Functional outcomes of hybrid hiatal hernia repair.

Gastroesophageal reflux disease (GERD) results in a total healthcare cost of 12.3 billion dollars to the United States annually. GERD is often seen with hiatal hernias. Our study aims to compare short-term functional outcomes and postoperative symptom relief afforded by hiatal hernia repair with transoral incisionless fundoplication (TIF), together known as hybrid repair, to those of hiatal hernia repair with surgical fundoplication (conventional repair). We performed a retrospective chart review on 112 consecutive patients who underwent robot assisted laparoscopic hiatal hernia repair at a community hospital by a single surgeon. We found that the short-term functional results and symptom relief with hybrid repair were no superior to those with conventional repair. We did not find a significant difference between hybrid and conventional repair in terms of in 30 day complications, ER visits or inpatients admissions. The number of patients who were symptomatic at delayed follow-up was not significantly different between both the groups. As such, short-term functional outcomes and symptom relief with hybrid hiatal hernia repair are no superior to those with conventional repair. Therefore, surgical repair of hiatal hernia with surgical fundoplication remains the standard of care until further data is available on long-term outcomes of the hybrid approach.

Gastric ischemia secondary to intestinal occlusion due to gallstone ileus.

Gallstone ileus is a rare complication of cholecystoduodenal fistula. Gastric ischemia due to intestinal obstruction is an extremely rare event that, if not diagnosed in time, can have a fatal outcome. We present the case of a patient with intestinal occlusion due to a gallstone obstructing the middle jejunum in which gastric ischemia was diagnosed intraoperatively due to the distension caused by the intestinal obstruction.

Hybrid hiatal hernia repair: is it cost-effective?

Fundoplication is often added to the crural repair for long-term relief of reflux in patients undergoing hiatal hernia repair. Fundoplication can be achieved surgically or with endoscopic means such as trans-oral incisionless fundoplication (TIF). Patients with hiatal hernias larger than 2 cm may undergo surgical hiatal hernia repair with concomitant TIF (hybrid repair). Our study aims to analyze the resources utilized for hybrid repair and compare it with hiatal hernia repair with surgical fundoplication (conventional repair). We conducted a retrospective review of 112 consecutive patients who underwent robotic-assisted hiatal hernia repair. Patients who underwent some form of fundoplication were selected and then divided into two groups-surgical fundoplication (conventional approach) or hybrid approach. This is a pool of patients operated by a single surgeon at a community hospital. Multiple variables were analyzed. The mean operative time was 39 min less; also the mean length of stay was 10 h less in hybrid approach group as compared to conventional repair group. Although statistically significant, there was no meaningful clinical significance to these findings. Cost analysis was performed for direct costs as well as indirect costs. Neither the 30-day outcomes nor the cost-effectiveness for hybrid repair was superior to those of conventional repair. Therefore, in our experience at the community-level hospital, we conclude that hiatal hernia repair with surgical fundoplication is more cost-effective than surgical repair of hiatal hernia with TIF.

Granada será tu cruz y escenario de tu reforma hospitalaria / Granada will be your cross and scene of your hospital reform

La ciudad de Granada está impregnada de la figura y obra de San Juan de Dios, pues fue donde llevó a cabo su renovada obra hospitalaria, donde pasó la última etapa de su vida, donde afrontó las mayores dificultades, pero también donde alcanzó el más alto reconocimiento. Hoy existe un itinerario juandediano en la ciudad que recorre el centro histórico para descubrir los múltiples emplazamientos donde su figura dejó huella y que la tradición ha llevado hasta nosotros. Por todo ello, según el director de la Casa de los Pisa, que fue donde el santo falleció, Granada es un lugar con un fuerte componente didáctico para conocer lo que este personaje aportó a la enfermería y a las profesiones relacionadas con la salud (AU)

UNICEF's lessons learned from the education response to the COVID-19 crisis and reflections on the implications for education policy.

COVID-19 triggered mass innovation that grew flexible learning modalities and pathways that can be built upon in future sector plans to make education systems more resilient. These tools must be paired with investments in the people expected to use them and strengthened data systems. To ensure plans are rooted in ever-pressurised budgets, Education Ministers will increasingly need to turn to economic analysis. Expansion of partnerships will be necessary to secure greater and more innovative forms of finance but also affordable digital learning solutions. If these opportunities are seized alongside the disruption wrought by the pandemic, they can equalize opportunities and accelerate progress.

Cryptorchidism as an obscure cause of adhesive small bowel obstruction in an adult, a case report.

INTRODUCTION AND IMPORTANCE: Cryptorchidism is seen in 3% of fullterm neonates. Rarely, it may cause small bowel obstruction. Knowledge of this presentation of cryptorchidism is essential to treat bowel obstruction arising due to cryptorchidism before the patient suffers complications. CASE PRESENTATION: We present a case of a patient who underwent exploratory laparotomy for small bowel obstruction that did not resolve with conservative management. At laparotomy, on initial exploration, this patient had adhesive bands causing the small bowel obstruction. On further exploration, the bands were found to arise from a cryptorchid testis. CLINICAL DISCUSSION: Cryptorchidism is a common finding among newborns and needs to be corrected by 1 year of age. Failure to correct cryptorchidism in a timely manner can result in complications such as bowel obstruction. CONCLUSION: Thorough intraoperative exploration is key at operation for all cases of small bowel obstruction, so as to find and treat anatomic causes of obstruction. Congenital causes of bowel obstruction should be suspected in all unexplained cases of bowel obstruction and may be revealed by careful physical examination and thorough intraoperative exploration.

