Prevertebral cervical approach to posterior mediastinum parathyroid adenomas.

BACKGROUND: About 4 years ago, we described the pure endoscopic cervical approach to posterior mediastinum parathyroid adenomas, which we called the "prevertebral cervical approach". At that time, we had operated on three patients and did not have enough quality videos to demonstrate this approach. After broadening our experience, we present our results and show this technique through a video. METHODS: From June 2015 to January 2021, information on patients undergoing the prevertebral cervical approach was obtained from a specific prospective database, including clinical presentation, biochemistry, preoperative imaging, surgical approach and patient outcomes. The step by step technique is described for both right- and left-sided adenomas, by means of a short video clip. RESULTS: Ten patients were operated on using this technique. Seven adenomas were right-sided and three were left-sided. The mean surgical time was 33 ± 7 min. There were neither intraoperative nor major postoperative complications. Seven patients presented with a slight subcutaneous emphysema, which did not cause complaints. All patients were discharged the day after surgery, except for one patient with a previous open neck removal of four glands due to secondary hyperparathyroidism, which required calcium replacement. Calcium and parathyroid hormone levels were normalised in the other nine patients after surgery. One patient experienced a transient recurrent laryngeal nerve injury which was spontaneously resolved within 1 month. No permanent recurrent laryngeal nerve injury was found. The postoperative cosmetic outcomes were excellent. CONCLUSION: In our experience, the pure cervical endoscopic approach has shown a high feasibility and short operation time, with excellent postoperative results regarding patient comfort, length of stay and disease cure. This approach also offers a very reasonable procedure cost, and may result in a less aggressive surgical option when compared with thoracic approaches.

Post-transplant lymphoproliferative disease in liver transplant recipients.

INTRODUCTION: Post-transplant lymphoproliferative syndrome (PTLD) is a rare and potentially life-threatening complication after liver transplantation. The aim of this study was to analyze the clinicopathologic features related to PTLD in a single institution after liver transplantation. METHODS: Observational study where we have retrospectively analyzed 851 cases who underwent liver transplantation. Ten cases have developed PTLD. Their clinical-pathological characteristics and the treatment received have been analyzed. RESULTS: PTLD incidence was 1.2% (10/851). The mean time from liver transplantation to PTLD diagnosis was 36 months (range 1.2 to 144 months). PTLD localization was extranodal in all cases, the most frequent location being intestinal. Seven cases showed a monomorphic lymphoma which in all cases was differentiated B cell lymphomas. Fifty per cent of the series were seropositive for Epstein-Barr virus. Five patients were alive at the time of the review. Among these patients, we observed three cases of complete remission and two cases of disease stabilization. The death rate was higher in the first year after diagnosis of PTLD. CONCLUSION: PTLD is a rare complication after liver transplantation, but it may pose a threat to the life of a liver transplant recipient. It is essential to identify patients at risk, to establish an early diagnosis and treatment that can change the outcome of the disease.

Implication of the presence of a variant hepatic artery during the Whipple procedure.

INTRODUCTION: The anatomical variants of the hepatic artery may have important implications for pancreatic cancer surgery. The aim of our study is to compare the outcome following a pancreatoduodenectomy (PD) in patients with or without a variant hepatic artery arising from superior mesenteric artery. MATERIAL AND METHODS: We reviewed 151 patients with periampullary tumoral pathology. All patients underwent oncological PD between January 2005 and February 2012. Our series was divided into two groups: Group A: Patients with a hepatic artery arising from superior mesenteric artery; and Group B: Patients without a hepatic artery arising from superior mesenteric artery. We expressed the results as mean +/- standard deviation for continuous variables and percentages for qualitative variables. Statistical tests were considered significant if p < 0.05. RESULTS: We identified 11 patients with a hepatic artery arising from superior mesenteric artery (7.3%). The most frequent variant was an aberrant right hepatic artery (n = 7), following by the accessory right hepatic artery (n = 2) and the common hepatic artery trunk arising from the superior mesenteric artery (n = 2). In 73% of cases the diagnosis of the variant was intraoperative. R0 resection was performed in all patients with a hepatic artery arising from superior mesenteric artery. There were no significant differences in the tumor resection margins and the incidence of postoperative complications. CONCLUSION: Oncological PD is feasible by the presence of a hepatic artery arising from superior mesenteric artery. The complexity of having it does not seem to influence in tumor resection margins, complications and survival.

The role of tridimensional dynamic ultrasound for pelvic floor evaluation.

