Endometriosis-associated intestinal tumors: a new challenge in clinical practice.

A 66-year-old female consulted due to headache associated with diaphoresis, constipation, and melena. A urinalysis revealed elevated metanephrines, and colonoscopy identified an extrinsic sigmoid stricture. CT and MRI showed a presacral mass infiltrating the sigma. Scintigraphy and SPECT ruled out a diagnosis of paraganglioma. Based on these findings, the patient was proposed to undergo surgery.

Diagnostic accuracy of C-reactive protein, procalcitonin and neutrophils for the early detection of anastomotic leakage after colorectal resection: a multicentric, prospective study.

AIM: The aim was to determine the accuracy of C-reactive protein (CRP), procalcitonin and neutrophils in the early detection (fourth postoperative day) of anastomotic leakage (AL) after colorectal surgery. METHODS: We conducted a multicentre, prospective study that included a consecutive series of patients who underwent colorectal resection with anastomosis without ostomy (September 2015 to December 2017). CRP, procalcitonin and neutrophil values on the fourth postoperative day after colorectal resection along with the postoperative outcome (60-day AL, morbidity and mortality) were prospectively included in an online, anonymous database. RESULTS: The analysis ultimately included 2501 cases. The overall morbidity and mortality was 30.1% and 1.6%, respectively, and the AL rate was 8.6%. The area under the receiver operating characteristic curve values (95% CI) for detecting AL were 0.84 (0.81-0.87), 0.75 (0.72-0.79) and 0.70 (0.66-0.74) for CRP, procalcitonin and neutrophils, respectively. The best cut-off level for CRP was 119 mg/l, resulting in 70% sensitivity, 81% specificity and 97% negative predictive value. After laparoscopic resection, the accuracy for CRP and procalcitonin was increased, compared with open resection. The combination of two or three of these biomarkers did not significantly increase their accuracy. CONCLUSION: On the fourth postoperative day, CRP was the most reliable marker for excluding AL. Its high negative predictive value, especially after laparoscopic resection, allows for safe hospital discharge on the fourth postoperative day. The routine use of procalcitonin or neutrophil counts does not seem to increase the diagnostic accuracy.

Complete Mesocolic Excision and D3 Lymphadenectomy versus Conventional Colectomy for Colon Cancer: A Systematic Review and Meta-Analysis.

BACKGROUNDS: Previous systematic reviews suggest that the implementation of 'complete mesocolon excision' (CME) for colon tumors entails better specimen quality but with limited long-term outcomes. We performed a meta-analysis to compare the pathological, perioperative, and oncological results of CME with conventional surgery (CS) in primary colon cancer. METHODS: Embase, MEDLINE and CENTRAL databases were searched using Medical Subject Headings for CME and D3 lymphadenectomy. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: A total of 18,989 patients from 27 studies were included. Postoperative complications were higher in the CME group (relative risk [RR] 1.13, 95% confidence interval [CI] 1.04-1.22, I2 = 0%), while no differences were observed in terms of anastomotic leak (I2 = 0%) or perioperative mortality (I2 = 49%). CME was associated with a higher number of lymph nodes harvested (I2 = 95%), distance to high tie (I2 = 65%), bowel length (I2 = 0%), and mesentery area (I2 = 95%). CME also had positive effects on 3- and 5-year overall survival (RR 1.09, 95% CI 1.04-1.15, I2 = 88%; and RR 1.05, 95% CI 1.02-1.08, I2 = 62%, respectively) and 3-year disease-free survival (RR 1.10, 95% CI 1.04-1.17, I2 = 22%), as well as decreased local (RR 0.35, 95% CI 0.24-0.51, I2 = 51%) and distant recurrences (RR 0.71, 95% CI 0.60-0.85, I2 = 34%). CONCLUSIONS: Limited evidence suggests that CME improves oncological outcomes with a higher postoperative adverse events rate but no increase in anastomotic leak rate or perioperative mortality, compared with CS.

Isquemia gástrica masiva aguda de causa idiopática / Acute Massive Idiopathic Gastric Ischemia

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Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective, multicentric study of 1102 patients.

