Cirugía y radioembolización de tumores hepáticos / Surgery and radioembolization of liver tumors

La resección quirúrgica se considera el tratamiento curativo por excelencia para los pacientes con tumores hepáticos primarios o metastásicos. Sin embargo, menos de 40% de ellos son candidatos a cirugía, ya sea por factores no modificables (comorbilidades, edad, disfunción hepática…), como por la invasión o proximidad del tumor a los principales pedículos vasculares, la falta de un futuro remanente hepático (FRH) adecuado para mantener una función hepática postoperatoria, o criterios de tamaño y numero tumoral. En estos últimos factores, la radioembolización hepática ha mostrado tener un papel como herramienta prequirúrgica, ya sea mediante la hipertrofia del FRH o mediante la reducción del tamaño tumoral que consigue disminuir la estadificación tumoral (término conocido como «downstaging»). A estos se suma un tercer factor, que es su capacidad de aplicar el test del tiempo, que permite identificar aquellos pacientes que presenten en un plazo corto de tiempo progresión de la enfermedad (tanto a nivel local como a distancia), evitándoles una cirugía innecesaria. En este trabajo se pretende hacer una revisión de la radioembolización como herramienta facilitadora de la cirugía hepática, tanto a través de la experiencia de nuestro centro como de la evidencia científica disponible (AU)

Surgical resection is considered the curative treatment par excellence for patients with primary or metastatic liver tumors. However, less than 40% of them are candidates for surgery, either due to non-modifiable factors (comorbidities, age, liver dysfunction...), or to the invasion or proximity of the tumor to the main vascular requirements, the lack of a future liver remnant (FLR) adequate to maintain postoperative liver function, or criteria of tumor size and number. In these last factors, hepatic radioembolization has been shown to play a role as a presurgical tool, either by hypertrophy of the FLR or by reducing tumor size that manages to reduce tumor staging (term known as “downstaging”). To these is added a third factor, which is its ability to apply the test of time, which makes it possible to identify those patients who present progression of the disease in a short period of time (both locally and at distance), avoiding a unnecessary surgery. This paper aims to review RE as a tool to facilitate liver surgery, both through the experience of our center and the available scientific evidence (AU)

Short-term outcomes of minimally invasive retromuscular ventral hernia repair using an enhanced view totally extraperitoneal (eTEP) approach: systematic review and meta-analysis.

BACKGROUND: The enhanced view totally extraperitoneal (eTEP) approach is becoming increasingly more widely accepted as a promising technique in the treatment of ventral hernia. However, evidence is still lacking regarding the perioperative, postoperative and long-term outcomes of this technique. The aim of this meta-analysis is to summarize the current available evidence regarding the perioperative and short-term outcomes of ventral hernia repair using eTEP. STUDY DESIGN: A systematic search was performed of PubMed, EMBASE, Cochrane Library and Web of Science electronic databases to identify studies on the laparoscopic or robotic-enhanced view totally extraperitoneal (eTEP) approach for the treatment of ventral hernia. A pooled meta-analysis was performed. The primary end point was focused on short-term outcomes regarding perioperative characteristics and postoperative parameters. RESULTS: A total of 13 studies were identified involving 918 patients. Minimally invasive eTEP resulted in a rate of surgical site infection of 0% [95% CI 0.0-1.0%], a rate of seroma of 5% [95% CI 2.0-8.0%] and a rate of major complications (Clavien-Dindo III-IV) of 1% [95% CI 0.0-3.0%]. The rate of intraoperative complications was 2% [95% CI 0.0-4.0%] with a conversion rate of 1.0% [95% CI 0.0-3.0%]. Mean hospital length of stay was 1.77 days [95% CI 1.21-2.24]. After a median follow-up of 6.6 months (1-24), the rate of recurrence was 1% [95% CI 0.0-1.0%]. CONCLUSION: Minimally invasive eTEP is a safe and effective approach for ventral hernia repair, with low reported intraoperative complications and good outcomes.

[Outbreak of toxic anterior segment syndrome after vitreous surgery]. / Brote de síndrome tóxico del segmento anterior después de cirugía vítrea.

CASE REPORT: An outbreak of Toxic Anterior Segment Syndrome after vitreoretinal surgery is reported. Two patients underwent exclusively vitrectomy while the other three patients were operated of vitrectomy and some other anterior segment procedure. DISCUSSION: Toxic Anterior Segment Syndrome is a sterile postoperative inflammation due to any non infectious substance that reaches the anterior segment during surgery. It occurs in outbreaks and while most of the cases have been reported after anterior segment procedures, this case demonstrates that development after vitreoretinal surgery is also a possibility.