INTRODUCTION: Dynamic endoanal ultrasound has emerged in recent years as a test that could replace the now existing tests in the diagnosis of pelvic floor disorders. The aim of this paper is to determine the usefulness of echodefecography in the diagnosis and evaluation of patients with symptoms of anorrectal obstruction, and show the results obtained after its implementation in a pelvic floor unit, as a complementary tool that could replace conventional defecography. METHODS: In this retrospective study we analyzed 66 patients with a mean age of 55 years (19-83), 61 women (92%). All dynamic ultrasound was performed in 3 dimensions and was correlated with symptoms and physical findings in the consultation. A descriptive and inferential study was performed to find a kappa correlation between physical examination and echodefecography. RESULTS: The reasons for consultation were: Anorrectal obstruction syndrome 36 patients (54.5%), pelvic organ prolapse 27 patients (40.9%), and anorrectal obstruction syndrome along with pelvic organ prolapse 3 patients (4.5%). The correlation of the 2 groups indicated that echodefecography diagnosed more patients with grade III rectocele, enteroceles, and anismus than the combination of scan-ultrasound-manometry-proctoscopy (Kappa 0.26, 0.38 and 0.21, 95% CI: from 0,07 to 1.00, 0.15 to 1.00 and from 0.12 to 1.00, respectively) (P<.001). Conversely, echodefecography diagnosed less perineal descense (Kappa 0.28, 95% CI: 0.12 to 1.00). CONCLUSIONS: Dynamic anal ultrasonography may have a role as a complementary test in patients with pelvic floor disorders, achieving diagnoses that would go undetected by inspection, physical examination and manometry.

Single-port Roux-en-Y gastric bypass: toward a less invasive procedure with the same surgical results and a better cosmesis.

BACKGROUND: The current tendency to use increasingly less aggressive procedures has facilitated the development of new minimally invasive techniques. In this context, single-port (SP) access procedures can become an alternative to the conventional laparoscopic approach. METHODS: A total of 22 morbidly obese patients were submitted to pure SP Roux-en-Y gastric bypass without additional ports. Selection for this approach was based on distance from the xiphoid to the umbilicus less than 28 cm, body mass index (BMI) lower than 50 kg/m(2), and preferably peripheral obesity. Access to the cavity was obtained through a single transverse, transumbilical incision, with placement of a SILS Port device. RESULTS: The mean age of the patients was 41 ± 8.98 years, and 95 % of the patients were women. The mean BMI of the series was 42.68 ± 2.28 kg/m(2), and the mean body weight was 111.34 ± 10.66 kg. Surgery was performed successfully in all cases through a transumbilical incision with a mean length of 26.68 ± 5.27 mm. The mean surgical time was 114.05 ± 21 min, and the mean hospital stay was 3.27 ± 1.01 days. No intraoperative or immediate postoperative deaths or complications occurred. The median postoperative BMI during a mean follow-up period of 12 months was 28 kg/m(2) (range, 18-35 kg/m(2)). The median weight loss was 39 kg, and the percentage loss of excess body weight was 86 %. In relation to improvement of the comorbidities, two of the three patients with arterial hypertension showed normalization of their blood pressure values. Likewise, the blood glucose levels were corrected in two of the three diabetic patients, as well as in the patient with altered fasting blood glucose. CONCLUSIONS: Single-port Roux-en-Y gastric bypass surgery seems to be a safe, viable, and reproducible technique, but randomized studies involving larger patient series and longer follow-up periods are needed to compare the SP access and the multiple-port laparoscopic approach.

Acute appendicitis during pregnancy: differences in clinical presentation, management, and outcome. / Diferencias en la presentación clínica, manejo y resultados de la apendicitis aguda en el embarazo.

OBJECTIVES: To analyze the clinical presentation, management, and outcome of acute appendicitis (AA) in pregnant and nonpregnant women of childbearing age. MATERIAL AND METHODS: Descriptive study of 2 cohorts of women (pregnant -P- and nonpregnant -NP-). The women, who were matched according to risk factors, were included when they underwent an emergency appendectomy based on clinical suspicion of AA. We recorded age, medical history, clinical presentation, management, and outcome. Pregnant women were classified according to gestational age of the fetus (trimester). RESULTS: . We included 153 women (51 P, 102 NP). The mean (SD) age was 28.8 (6.5) years (P women, 29.7 [5.8] years; NP, 28.3 [6.8]; P=.242). The mean Alvarado score was 7.1 (1.6) (P, 6.7 [1.7]; NP, 7.3 [1.5]; P=.016). The rate of complicated AA was higher in P (19.6%) than NP (2.9%) women (P<.001). Pregnancy was also associated with higher rates of surgical wound infection (P, 14.0%; NP, 3.0%; P=.016) and a longer mean hospital stay (P, 5.1 [4.8] days; NP, 1.7 [1.0]; P<.001). In the third trimester of P, poorer outcomes were recorded in relation to these risks (P=.031; P=.003, and P<.001, respectively). CONCLUSION: The atypical clinical presentation of AA during pregnancy makes diagnosis difficult and may lead to a higher incidence of complicated AA and surgical wound infection as well as longer hospital stays, particularly when AA presents in the third trimester.