Deep brain stimulation of midbrain locomotor circuits in the freely moving pig.

BACKGROUND: Deep brain stimulation (DBS) of the mesencephalic locomotor region (MLR) has been studied as a therapeutic target in rodent models of stroke, parkinsonism, and spinal cord injury. Clinical DBS trials have targeted the closely related pedunculopontine nucleus in patients with Parkinson's disease as a therapy for gait dysfunction, with mixed reported outcomes. Recent studies suggest that optimizing the MLR target could improve its effectiveness. OBJECTIVE: We sought to determine if stereotaxic targeting and DBS in the midbrain of the pig, in a region anatomically similar to that previously identified as the MLR in other species, could initiate and modulate ongoing locomotion, as a step towards generating a large animal neuromodulation model of gait. METHODS: We implanted Medtronic 3389 electrodes into putative MLR structures in Yucatan micropigs to characterize the locomotor effects of acute DBS in this region, using EMG recordings, joint kinematics, and speed measurements on a manual treadmill. RESULTS: MLR DBS initiated and augmented locomotion in freely moving micropigs. Effective locomotor sites centered around the cuneiform nucleus and stimulation frequency controlled locomotor speed and stepping frequency. Off-target stimulation evoked defensive and aversive behaviors that precluded locomotion in the animals. CONCLUSION: Pigs appear to have an MLR and can be used to model neuromodulation of this gait-promoting center. These results indicate that the pig is a useful model to guide future clinical studies for optimizing MLR DBS in cases of gait deficiencies associated with such conditions as Parkinson's disease, spinal cord injury, or stroke.

Success of endoscopic vacuum therapy for persistent anastomotic leak after esophagectomy - A case report.

INTRODUCTION: Endoscopic vacuum (endovac) therapy has shown excellent outcomes when used for esophageal anastomotic leaks. The results of endovac therapy are superior to those of other endoscopic therapies for esophageal leaks. CASE PRESENTATION: We present a case of a 70-year-old male with esophageal adenocarcinoma who underwent Ivor Lewis esophagogastrectomy that was complicated by an esophageal leak. After failure of multiple endoscopic therapies (i.e. stents and clips), he responded well to endovac therapy. DISCUSSION: Endovac therapy is extremely useful for the treatment of esophageal leaks. The widespread use of endovac therapy is feasible, even in smaller community hospitals. CONCLUSION: Endovac therapy is a valuable tool that can be used widely for the management of esophageal leaks. Commercially available devices need to be developed in order to facilitate endovac placement and exchange so that the procedure is less dependent on the skill of the operator.

Nonsurgical management of an asymptomatic popliteal venous aneurysm.

An 81-year-old male with a history of poorly controlled congestive heart failure, chronic obstructive pulmonary disease and atrial fibrillation among other comorbidities was admitted to the hospital for worsening bilateral leg swelling and cellulitis. The patient had an injury to his left medial malleolus 2 weeks prior, which failed outpatient care. During the physical exam, a soft mobile mass was palpated in the right popliteal fossa along with bilateral varicose veins, +1 pitting edema in bilateral lower extremities up to mid-calf. Duplex ultrasound revealed a saccular dilation in the right popliteal vein measuring 2.2 × 1.8 × 2.8 cm, without any evidence of superficial or deep vein thrombosis. After an extended conversation with the patient and his care team, a decision to continue with medical management with close monitoring was made. Follow-up ultrasounds performed at 1, 6 and 12 months show no changes.

Cortical and Subcortical Effects of Transcutaneous Spinal Cord Stimulation in Humans with Tetraplegia.

An increasing number of studies supports the view that transcutaneous electrical stimulation of the spinal cord (TESS) promotes functional recovery in humans with spinal cord injury (SCI). However, the neural mechanisms contributing to these effects remain poorly understood. Here we examined motor-evoked potentials in arm muscles elicited by cortical and subcortical stimulation of corticospinal axons before and after 20 min of TESS (30 Hz pulses with a 5 kHz carrier frequency) and sham-TESS applied between C5 and C6 spinous processes in males and females with and without chronic incomplete cervical SCI. The amplitude of subcortical, but not cortical, motor-evoked potentials increased in proximal and distal arm muscles for 75 min after TESS, but not sham-TESS, in control subjects and SCI participants, suggesting a subcortical origin for these effects. Intracortical inhibition, elicited by paired stimuli, increased after TESS in both groups. When TESS was applied without the 5 kHz carrier frequency both subcortical and cortical motor-evoked potentials were facilitated without changing intracortical inhibition, suggesting that the 5 kHz carrier frequency contributed to the cortical inhibitory effects. Hand and arm function improved largely when TESS was used with, compared with without, the 5 kHz carrier frequency. These novel observations demonstrate that TESS influences cortical and spinal networks, having an excitatory effect at the spinal level and an inhibitory effect at the cortical level. We hypothesized that these parallel effects contribute to further the recovery of limb function following SCI.SIGNIFICANCE STATEMENT Accumulating evidence supports the view that transcutaneous electrical stimulation of the spinal cord (TESS) promotes recovery of function in humans with spinal cord injury (SCI). Here, we show that a single session of TESS over the cervical spinal cord in individuals with incomplete chronic cervical SCI influenced in parallel the excitability cortical and spinal networks, having an excitatory effect at the spinal level and an inhibitory effect at the cortical level. Importantly, these parallel physiological effects had an impact on the magnitude of improvements in voluntary motor output.