[Inflammatory optic neuritis]. / Neuritis óptica inflamatoria.

Inflammatory Optic Neuritis (ON) is the most frequent cause of acute visual loss in young adults. Although the visual prognosis is excellent in the majority of cases, many patients develop pathology, such as multiple sclerosis, in its subsequent evolution. The natural history of ON has been studied in numerous works in recent years; one of the most important of which is Optic Neuritis Treatment Trial. Magnetic Resonance plays a fundamental role in the etiological diagnosis of ON and in predicting the risk of conversion into multiple sclerosis. New exploratory techniques have recently been incorporated, such as optical coherence tomography, useful for diagnosis and prognosis; serum biomarkers have been identified in the diagnosis of other pathologies with an autoimmune nature that produce ON. A better understanding of the clinical and exploratory data of typical ON will make a more rapid and accurate diagnostic study possible. Treatment of ON with steroids must be individualised bearing in mind that they do not alter the long-term prognosis and an immunomodulating therapy must be proposed for patients with a high risk of conversion into multiple sclerosis. This article reviews the existing data in the literature on its clinical manifestations, its etiological and differential diagnosis, and the treatment of inflammatory ON.

Brote de síndrome tóxico del segmento anterior después de cirugía vítrea / Outbreak of toxic anterior segment syndrome after vitreous surgery

Caso clínico: Se describe un brote de SíndromeTóxico del Segmento Anterior después de cirugíavítrea. Dos pacientes habían sido intervenidosexclusivamente mediante vitrectomía mientras quelos otros tres fueron sometidos a vitrectomía yalgún otro procedimiento del segmento anterior.Discusión: El Síndrome Tóxico del SegmentoAnterior es una inflamación postoperatoria estérilprovocada por alguna sustancia no infecciosa quealcanza el polo anterior durante la cirugía. Sueleocurrir en brotes y aunque la mayoría de los casoshan sido descritos después de cirugía del segmentoanterior, los casos que presentamos demuestran quees posible su aparición tras cirugía vítrea(AU)

Case report: An outbreak of Toxic Anterior SegmentSyndrome after vitreoretinal surgery is reported.Two patients underwent exclusively vitrectomywhile the other three patients were operated of vitrectomyand some other anterior segment procedure.Discussion: Toxic Anterior Segment Syndrome is asterile postoperative inflammation due to any noninfectious substance that reaches the anterior segmentduring surgery. It occurs in outbreaks and whilemost of the cases have been reported after anteriorsegment procedures, this case demonstrates thatdevelopment after vitreoretinal surgery is also a possibility(AU)

Neuritis óptica inflamatoria / Inflammatory optic neuritis

La neuritis óptica inflamatoria (NO) es la causa másfrecuente de pérdida visual aguda en adultos jóvenes.Aunque el pronóstico visual es excelente en la mayoríade los casos, muchos pacientes desarrollarán otra patologíacomo esclerosis múltiple en la evolución posterior.La historia natural de la NO ha sido estudiada enmúltiples trabajos en los últimos años; uno de los másimportantes es el Optic Neuritis Treatment Trial.La Resonancia Magnética tiene un papel fundamentalen el diagnóstico etiológico de la NO y en la prediccióndel riesgo de conversión a esclerosis múltiple.Recientemente se han incorporado nuevas técnicasexploratorias como la tomografia de coherenciaóptica, útil para el diagnóstico y pronóstico; se hanidentificado biomarcadores séricos que ayudan en eldiagnóstico de otras patologías de naturaleza autoinmuneque producen NO.Un mejor conocimiento de los datos clínicos y exploratoriosde la NO típica permitirá un estudio diagnósticomás rápido y certero. El tratamiento de la NOcon esteroides debe ser individualizado teniendo encuenta que no modifican el pronóstico a largo plazo yen pacientes con alto riesgo de conversión a esclerosismúltiple debe plantearse terapia inmunomoduladora.Este trabajo revisa los datos existentes en la literaturareferentes a las manifestaciones clínicas, el diagnósticoetiológico y diferencial y tratamiento de la NO inflamatoria(AU)