BACKGROUND: Studies focused on postoperative outcome after oncologic right colectomy are lacking. The main objective was to determine pre-/intraoperative risk factors for anastomotic leak after elective right colon resection for cancer. Secondary objectives were to determine risk factors for postoperative morbidity and mortality. METHODS: Fifty-two hospitals participated in this prospective, observational study (September 2011-September 2012), including 1102 patients that underwent elective right colectomy. Forty-two pre-/intraoperative variables, related to patient, tumor, surgical procedure, and hospital, were analyzed as potential independent risk factors for anastomotic leak and postoperative morbidity and mortality. RESULTS: Anastomotic leak was diagnosed in 93 patients (8.4 %), and 72 (6.5 %) of them needed radiological or surgical intervention. Morbidity, mortality, and wound infection rates were 29.0, 2.6, and 13.4 %, respectively. Preoperative serum protein concentration was the only independent risk factor for anastomotic leak (p < 0.0001, OR 0.6 per g/dL). When considering only clinically relevant anastomotic leaks, stapled technique (p = 0.03, OR 2.1) and preoperative serum protein concentration (p = 0.004, OR 0.6 g/dL) were identified as the only two independent risk factors. Age and preoperative serum albumin concentration resulted to be risk factors for postoperative mortality. Male gender, pulmonary or hepatic disease, and open surgical approach were identified as risk factors for postoperative morbidity, while male gender, obesity, intraoperative complication, and end-to-end anastomosis were risk factors for wound infection. CONCLUSIONS: Preoperative nutritional status and the stapled anastomotic technique were the only independent risk factors for clinically relevant anastomotic leak after elective right colectomy for cancer. Age and preoperative nutritional status determined the mortality risk, while laparoscopic approach reduced postoperative morbidity.

Emergency surgery in chronic intestinal pseudo-obstruction due to mitochondrial neurogastrointestinal encephalomyopathy: case reports.

Chronic intestinal pseudo-obstruction (CIPO) is a syndrome characterized by recurrent clinical episodes of intestinal obstruction in the absence of any mechanical cause occluding the gut. There are multiple causes related to this rare syndrome. Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is one of the causes related to primary CIPO. MNGIE is caused by mutations in the gene encoding thymidine phosphorylase. These mutations lead to an accumulation of thymidine and deoxyuridine in blood and tissues of these patients. Toxic levels of these nucleosides induce mitochondrial DNA abnormalities leading to an abnormal intestinal motility.Herein, we described two rare cases of MNGIE syndrome associated with CIPO, which needed surgical treatment for gastrointestinal complications. In one patient, intra-abdominal hypertension and compartment syndrome generated as a result of the colonic distension forced to perform emergency surgery. In the other patient, a perforated duodenal diverticulum was the cause that forced to perform surgery. There is not a definitive treatment for MNGIE syndrome and survival does not exceed 40 years of age. Surgery only should be considered in some selected patients.

[Risk factors in patients older than 70 years with complicated colorectal carcinoma]. / Factores de riesgo en pacientes mayores de 70 años con carcinoma colorrectal complicado.

OBJECTIVE: The aim of this study was to analyze the outcome of patients over 70 years of age who underwent emergency surgery for complicated colorectal carcinoma, as well as to identify the factors that might have some influence on outcome. PATIENTS AND METHOD: A retrospective study of 54 patients older than 70 years who underwent emergency surgery for complicated colorectal cancer (42 with obstruction and 12 with perforation) between 1991 and 2002 was performed. Morbidity and mortality after surgery were studied. To determine prognostic factors of morbidity and mortality a multivariate logistic regression analysis was also performed. RESULTS: Overall and major morbidity rates were 81.5% and 42.6%, respectively. The mortality rate was 27.8%. Multivariate analysis revealed that perioperative transfusion (p = 0.014) was an independent predictive factor of major complications and that a high APACHE II score (p = 0.031) and the presence of perforation proximal to the tumor (p = 0.042) independently predicted mortality. CONCLUSIONS: Emergency surgery for complicated colorectal carcinoma in elderly patients carries elevated morbidity and mortality. The presence of risk factors should be taken into account when choosing the most suitable surgical technique and evaluating the need for intensive postoperative treatment.

Factores de riesgo en pacientes mayores de 70 años con carcinoma colorrectal complicado / Risk factors in patients older than 70 years with complicated colorectal carcinoma

Objetivo. El fin de este estudio fue analizar la evolución clínica de los pacientes mayores de 70 años operados de urgencia por carcinoma colorrectal complicado y, además, evaluar los factores con posible influencia en la evolución clínica. Pacientes y método. Se han revisado retrospectivamente los datos de 54 pacientes mayores de 70 años intervenidos de urgencia por carcinoma colorrectal complicado (42 con obstrucción y 12 con perforación) durante el período 1991-2002. Se estudió la morbimortalidad tras la cirugía y se realizó un análisis de regresión logística multivariable para determinar los factores pronósticos de morbilidad y de mortalidad. Resultados. Las tasas de morbilidad global y mayor, y de mortalidad fueron del 81,5, 42,6 y 27,8%, respectivamente. El análisis multivariable mostró que la transfusión perioperatoria (p = 0,014) fue un factor predictivo independiente de complicación mayor y que un índice APACHE II alto (p = 0,031) y la presencia de perforación a distancia (p = 0,042) fueron factores relacionados con la mortalidad.Conclusiones. La cirugía urgente por carcinoma colorrectal complicado en pacientes de edad avanzada conlleva una elevada morbimortalidad. La presencia de factores de riesgo debería tenerse en cuenta al elegir la técnica quirúrgica más adecuada y al valorar la necesidad de un tratamiento postoperatorio intensivo (AU)

