancer (CC). MATERIAL AND METHODS: Retrospective study of all patients undergoing scheduled CC surgery at a Spanish university hospital from September 2012 to August 2016. Patients with rectal cancer were excluded. The variables included in the definition of TO were: R0 resection, number of isolated nodes ≥ 12, no Clavien-Dindo ≥ IIIa complications, no prolonged stay, no readmissions, and no mortality in the first 30 days. The main objective of this study is to analyse the achievement of TO in these patients and to assess the relationship between TO and overall and disease-free survival. RESULTS: Five hundred and sixty-four patients were included in the study. TO was achieved in 49.8%. The sample had a mean age of 69 ± 11 years, and 60% were male. Female sex (OR 1.61; 95% CI 2.30-1.13), T3 and T4 classification (OR 2.50, 95% CI 4.59-1.36, and OR 2.55, 95% CI 5.21-1.24 respectively) and laparoscopic approach (OR 1.53, 95% CI 2.33-1.00) were independent factors that were significantly associated with achieving a TO. Patients who achieved TO had higher overall survival (p = 0.008) than those who did not. However, with regard to disease-free survival, no statistically significant differences were found (p = 0.303). CONCLUSION: TO is a useful, easy-to-interpret management tool for measuring oncological results and for predicting patient survival.

A novel study, textbook outcome in adrenalectomy: retrospective observational study in an endocrine surgical unit.

Textbook outcome is a multidimensional quality management tool that uses a set of traditional surgical measures to reflect an "ideal" surgical result for a particular pathology. Retrospective study of all patients undergoing scheduled for adrenal tumors surgery at an endocrine surgery unit from January 2010-December 2022. The definition of Textbook Outcome were: R0 resection, no Clavien-Dindo ≥ IIIa complications, no prolonged stay (< P75), no readmissions, and no mortality in the first 30 days. The main objective was to analyze the rate of Textbook Outcome obtained. One hundred and five patients were included in the study. Textbook Outcome was achieved in 71.4%. Surgical approach (p < 0.001), Charlson scale (p = 0.031), American Society of Anesthesiologists Classification (p = 0.047) and surgical time (p < 0.001) were all significantly associated with the achievement of Textbook Outcome. The laparoscopic approach was associated as an independent factor with obtaining Textbook Outcome (OR:5.394; p = 0.016), as was surgical time (OR:0.986; p = 0.004). Textbook Outcome is a novel, useful, easy-to-interpret tool for measuring results in adrenal surgery. The laparoscopic approach is associated with a higher rate of "ideal" surgical results. The study was registered in the public accessible database clinicaltrials.gov with the ClinicalTrials.gov ID: NCT05888753.

Impact of percutaneous cholecystostomy in the management of acute cholecystitis: a retrospective cohort study at a tertiary center.

Laparoscopic cholecystectomy is the gold standard for the treatment of acute cholecystitis (AC). Percutaneous cholecystostomy (PC) for management of AC is increasing; safe and less invasive than laparoscopic cholecystectomy and is very useful in selected patients with severe comorbidities, not suitable for surgery/general anesthesia. We conducted a retrospective observational study between 2016 and 2021 of patients treated with PC for AC, based on the application of the Tokyo guidelines 13/18. The aim was to analyse the clinical results and management of PC in patients undergoing elective or emergency cholecystectomy. Subsequently, a retrospective analytical study was designed to compare various cohorts: elective or emergency surgery and management with PC alone; patients with/without a high surgical risk; and elective vs emergency surgery. Hundred and ninety five patients with AC were treated with PC. Mean age was 74 years, 59.5% were ASA class III/IV, and the mean Charlson comorbidity index was 5.5. Adherence to Tokyo guidelines regarding indication of PC was 50.8%. The rate of complications associated to PC was 12.3% and the 90-day mortality rate was 14.4%. Mean length of time using PC was 10.7 days. Emergency surgery was performed in 4.6%. The overall success rate using PC was 66.7%, and the 1-year readmission rate due to biliary complications after PC was 28.2%. The rate of scheduled cholecystectomy after PC was 22.6%. Conversion to laparotomy and open approach was more frequent in patients who underwent emergency surgery (p = 0.009). No differences were found in 90-day mortality or in the complication rate. PC achieves improvements in the inflammation and infection associated with AC. In our series, it proved to be an effective and safe treatment during the acute episode of AC. Mortality in patients treated with PC is high due to their older age, greater morbidity, and higher Charlson comorbidity index scores. After PC, emergency surgery is uncommon but readmission due to biliary events is high. Cholecystectomy after PC is the definitive treatment and the laparoscopic approach is feasible. Clinical trial registery: The study was registered in the public accessible database clinicaltrials.gov with the ClinicalTrials.gov ID: NCT05153031. Public release date: 12/09/2021.

Pancreatic Surgery in Chronic Pancreatitis Complicated by Extrahepatic Portal Hypertension or Cavernous Transformation of the Portal Vein: A Systematic Review.

OBJECTIVES: Chronic pancreatitis produces disabling pain and loss of pancreatic endocrine/exocrine function. Almost half of the patients will need surgery during the course of the disease. Certain conditions, such as extrahepatic portal hypertension or cavernous transformation of the portal vein, can increase the risk of morbidity and mortality. These complications must be borne in mind in the design of the surgical treatment of chronic pancreatitis. This study is a systematic review on the coexistence of chronic pancreatitis and extrahepatic portal hypertension/cavernous transformation in patients undergoing pancreatic surgery. METHODS: We conducted an unlimited search updated on 10 December 2017, which yielded 535 results. We selected 11 articles. RESULTS: Main indication for surgery was intractable pain. Presence of extrahepatic portal hypertension and/or cavernous transformation increased intraoperative bleeding and general postoperative morbidity, though the increase in general morbidity was less when the different postoperative complications were analyzed individually. Case series showed a higher mortality in patients with extrahepatic portal hypertension. CONCLUSION: Little is known about the presence of extrahepatic portal hypertension in patients undergoing pancreatic surgery for chronic pancreatitis. More studies are needed in order to standardize criteria for vascular involvement in patients with chronic pancreatitis, in order to select the surgical technique and, if necessary, to establish contraindications, in this subgroup of patients.