Inflammatory Optic Neuritis (ON) is the mostfrequent cause of acute visual loss in young adults.Although the visual prognosis is excellent in the majorityof cases, many patients develop pathology, such asmultiple sclerosis, in its subsequent evolution.The natural history of ON has been studied in numerousworks in recent years; one of the most importantof which is Optic Neuritis Treatment Trial.Magnetic Resonance plays a fundamental role inthe etiological diagnosis of ON and in predicting therisk of conversion into multiple sclerosis.New exploratory techniques have recently beenincorporated, such as optical coherence tomography,useful for diagnosis and prognosis; serum biomarkershave been identified in the diagnosis of other pathologieswith an autoimmune nature that produce ON.A better understanding of the clinical and exploratorydata of typical ON will make a more rapid and accuratediagnostic study possible. Treatment of ON withsteroids must be individualised bearing in mind thatthey do not alter the long-term prognosis and an immunomodulatingtherapy must be proposed for patientswith a high risk of conversion into multiple sclerosis.This article reviews the existing data in the literatureon its clinical manifestations, its etiological and differentialdiagnosis, and the treatment of inflammatory ON(AU)

[Agreement among ophthalmologists and primary care physicians in the evaluation of retinographies of diabetic patients]. / Concordancia en el estudio de retinografías en diabéticos: oftalmólogos vs médicos de familia.

PURPOSE: To assess the extent of agreement in the evaluation of non-mydriatic retinographies of diabetic patients among ophthalmologists and a group of primary care physicians with previous training. METHODS: The study was divided in two phases. In the first phase, the four participants were instructed in the interpretation of retinographies. The second phase involved the evaluation of 1000 images of 200 patients, 100 without retinopathy and 100 with signs of diabetic retinopathy. The four participants had to decide if the images did or did not show evidence of diabetic retinopathy. Kappa index was used to assess the extent of agreement. A percentage disagreement of 15% with a precision of 5% (+/-5%) with a confidence level of 95% was considered adequate. RESULTS: The percentage of coincident diagnoses among ophthalmologists and primary care physicians was between 89 and 97.5%. With respect to the assessment of the agreement, the kappa index was between 80 and 95%. In all cases the confidence interval was at least 85%. CONCLUSIONS: After an adequate training process, the reliability of evaluation of non-mydriatic retinographies of diabetic patients by primary care physicians was very high. This could allow the establishment of screening for diabetic retinopathy at the primary care level. Advantages of this system include a greater involvement of primary care physicians in the global management of diabetic patients and a lower demand for ophthalmic attention.

Concordancia en el estudio de retinografías en diabéticos: oftalmólogos vs médicos de famlia / Agreement among ophthalmologists and primary care physicians in the evaluation of retinographies of diabetic patients

Objetivo: Determinar la concordancia en la interpretación de retinografías no midriáticas de pacientes diabéticos entre oftalmólogos y un grupo de médicos de atención primaria previamente sometidos a un proceso de adiestramiento. Métodos: El estudio fue dividido en dos fases. En la primera se adiestró a los participantes en la interpretación de imágenes retinográficas. La segunda fase se realizó sobre 1000 imágenes correspondientes a 200 pacientes, 100 sin retinopatía diabética y 100 con retinopatía. Los participantes debían decidir si las imágenes presentaban o no signos de retinopatía diabética. Para la valoración de la concordancia se utilizó el índice kappa. Se estimó como adecuado un porcentaje de desacuerdo del 15% con una precisión del 5% (±5%) con un nivel de confianza del 95%. Resultados: El porcentaje de diagnósticos coincidentes entre oftalmólogos y médicos de atención primaria está entre 89 y 97,5%. Por lo que respecta a la evaluación de la concordancia, el índice kappa se sitúa entre 80 y 95%. En todos los casos el intervalo de confianza incluye el 85%. Conclusiones: Después de un adecuado adiestramiento, la fiabilidad de facultativos de atención primaria en interpretar retinografías no midriáticas de diabéticos es muy alta. Esto permitiría establecer en atención primaria el filtro para el cribado de la retinopatía diabética. Las ventajas de esta medida serían una mayor implicación de atención primaria en el manejo global de los diabéticos y una disminución de la demanda de atención oftalmológica