Objective. The aim of this study was to analyze the outcome of patients over 70 years of age who underwent emergency surgery for complicated colorectal carcinoma, as well as to identify the factors that might have some influence on outcome. Patients and method. A retrospective study of 54 patients older than 70 years who underwent emergency surgery for complicated colorectal cancer (42 with obstruction and 12 with perforation) between 1991 and 2002 was performed. Morbidity and mortality after surgery were studied. To determine prognostic factors of morbidity and mortality a multivariate logistic regression analysis was also performed. Results. Overall and major morbidity rates were 81.5% and 42.6%, respectively. The mortality rate was 27.8%. Multivariate analysis revealed that perioperative transfusion (p = 0.014) was an independent predictive factor of major complications and that a high APACHE II score (p = 0.031) and the presence of perforation proximal to the tumor (p = 0.042) independently predicted mortality. Conclusions. Emergency surgery for complicated colorectal carcinoma in elderly patients carries elevated morbidity and mortality. The presence of risk factors should be taken into account when choosing the most suitable surgical technique and evaluating the need for intensive postoperative treatment (AU)

Presentación y evolución clínica de las hernias externas incarceradas en pacientes adultos / Presentation and outcome of incarcerated external hernias in adults

Objetivo. Estudiar la presentación y la evolución clínica de pacientes adultos con hernias externas incarceradas y tratar de identificar los factores que podrían tener algún efecto en su curso evolutivo. Pacientes y método. Se ha revisado retrospectivamente a 230 pacientes adultos intervenidos de urgencia por una hernia externa incarcerada durante el período 1992-2001. Se estudiaron las características de la presentación clínica, el tipo de anestesia, los métodos quirúrgicos, las complicaciones y la mortalidad. También se realizó un análisis univariable para determinar los factores con posible influencia en la evolución clínica. Resultados. Hubo 77 hernias crurales, 70 inguinales, 43 umbilicales y 40 eventraciones. Un total de 74 enfermos (32,2%) acudió con más de 48 h de evolución. En 135 pacientes (58,7%) había enfermedades asociadas significativas. En 140 pacientes (60,9%) se usó anestesia general, en 86 raquianestesia y en 4 anestesia local. Los métodos quirúrgicos más utilizados fueron la reparación anatómica y la hernioplastia sin tensión. En 31 casos (13,5%) fue necesaria una resección intestinal. Las tasas de morbilidad global y mayor y de mortalidad fueron del 37,8, el 10 y el 3,9%, respectivamente. Los factores asociados de manera significativa con una evolución desfavorable fueron una sintomatología prolongada, la hospitalización tardía, la presencia de enfermedades asociadas y un grado ASA alto. Conclusiones. El tratamiento urgente de las hernias externas conlleva una elevada morbimortalidad, por lo que un diagnóstico precoz y la reparación electiva de las hernias no complicadas deberían ser la estrategia terapéutica adecuada en los pacientes adultos (AU)

Objective. The aim of this study was to determine the clinical presentation and outcome of incarcerated external hernias in adults, as well as to identify the factors that might have some influence on outcome. Patients and method. A retrospective study of 230 adult patients who underwent emergency surgical repair of incarcerated external hernias from 1992 to 2001 was performed. The characteristics of clinical presentation, type of anesthesia, surgical procedures, complications and mortality were studied. To determine clinical factors that might have some influence on outcome, an univariate analysis was also performed. Results. There were 77 femoral hernias, 70 inguinal, 43 umbilical and 40 incisional hernias. Seventy-four patients (32.2%) presented after 48 h of symptom onset. Significant associated diseases were found in 135 patients (58.7%). General anesthesia was used in 140 patients (60.9%), spinal anesthesia in 86 patients and local anesthesia in four patients. The most commonly used procedures were anatomic repair and tension-free hernioplasty. Bowel resection was required in 31 patients (13.5%). Overall and major morbidity and mortality were 37.8%, 10% and 3.9%, respectively. Factors that were significantly associated with unfavorable outcome were longer duration of symptoms, late hospitalization, concomitant diseases, and a high ASA class. Conclusions. External hernias produce elevated morbidity and mortality if treatment is undertaken as an emergency. Thus, early diagnosis and elective repair of uncomplicated hernias should be performed in adults (AU)

[Presentation and outcome of incarcerated external hernias in adults]. / Presentación y evolución clínica de las hernias externas incarceradas en pacientes adultos.