[Congenital hypertrophy of retinal pigment epithelium in familial colonic polyposis. Study of a family]. / Hipertrofia congénita del epitelio pigmentario de la retina en la poliposis colónica familiar. Estudio de una familia.

In the last years the relationship between congenital hypertrophy of retinal pigment epithelium (CHPRE) and familial adenomatous polyposis (FAP) has been described. It has been said that ophthalmoscopy would be a good screening method for following up the relatives of patients with FAP. We present an ophthalmoscopic study of 14 member of a family with FAP. Four members with FAP were operated on in our department. Only a six years-old child, to this date without FAP, presented CHPRE. We review the relationship between FAP and CHPRE, and emphasize the importance of follow-up in FAP specially when CHPRE is present.

[Cecal hernia through the Winslow's hiatus]. / Hernia de ciego a través del hiato de Winslow.

A new case of cecal herniation through the foramen of Winslow is reported in a 67 year-old woman, preoperatively diagnosed by water-soluble contrast enema. Herniation through Winslow's foramen is an uncommon variety of internal hernias. Of 144 cases reported up to 1991 in the world literature, the cecum was involved in only 25-30%; and less than 10% of these were radiologically diagnosed before surgery.

[Small cell anaplastic carcinoma of the colon]. / Carcinoma anaplásico de células pequeñas de localización colónica.

Small-cell anaplastic carcinoma of the colon is a very infrequent tumour (less than 1% of all colorectal neoplasms). Thirty-two cases have been described in the international literature up to 1992. A case, in a 54 year-old patient who underwent successful resection is presented. The importance of this tumour is due to its great aggressivity, and its great tendency to produce early hematogenous and lymph node metastases. It implies a bad prognosis and a survival of around 0% at one year. Because of these facts, treatment must include, beside surgical resection, an aggressive systemic protocol.

[Hepatic adenoma and focal nodular hyperplasia: difficult differential diagnosis. Presentation of a case of focal nodular hyperplasia]. / Adenoma hepático e hiperplasia nodular focal: difícil diagnóstico diferencial. Presentación de un caso de hiperplasia nodular focal.

Hepatic adenoma and focal nodular hyperplasia are unfrequent benign lesions of the liver with individual histologic characteristics, but not always clinically distinguishable. The main difference is the intratumoral or intraperitoneal bleeding risk (high in adenoma and virtually zero in focal nodular hyperplasia). Surgery is the elective treatment for the first, while a more conservative attitude is allowed for the second. We present the case of a woman with an hepatic mass that clinically and radiologically seemed to be an adenoma. An atypical hepatectomy was done uneventfully. The examination of the specimen showed shaw focal nodular hyperplasia. We review the diagnostic and therapeutic controversy between these entities, because only the histologic examination of the entire surgical specimen could demonstrate the real nature of the lesion.

[Symptomatic subcapsular hepatic hematoma after renal extracorporeal shock wave lithotripsy]. / Hematoma subcapsular hepático sintomático tras litotricia renal extracorpórea mediante ondas de choque.

The presentation of a hepatic subcapsular hematoma as a complication following the carrying out of an extracorporeal renal shock wave lithotripsy is fairly uncommon. We would like to describe the case of a patient who showed after extracorporeal renal post-lithotripsy intense abdominal symptoms and in which the presence of any prior hepatic pathology was ruled out, alterations in the blood coagulation system as well as anomalies in the execution of the extracorporeal lithotripsy as etiological mechanisms. We carried out a bibliographical review due to the rarity of the process described.

[Adrenal pseudocysts. Therapeutic attitude]. / Pseudoquistes suprarrenales. Actitud terapéutica.

OBJECTIVE: Cystic tumors of the adrenal gland are uncommon, but are being increasingly more frequently diagnosed during routine radiological evaluation as "incidentalomas". We discuss the differential diagnosis, therapeutic approach and the existing controversies concerning the management of this tumor type. METHODS: Two additional cases of adrenal pseudocyst in two women aged 47 and 38 years are presented. In one case the tumor was discovered incidentally, whereas the other case presented with acute pain arising from intracystic hemorrhage. RESULTS: The fist patient had a cystic tumor of 8 cm with some inner walls. Fine needle aspiration biopsy revealed a benign cystic lesion of the right adrenal gland. At laparotomy, an 8.5 x 4.5 cm multiloculated cystic lesion was excised. The second patient presented with abdominal pain due to intracystic hemorrhage. A Doppler US did not disclose any vessel inside the lesion. We performed a lumbotomy and excised a 7.5 x 6 cm cystic tumor located in the right adrenal gland. Both lesions were diagnosed as adrenal pseudocyst; the second case was a hemorrhagic one. CONCLUSIONS: The therapeutic approach in adrenal cystic tumors can be based upon the radiological and cytological findings since malignant cystic tumors are uncommon. A clear liquid and a negative cytology practically discard malignant tumors. Furthermore, cystic adenocarcinomas are usually large and the cystic liquid is cloudy with abundant cellularity. Surgical treatment is justified in the symptomatic, big or complex tumors (mixed, non-homogeneous).