Purpose: To assess the extent of agreement in the evaluation of non-mydriatic retinographies of diabetic patients among ophthalmologists and a group of primary care physicians with previous training. Methods: The study was divided in two phases. In the first phase, the four participants were instructed in the interpretation of retinographies. The second phase involved the evaluation of 1000 images of 200 patients, 100 without retinopathy and 100 with signs of diabetic retinopathy. The four participants had to decide if the images did or did not show evidence of diabetic retinopathy. Kappa index was used to assess the extent of agreement. A percentage disagreement of 15% with a precision of 5% (±5%) with a confidence level of 95% was considered adequate. Results: The percentage of coincident diagnoses among ophthalmologists and primary care physicians was between 89 and 97.5%. With respect to the assessment of the agreement, the kappa index was between 80 and 95%. In all cases the confidence interval was at least 85%. Conclusions: After an adequate training process, the reliability of evaluation of non-mydriatic retinographies of diabetic patients by primary care physicians was very high. This could allow the establishment of screening for diabetic retinopathy at the primary care level. Advantages of this system include a greater involvement of primary care physicians in the global management of diabetic patients and a lower demand for ophthalmic attention (Arch Soc Esp Oftalmol 2008; 83: 527-532)

Retinopatía diabética / Diabetic retinopathy

La diabetes mellitus es una patología metabólicaque en su evolución afecta a diferentes órganos, entreellos los ojos. La microangiopatía diabética afecta demanera precoz y específica a la retina. La aparición dela retinopatía está directamente relacionada con eltiempo de evolución de la enfermedad y del controlmetabólico. La microangiopatía diabética en la retinamuestra alteraciones específicas como son los microaneurismas,los exudados duros o blandos, las microhemorragiasintrarretinianas, dilataciones venosas arrosariadasy anomalías microvasculares intrarretinianas.Estas alteraciones en la microcirculación retiniana causandos fenómenos fisiopatológicos: cierre capilar conla consiguiente isquemia o extravasación del contenidointravascular al estroma provocando edema. Eneste capítulo se exponen la clasificación y tratamientosde la retinopatía diabética, excluyendo el edema macular,según los diferentes estudios multicéntricos presentesen la bibliografía actual

Diabetes mellitus is a metabolic pathology whoseevolution affects different organs, amongst them theeye. Diabetic microangiopathy affects the retina in anearly and specific way. The appearance of retinopathyis directly related to the time of evolution of thedisease and metabolic control. Diabeticmicroangiopathy in the retina shows specificalterations such as micro-aneurysms, soft or hardexudates, intra-retinal micro-haemorrhages, beadedveins and intraretinal microvascular anomalies.These alterations in the retinal microcirculation causetwo physiopathological phenomena: capillary closurewith the resulting ischaemia or extravasation ofintravascular content to the stroma causing edema. Inthis chapter we set out the classification andtreatments of diabetic retinopathy, excluding macularedema, according to the different multicentric studiespresent in the current bibliography

Optical coherence tomography evaluation of the corneal cap and stromal bed features after laser in situ keratomileusis for high myopia and astigmatism.

OBJECTIVE: To study the corneal microstructure by optical coherence tomography (OCT) after laser in situ keratomileusis (LASIK) for high myopia with and without astigmatism. DESIGN: Nonrandomized self-controlled comparative trial. PARTICIPANTS: Sixty-three consecutive LASIK eyes with spherical equivalent refraction between -6.0 and -17.0 diopters (D) and astigmatism between 0.0 and -5.0 D were prospectively recruited for examination. INTERVENTION: LASIK was performed with the Chiron Hansatome microkeratome (160-microm fixed plate) and Summit Apex Plus excimer laser using a 5.5/6.0/6.5-mm multizone pattern. Proper preoperative calculations were performed to ensure stromal beds thicker than 250 microm. MAIN OUTCOME MEASURES: OCT imaging and measurement of corneal thickness was performed preoperatively. In addition, corneal cap and stromal bed thickness measurements were performed 1 day, 1 month, and 3 months postoperatively. RESULTS: The average central corneal pachymetry was 538.9 +/- 26.2 microm preoperatively. Mean corneal cap thickness measured 124.8 +/- 18.5 microm 1-day postoperatively. Mean stromal bed thickness was 295.2 +/- 37.1 microm on the first postoperative day. Compared with the 1-day postoperative examination, the average stromal bed thickness increased significantly by 5.9 microm (P = 0.001) and 7.2 microm (P = 0.001) at the 1-month and 3-month postoperative examinations, respectively. Mean difference between actual (118.7 +/- 27.8 microm) and predicted (104.1 +/- 20.8 microm) central ablation depths was 14.6 +/- 16.7 microm (P = 0.0001). A weak but statistically significant positive association was found between preoperative refraction and the difference between expected and real ablation depth values (R = 0.26; P = 0.042). Posterior stromal beds were more than 250-microm thick in 58 eyes (89.9%) 1 day postoperatively. This safety requirement improved at the 1-month postoperative examination, when the partial regression accounted for slightly thicker stromal beds and only two cases (3.2%) exhibited posterior stromal tissue thinner than 250 microm. These two cases were seen only for corrections exceeding 12 D (P = 0.04). CONCLUSIONS: OCT appears to be a useful tool for the evaluation of both the qualitative and quantitative anatomic outcome of LASIK. Corrections of higher degrees of ametropia run a higher risk of producing a thinner than expected central cornea. Particularly, corrections greater than 12 D may lead eventually to stromal beds thinner than 250 microm, despite proper preoperative calculations. Because corneal flaps are usually thinner than expected with the microkeratome used herein, adequate posterior corneal stroma is preserved in most instances.

