Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis.

BACKGROUND & AIMS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. METHODS: An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. RESULTS: A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). CONCLUSIONS: Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. IMPACT AND IMPLICATIONS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.

Giant sigmoid diverticulum.

Unlike acute diverticulitis, giant diverticulum larger than 4 cm is a rare entity with few cases described in the literature. We present a case of a 66-year-old male patient diagnosed with colonic diverticulosis. He presented to the emergency department with symptoms of acute abdomen and was diagnosed by CT scan with a 13x14 cm giant diverticulum showing signs of complication. Given the findings, an urgent surgical intervention was decided, and diverticulectomy at the diverticular neck was performed using an endostapler. The etiology of giant diverticula is related to a mechanism of one-way valve at the diverticular neck. Diagnosis poses a challenge as the clinical presentation is nonspecific. The imaging modality of choice is CT scan, which reveals a large cystic image dependent on the sigmoid colon. Definitive treatment is surgical, either by resecting the affected segment including the lesion or by performing a simple diverticulectomy in uncomplicated cases.

Burkitt's lymphoma in the adult as an unusual cause of large bowel obstruction.

Bowel obstruction is an uncommon clinical presentation in Burkitt´s lymphoma, specially in adults. This type of lymphoma is classified within B-cell non-Hodgkin´s lymphomas, which is characterized by its aggressiveness and quickly tumoral growth. The clinical presentation related to the gastrointestinal tract is unusual, but it can be presented as intussusception, obstruction or ischemic perforation. Here we describe a case of Burkitt´s lymphoma with bowel obstruction as a clinical debut.

Mucinous adenocarcinoma arising from complex perianal fistula: a diagnostic and therapeutic challenge.

We present a case of a 64-year-old male with a history of perianal abscesses that have been surgically treated on 10 occasions. Eight months after the last drainage procedure, he presented with a new abscess. Drainage was performed, revealing a cavity with smooth walls, a chronic appearance, filled with mucoid material. An internal fistulous opening was identified at the 6 o'clock position above the anorectal line, which communicated with the described cavity, forming a trans-sphincteric fistula to the mid-anal canal. Biopsy with pathological anatomy showed a mucinous adenocarcinoma with possible intestinal origin (CK20+, CDX2+, TTF1-, CK7+). After completing the evaluation, he was diagnosed with T4N1M0 rectal neoplasia. A diverting colostomy was performed, followed by neoadjuvant therapy, and subsequently, a laparoscopic abdominoperineal amputation. Pathological anatomy revealed residual adenocarcinoma ypT2N0 N0V0L0, R0. This case is notable for both the rarity of a mucinous adenocarcinoma originating in a perianal fistula and the nonspecific clinical presentation of such tumors. Clinical suspicion is crucial, especially in cases of recurrent abscesses with the discharge of mucoid material through fistulous openings, prompting the need for biopsies to ensure proper diagnosis and subsequent optimal treatment.

Prostate gland metastasis as a late relapse of rectal adenocarcinoma.

We present a case report of a 49 year old patient with a known history of rectal adenocarcinoma treated with extended abdominal perineal resection. After five the patient was diagnosed with metastases to the prostate gland. This case stands out not only due to the infrequency of an onset of a colorectal tumor in the prostatic gland but also the late onset of the tumor. In these cases the differential diagnosis between a metastatic tumor and a primary urologic tumor is difficult due to similar morphology and histology, making the CDX-2 immunohistochemical maker expression an important tool to define the histopathology of the tumor.

An uncommon cause of intestinal obstruction: Vanek's tumor.

Vanek's Tumor, also known as Inflammatory Fibroid Polyp (IFP), is a rare submucosal mesenchymal lesion with spindle cells and eosinophilic infiltration. Its etiology is unknown but linked to chronic cellular damage. IFP can develop in various gastrointestinal segments, most commonly in the gastric antrum (70%), small intestine (18-20%), colon, and rectum (4-7%). IFP are usually symptomless and are often found incidentally during colonoscopies or gastroscopies. Most cases can be treated with simple endoscopic resection. In rare cases where larger lesions over 1 cm are identified through endoscopic ultrasound without deeper layer involvement, submucosal endoscopic dissection can be done with good outcomes and minimal risk. Some polyps may cause dyspeptic, hemorrhagic, or obstructive symptoms based on size and location. We report a case of a 56-year-old patient with a 24-hour history of obstructive symptoms, including bowel cessation and vomiting. The patient also had abdominal pain and gradual weight loss over the past two months. Notably, the patient had a prior diagnosis of Crohn's disease 12 years ago, without treatment or continuous medical monitoring.

Obstructive jaundice secondary to a pseudoaneurysm of the superior mesenteric artery.