OBJECTIVE: The aim of this study was to determine the clinical presentation and outcome of incarcerated external hernias in adults, as well as to identify the factors that might have some influence on outcome. PATIENTS AND METHOD: A retrospective study of 230 adult patients who underwent emergency surgical repair of incarcerated external hernias from 1992 to 2001 was performed. The characteristics of clinical presentation, type of anesthesia, surgical procedures, complications and mortality were studied. To determine clinical factors that might have some influence on outcome, an univariate analysis was also performed. RESULTS: There were 77 femoral hernias, 70 inguinal, 43 umbilical and 40 incisional hernias. Seventy-four patients (32.2%) presented after 48 h of symptom onset. Significant associated diseases were found in 135 patients (58.7%). General anesthesia was used in 140 patients (60.9%), spinal anesthesia in 86 patients and local anesthesia in four patients. The most commonly used procedures were anatomic repair and tension-free hernioplasty. Bowel resection was required in 31 patients (13.5%). Overall and major morbidity and mortality were 37.8%, 10% and 3.9%, respectively. Factors that were significantly associated with unfavorable outcome were longer duration of symptoms, late hospitalization, concomitant diseases, and a high ASA class. CONCLUSIONS: External hernias produce elevated morbidity and mortality if treatment is undertaken as an emergency. Thus, early diagnosis and elective repair of uncomplicated hernias should be performed in adults.

Adenocarcinoma gástrico en pacientes mayores de 80 años / Gastric adenocarcinoma in patients older than 80 years

Introducción. El objetivo del trabajo es analizar, mediante la comparación de distintas variables, el comportamiento del adenocarcinoma gástrico en pacientes de 80 años o más respecto a los de menor edad. Métodos. Estudio retrospectivo sobre 212 pacientes con adenocarcinoma gástrico entre enero de 1988 y diciembre de 1998, de los que 27 tenían 80 años o más (grupo A) y 185 menos de 80 (grupo B). Se compararon el sexo, la edad, las enfermedades asociadas, el tiempo de evolución, las manifestaciones clínicas, la localización, el aspecto macroscópico, la intervención, el estadio TNM, la morbimortalidad postoperatoria, la reintervención, la estancia y la supervivencia. Resultados. El porcentaje de complicaciones en el grupo A y B fue del 65 y el 45 por ciento, respectivamente. La mortalidad hospitalaria global fue de 15 pacientes y la postoperatoria de nueve. Al comparar ambos grupos se halló que en el grupo A había mayor presencia de vómitos (p = 0,05), de masa palpable (p = 0,004), operabilidad inferior (p = 0,01), diseminación extragástrica abdominal superior (p = 0,03), peor estadio TNM (p = 0,02), mayor presencia de estadios N1-N2 (p = 0,01), mayor número de complicaciones sistémicas (p = 0,05) y menor supervivencia (p = 0,008). El resto de variables no presentaron diferencias significativas. Conclusiones. Los pacientes octogenarios presentaron tasas superiores de enfermedad localmente avanzada que indujeron peor estadio TNM y menor supervivencia (AU)

Paraganglioma renal no funcionante asociado con un paraganglioma carotídeo y un mucocele apendicular / Nonfunctional renal paraganglioma associated with carotid paraganglioma and appendicular mucocele

OBJETIVOS: Presentamos una paciente con un paraganglioma renal no funcionante que estaba asociado con un mucocele apendicular y de forma metacrónica con un paraganglioma carotídeo. MÉTODOS/RESULTADOS: Paciente de 68 años que consultó por molestias abdominales. Mediante ecografía, TAC y enema opaco se observó una masa alargada que improntaba sobre el ciego y de forma incidental una masa sólida en riñón derecho. Se realizó apendicectomía y nefrectomía radical derecha. La anatomía patológica nos reveló la existencia de un mucocele apendicular y de un paraganglioma renal. Postoperatoriamente los estudios hormonales fueron normales. Ocho meses más tarde fue extirpado un paraganglioma carotídeo. CONCLUSIONES: Los tumores renales derivados de las células de la cresta neural son muy poco frecuentes, este es el tercer caso descrito en la literatura de un paraganglioma renal no funcionante. La asociación con un mucocele apendicular ha sido casual (AU)