OBJETIVO: Evaluar la presentación clínica, el manejo y los resultados de la apendicitis aguda (AA) en mujeres de edad fértil en función de la presencia de embarazo y su estado evolutivo. METODO: Estudio observacional de dos cohortes (gestantes [G] y no gestantes [NG]), apareadas según técnicas de propensión de riesgo, que incluyó mujeres adultas en edad fértil sometidas a apendicectomía urgente por la sospecha clínica de AA. Se recogieron variables relacionadas con la edad, los antecedentes personales, la presentación clínica, el manejo y los resultados. Se realizó un análisis según la presencia de embarazo y el trimestre de gestación. RESULTADOS: Se incluyeron 153 mujeres (51 G y 102 NG). La edad media fue de 28,8 (DE 6,5) años (G: 29,7 [DE 5,8] vs NG: 28,3 [DE 6,8]; p = 0,242). La puntuación de la escala de Alvarado fue de 7,1 (DE 1,6) (G: 6,7 [DE 1,7] vs NG: 7,3 [DE 1,5]; p = 0,016). Las G presentaron mayor incidencia de AA complicada (G: 19,6% vs NG: 2,9%; p < 0,001), infección del sitio quirúrgico (G: 14,0% vs NG: 3,0; p = 0,016), estancia media (G: 5,1 [DE 4,8] vs NG: 1,7 [DE 1,0]; p < 0,001). Los resultados fueron peores, entre las G del tercer trimestre (p = 0,031, p = 0,003 y p < 0,001, respectivamente). CONCLUSIONES: La presentación clínica atípica de la AA durante el embarazo dificulta su diagnóstico, lo que podría traducirse en una mayor incidencia de AA complicada, infección del sitio quirúrgico y tiempo de estancia hospitalaria, sobre todo si se presenta la AA durante el tercer trimestre de gestación.

Translational pancreatic cancer research: A comparative study on patient-derived xenograft models.

AIM: To assess the viability of orthotopic and heterotopic patient-derived pancreatic cancer xenografts implanted into nude mice. METHODS: This study presents a prospective experimental analytical follow-up of the development of tumours in mice upon implantation of human pancreatic adenocarcinoma samples. Specimens were obtained surgically from patients with a pathological diagnosis of pancreatic adenocarcinoma. Tumour samples from pancreatic cancer patients were transplanted into nude mice in three different locations (intraperitoneal, subcutaneous and pancreatic). Histological analysis (haematoxylin-eosin and Masson's trichrome staining) and immunohistochemical assessment of apoptosis (TUNEL), proliferation (Ki-67), angiogenesis (CD31) and fibrogenesis (α-SMA) were performed. When a tumour xenograft reached the target size, it was re-implanted in a new nude mouse. Three sequential tumour xenograft generations were generated (F1, F2 and F3). RESULTS: The overall tumour engraftment rate was 61.1%. The subcutaneous model was most effective in terms of tissue growth (69.9%), followed by intraperitoneal (57.6%) and pancreatic (55%) models. Tumour development was faster in the subcutaneous model (17.7 ± 2.6 wk) compared with the pancreatic (23.1 ± 2.3 wk) and intraperitoneal (25.0 ± 2.7 wk) models (P = 0.064). There was a progressive increase in the tumour engraftment rate over successive generations for all three models (F1 28.1% vs F2 71.4% vs F3 80.9%, P < 0.001). There were no significant differences in tumour xenograft differentiation and cell proliferation between human samples and the three experimental models among the sequential generations of tumour xenografts. However, a progressive decrease in fibrosis, fibrogenesis, tumour vascularisation and apoptosis was observed in the three experimental models compared with the human samples. All three pancreatic patient-derived xenograft models presented similar histological and immunohistochemical characteristics. CONCLUSION: In our experience, the faster development and greatest number of viable xenografts could make the subcutaneous model the best option for experimentation in pancreatic cancer.