Superior mesenteric arteries pseudoaneurysms are rare entity, usually asymptomatic but they can appear as an abdominal pain, throbbing mass or shock, being jaundice an exceptional type of presentation. Diagnosis is made by imaging tests (CT) and currently the endovascular approach is the most widespread, reserving open surgery in selected cases. We describe the case of a patient with an 86mm SMA pseudoaneurysm with compression of the extrahepatic bile duct.

Pancreatic lipoma: diagnostic boom of a rare mesenchymal tumor.

Following the incidental finding of a tumor in a 58-year-old female, diagnosed as pancreatic lipoma, histologically confirmed by fine-needle aspiration biopsy (FNAB) with endoscopic ultrasound (EUS), we made a review in our center between 2018 and 2020, with 14 cases diagnosed of pancreatic lipoma by computarized tomography (CT) or magnetic resonance imaging (MRI).

Cytomegalovirus colitis seems to be colon cancer. HIV debut.

Cytomegalovirus (CMV) infection is very common in immunosuppressed patients. It can y puede afectar a todo el tracto gastrointestinal, presentándose como úlceras o pseudotumores. A 43-year-old male with no personal background of interest, was studied due to constitutional syndrome. The diagnosis was neoplasia of the right colon, reported by colonoscopy and CT scan. A right hemicolectomy was performed with oncologic character. The definitive histology was CMV infectious colitis with positive immunohistochemical staining. Treatment with ganciclovir was started and the patient was diagnosed with HIV infection. The unusual finding of CMV infection as a pseudotumor can simulate, clinically and radiologically, a colonic neoplasm. It has been described in the literature in patients immunocompromised by HIV; however, the absence of risk factors means that it can be confused with a primary neoformative process.

Sigmoid colon Schwannoma simulating colon cancer.

Schwannomas tumours are uncommonly developed in the gastrointestinal tract (2-6%), located in 12% of cases in small and large intestines. An 87-year-old woman was studied due to epigastric pain and dyspepsia. CT scan and colonoscopy showed a neoplastic process in the sigmoid colon. It was performed an oncologic laparoscopic sigmoidectomy. Histological study described a schwannoma and a positive immunohistochemistry to S-100. The diagnostic challenge is that this is a submucosa lesion, therefore, endoscopy biopsy is realized only in the mucosa. This becomes the differential diagnostic very difficult in order to differentiate from another mesenchymal tumor (GIST or leiomyoma). The immunohistochemistry helps in the diagnostic if it is positive to S- 100 and negative to C-KIT, CD-34, actine and desmine (findings of GIST tumors and leiomyoma). In conclusion, schwannoma diagnostic is tough. Those are asymptomatic tumors with nonspecific radiological findings. Diagnostic confirmation is a S-100 positive immunohistochemistry in the histological study.

Comparison of flipped learning and traditional lecture method for teaching digestive system diseases in undergraduate medicine: A prospective non-randomized controlled trial.

INTRODUCTION: This study examined the effects of a large-scale flipped learning (FL) approach in an undergraduate course of Digestive System Diseases. METHODS: This prospective non-randomized trial recruited 404 students over three academic years. In 2016, the course was taught entirely in a Traditional Lecture (TL) style, in 2017 half of the course (Medical topics) was replaced by FL while the remaining half (Surgical topics) was taught by TL and in 2018, the whole course was taught entirely by FL. Academic performance, class attendance and student's satisfaction surveys were compared between cohorts. RESULTS: Test scores were higher in the FL module (Medical) than in the TL module (Surgical) in the 2017 cohort but were not different when both components were taught entirely by TL (2016) or by FL (2018). Also, FL increased the probability of reaching superior grades (scores >7.0) and improved class attendance and students' satisfaction. CONCLUSION: The holistic FL model is more effective for teaching undergraduate clinical gastroenterology compared to traditional teaching methods and has a positive impact on classroom attendances.

Applicability of 3D-printed models in hepatobiliary surgey: results from "LIV3DPRINT" multicenter study.