Final clear corneal incision size for AcrySof intraocular lenses.

PURPOSE: To evaluate clear corneal incision size variation in phacoemulsification surgery after the implantation of 2 models of AcrySof intraocular lenses (IOLs). SETTING: Departamento de Oftalmología, Clínica Universitaria de Navarra, Universidad de Navarra, Pamplona, Spain. METHODS: This prospective study comprised 108 eyes that had phacoemulsification and implantation of an Acrysof IOL model MA60BM (56 eyes) or MA30BA (52 eyes). Wound incision size was quantified using the Nordan incision size measurer. The incision size for each IOL model was evaluated before and after implantation and its relationship with the complications during implantation analyzed. RESULTS: Mean incision size varied from 3.7 mm +/- 0.14 (SD) before implantation to 3.9 +/- 0.11 mm after implantation for the MA60BM model (P = .001) and from 3.3 +/- 0.15 mm to 3.4 +/- 0.13 mm for the MA30BA model (P = .001). Intraoperative complications occurred in 14 eyes, and difficulty during IOL implantation, in 23 eyes. There was no association between final incision size and complications. CONCLUSIONS: Incision size increased after the implantation of the 2 AcrySof IOL models used in this study. Modifications to model MA30BA have led to an average decrease in wound size of 0.5 mm with respect to the MA60BM model. Most difficulties encountered were attributable to improper IOL unfolding.

Variation in clear cornea incision size after phacoemulsification and foldable lens implantation.

PURPOSE: To study the changes in clear cornea incision size after phacoemulsification and implantation of a three-piece, silicone, foldable intraocular lens (IOL). SETTING: Departamento de Oftalmologia, Clinica Universitaria de Navarra, Pamplona, Spain. METHODS: In this prospective study, phacoemulsification with implantation of a foldable IOL (AMO SI-30NB) was performed in 133 eyes. Surgery was carried out by four surgeons who implanted the IOL with the same forceps. The external incision size was measured before and after phacoemulsification and irrigation/aspiration and before and after IOL implantation. RESULTS: Before phacoemulsification the mean incision size was 3.07 mm; after phacoemulsification and irrigation/aspiration, it enlarged to 3.09 mm (P = .001). The mean incision size before foldable IOL implantation was 3.16 mm, and after implantation it increased to 3.32 mm (P = .0001). When the IOL was less than 22.0 diopters (D), the final incision size was 3.31 mm +/- 0.11 (SD); when the IOL was 22.0 to 26.0 D, the final size was 3.32 +/- 0.01 mm; and when the IOL was 26.0 D or more, the final size was 3.39 +/- 0.08 mm (P = .01). CONCLUSIONS: Phacoemulsification and foldable IOL implantation enlarged the size of the clear cornea incision in this study. The IOL power may be a significant factor in determining the minimal incision size prior to IOL insertion and the final incision size.

Medial canthus tumor surgery: a prospective study of microscopically controlled excision.

OBJECTIVES: We set out to demonstrate that medial canthus tumors are malignancies requiring microscopically-controlled excision for a high cure rate. We also aim to show that reconstruction can have good esthetic results with a few simple techniques. METHODS: During 1992, we treated 38 basal cell carcinomas of the medial canthus, employing our own two-step Mohs' surgery. All cases were reconstructed with five simple techniques: "laissez faire", full thickness graft, nasoglabellar flap, mild-line forehead flap or combination of flaps. RESULTS: No recurrent basal cell carcinomas have been observed in our patients during the last four years. All the medial canthus tumours were basal cell carcinomas, eight involving morpheiform infiltration. Perineural infiltration was observed in two cases. CONCLUSIONS: Micrographic surgery for medial canthus malignant tumors is the best resection technique. Infiltrating, basal cell carcinomas, are the most common tumors of medial canthus, but also have an excellent cure rate. Reconstruction with a small number of flaps and skin graft is generally an easy process, producing highly satisfactory results.