BACKGROUND: Hepatobiliary resections are challenging due to the complex liver anatomy. Three-dimensional printing (3DP) has gained popularity due to its ability to produce anatomical models based on the characteristics of each patient. METHODS: A multicenter study was conducted on complex hepatobiliary tumours. The endpoint was to validate 3DP model accuracy from original image sources for application in the teaching, patient-communication, and planning of hepatobiliary surgery. RESULTS: Thirty-five patients from eight centers were included. Process testing between 3DP and CT/MRI presented a considerable degree of similarity in vascular calibers (0.22 ± 1.8 mm), and distances between the tumour and vessel (0.31 ± 0.24 mm). The Dice Similarity Coefficient was 0.92, with a variation of 2%. Bland-Altman plots also demonstrated an agreement between 3DP and the surgical specimen with the distance of the resection margin (1.15 ± 1.52 mm). Professionals considered 3DP at a positive rate of 0.89 (95%CI; 0.73-0.95). According to student's distribution a higher success rate was reached with 3DP (median:0.9, IQR: 0.8-1) compared with CT/MRI or 3D digital imaging (P = 0.01). CONCLUSION: 3DP hepatic models present a good correlation compared with CT/MRI and surgical pathology and they are useful for education, understanding, and surgical planning, but does not necessarily affect the surgical outcome.

Breast implant during orthotopic liver transplant to avoid hepatic outflow obstruction.

Donor-recipient size mismatch in liver transplantation is a recognized but uncommon situation. It can lead to a partial or complete obstruction of the inferior vena cava with subsequent hepatic outflow obstruction. Placement of a breast implant in the right upper quadrant of the abdomen during liver transplantation is a technically easy resource and can protect the liver graft from kinking or rotation.

Clinical and cost-effectiveness analysis of early detection of patients at nutrition risk during their hospital stay through the new screening method CIPA: a study protocol.

BACKGROUND: Malnutrition is highly prevalent in hospitalized patients and results in a worsened clinical course as well as an increased length of stay, mortality, and costs. Therefore, simple nutrition screening systems, such as CIPA (control of food intake, protein, anthropometry), may be implemented to facilitate the patient's recovery process. The aim of this study is to evaluate the effectiveness and cost-effectiveness of implementing such screening tool in a tertiary hospital, consistent with the lack of similar, published studies on any hospital nutrition screening system. METHODS: The present study is carried out as an open, controlled, randomized study on patients that were admitted to the Internal Medicine and the General and Digestive Surgery ward; the patients were randomized to either a control or an intervention group (n = 824, thereof 412 patients in each of the two study arms). The control group underwent usual inpatient clinical care, while the intervention group was evaluated with the CIPA screening tool for early detection of malnutrition and treated accordingly. CIPA nutrition screening was performed upon hospital admission and classified positive when at least one of the following parameters was met: 72 h food intake control < 50%, serum albumin < 3 g/dL, body mass index < 18.5 kg/m2 (or mid-upper arm circumference ≤ 22.5 cm). In this case, the doctor decided on whether or not providing nutrition support. The following variables will be evaluated: hospital length of stay (primary endpoint), mortality, 3-month readmission, and in-hospital complications. Likewise, the quality of life questionnaires EQ-5D-5 L are being collected for all patients at hospital admission, discharge, and 3 months post-discharge. Analysis of cost-effectiveness will be performed by measuring effectiveness in terms of quality-adjusted life years (QALYs). The cost per patient will be established by identifying health care resource utilization; cost-effectiveness will be determined through the incremental cost-effectiveness ratio (ICER). We will calculate the incremental cost per QALY gained with respect to the intervention. DISCUSSION: This ongoing trial aims to evaluate the cost-effectiveness of implementing the malnutrition screening tool CIPA in a tertiary hospital. TRIAL REGISTRATION: Clinical Trial.gov ( NCT02721706 ). First receivevd: March 1, 2016 Last updated: April 8, 2017 Last verified: April 2017.

Nutrition management in enhanced recovery after abdominal pancreatic surgery. / Manejo nutricional en la rehabilitación multimodal precoz en cirugía pancreática.

Multimodal rehabilitation programs are perioperative standardized strategies with the objective of improving patient recovery, and decreasing morbidity, hospital stay and health cost. The nutritional aspect is an essential component of multimodal rehabilitation programs and therefore nutritional screening is recommended prior to hospital admission, avoiding pre-surgical fasting, with oral carbohydrate overload and early initiation of oral intake after surgery. However, there are no standardized protocols of diet progression after pancreatic surgery. A systematic review was been performed of papers published between 2006 and 2016, describing different nutritional strategies after pancreatic surgery and its possible implications in postoperative outcome. The studies evaluated are very heterogeneous, so conclusive results could not be drawn on the diet protocol to be implemented, its influence on clinical variables, or the need for concomitant artificial nutrition.

Cervical ultrasound for the evaluation of the vocal cords: A pilot study in an endocrine surgery unit.

INTRODUCTION: Cervical ultrasound (CE) has emerged as a promising tool in recent years for vocal cord (VC) assessment in patients undergoing thyroid surgery. Our aim is to assess the reliability of CE once implemented in an endocrine surgery unit and performed by the surgeons themselves. MATERIAL AND METHOD: 86 participants with no history of laryngeal pathology or cervical surgery underwent CE by three independent endocrine surgeons. Laryngeal structures and specifically the VCs were analysed. To consider the examination as diagnostic, the VCs had to be visualised statically and during phonation. The time taken to perform the technique and the interobserver variability were also analysed. RESULTS: Of the 86 participants, 51.2% were male with a mean age of 43 years. The range of diagnostic examinations between surgeons was 60-68%, with substantial agreement between the 3 explorers (Fleiss's K-value = .714). Male sex and advanced age were factors associated with non-assessability of the technique. The mean procedure time was 72 s. CONCLUSIONS: CE is a fast, non-invasive, feasible bedside tool useful for the assessment of VCs prior to thyroid surgery, mainly in young women.

Atraumatic splenic rupture secondary to appendicular perforation by cecal volvulus.

Atraumatic splenic rupture, an infrequent surgical emergency, constitutes a life-threatening situation. The lack of a traumatic background makes it difficult to suspect. We present a case of a 45-year-old woman, with history of bariatric surgery, referred to our emergency due to 3 weeks long abdominal and lumbar pain, in shock. Imaging diagnosis of splenic rupture, emergent surgery was performed with atypical findings and good evolution. The bibliographic review, background and surgical findings allowed to postulate causality in this unusual presentation. Despite its low frequency, this pathology involves significant mortality and must be present in the patient in shock in the emergency room.

La rotura esplénica atraumática, una emergencia quirúrgica infrecuente, constituye una situación de riesgo vital. La falta de antecedente traumático dificulta su sospecha. Presentamos el caso de una mujer de 45 años, con antecedente de cirugía bariátrica, remitida a nuestro servicio de urgencias por dolor abdominal y lumbar de 3 semanas, en shock. Con el diagnóstico imagenológico de rotura esplénica, se realizó cirugía emergente, con hallazgos atípicos, y la paciente tuvo una buena evolución. La revisión bibliográfica, los antecedentes y los hallazgos quirúrgicos permitieron postular la causalidad en esta inusual presentación. Pese a su poca frecuencia, esta patología comporta una mortalidad importante y debe tenerse presente ante un paciente en shock en la sala de urgencias.

Comparison of Clinical Outcomes in Surgical Patients Subjected to CIPA Nutrition Screening and Treatment versus Standard Care.

Malnutrition is prevalent in surgical patients and leads to comorbidities and a poorer postoperative course. There are no studies that compare the clinical outcomes of implementing a nutrition screening tool in surgical patients with standard clinical practice. An open, non-randomized, controlled study was conducted in general and digestive surgical hospitalized patients, who were either assigned to standard clinical care or to nutrition screening using the Control of Food Intake, Protein, and Anthropometry (CIPA) tool and an associated treatment protocol (n = 210 and 202, respectively). Length of stay, mortality, readmissions, in-hospital complications, transfers to critical care units, and reinterventions were evaluated. Patients in the CIPA group had a higher Charlson index on admission and underwent more oncological and hepatobiliary-pancreatic surgeries. Although not significant, a shorter mean length of stay was observed in the CIPA group (-1.48 days; p < 0.246). There were also fewer cases of exitus (seven vs. one) and fewer transfers to critical care units in this group (p = 0.068 for both). No differences were detected in other clinical variables. In conclusion, patients subjected to CIPA nutrition screening and treatment showed better clinical outcomes than those receiving usual clinical care. The results were not statistically significant, possibly due to the heterogeneity across patient groups.

[Crossed renal ectopia in a patient with a complicated sigma neoplasia]. / Ectopia renal cruzada en un paciente con neoplasia de sigma complicada.

BACKGROUND: Crossed renal ectopia is a rare pathology that is often asymptomatic. Intraoperative detection with a sigma complicated neoplasia is more infrequent and requires correct management to avoid a renal ureteral injury. AIM: To present a case report of a patient with a sigma complicated neoplasia and a crossed renal ectopia detected incidentally. CASE REPORT: We present the case of a 62-year-old man that was submitted for emergency surgery for a sigma perforated neoplasm, and who presented with a previously undiagnosed left-side CRE. During surgery there was a need to insert 2-double-J stents as a guide to both ureters and to avoid any injury to them. DISCUSSION: Crossed renal ectopia is a rare, often asymptomatic entity, the diagnosis of which is usually incidental. In our case, the detection of a concomitant complicated neoplasm, required identification of both ureters due the anatomic doubt of its localization and to avoid them being injured. In conclusion, upon finding a casual crossed renal ectopia during an emergency surgery of sigma, we recommend the identification of the ureters to facilitate its location and to avoid any injury to the ureters.