Neurophysiological Changes in the First Year After Cell Transplantation in Sub-acute Complete Paraplegia.

Neurophysiological testing can provide quantitative information about motor, sensory, and autonomic system connectivity following spinal cord injury (SCI). The clinical examination may be insufficiently sensitive and specific to reveal evolving changes in neural circuits after severe injury. Neurophysiologic data may provide otherwise imperceptible circuit information that has rarely been acquired in biologics clinical trials in SCI. We reported a Phase 1 study of autologous purified Schwann cell suspension transplantation into the injury epicenter of participants with complete subacute thoracic SCI, observing no clinical improvements. Here, we report longitudinal electrophysiological assessments conducted during the trial. Six participants underwent neurophysiology screening pre-transplantation with three post-transplantation neurophysiological assessments, focused on the thoracoabdominal region and lower limbs, including MEPs, SSEPs, voluntarily triggered EMG, and changes in GSR. We found several notable signals not detectable by clinical exam. In all six participants, thoracoabdominal motor connectivity was detected below the clinically assigned neurological level defined by sensory preservation. Additionally, small voluntary activations of leg and foot muscles or positive lower extremity MEPs were detected in all participants. Voluntary EMG was most sensitive to detect leg motor function. The recorded MEP amplitudes and latencies indicated a more caudal thoracic level above which amplitude recovery over time was observed. In contrast, further below, amplitudes showed less improvement, and latencies were increased. Intercostal spasms observed with EMG may also indicate this thoracic "motor level." Galvanic skin testing revealed autonomic dysfunction in the hands above the injury levels. As an open-label study, we can establish no clear link between these observations and cell transplantation. This neurophysiological characterization may be of value to detect therapeutic effects in future controlled studies.

Estado de conservación de Myrcianthes ferreyrae un árbol endémico de las lomas costeras del sur del Perú / State of conservation de Myrcianthes ferreyrae an endemic tree of the coastal hills of southern Peru

Myrcianthes ferreyrae (McVaugh) McVaugh, el "arrayan" es un árbol endémico y amenazado de las lomas costeras del sur de Perú. El presente trabajo evaluó su estado de conservación entre marzo 2011 a agosto 2012. Se realizó el conteo de todos los individuos en casi todo su rango de distribución conocido (lomas de Atiquipa, Taymara y Chala viejo en la Provincia de Caraveli, Arequipa); se estableció un total de 9 parcelas de 0.25 ha, tres en cada localidad y en cada una se tomaron datos estructurales de todos los árboles con un diámetro un basal mayor a 10 cm; además, se evaluaron parámetros de mortalidad, regeneración natural y la presencia de disturbios. El arrayan tiene una población de 586 individuos, presenta una distribución diamétrica en forma de campana, la categoría de mortalidad más común es la tala de individuos; el porcentaje de regeneración natural es 33.12%, todos pertenecientes a las lomas de Atiquipa. Se concluye que poblacion de M. ferreyrae esta fuertemente amenazada, conformada por individuos adultos y con poca regeneración natural. En el manejo de esta especie debe considerarse su fragilidad y los problemas que tiene para su regeneración.

Myrcianthes ferreyrae (McVaugh) McVaugh, "arrayan" is an endemic and threatened tree of the "lomas" formations of south Peru. We evaluated their conservation status between March 2011 to August 2012; for which, all individuals were counted in its distributional range known (Atiquipa, Taymara and Chala Viejo hills in the Province of Caraveli, Arequipa). We established 9 plots of 0.25 hectares, three in each locality; in each plot we obtained data of all trees greater than 10 cm basal diameter, plus mortality parameters, its natural regeneration and presence of disturbances. Myrcianthes ferreyrae has a population of 586 individuals, its diameter distribution shows a bell form, the most common category mortality was logging; the natural regeneration was 33.12%, all belonging to the Atiquipa hills. We conclude that M. ferreyrae is strongly threatened, formed by adult individuals and with little natural regeneration. In management of M. ferreyrae should be considered its fragility and the problems it has for its regeneration.

Clinical and Neurophysiological Changes after Targeted Intrathecal Injections of Bone Marrow Stem Cells in a C3 Tetraplegic Subject.

High-level quadriplegia is a devastating condition with limited treatment options. Bone marrow derived stem cells (BMSCs) are reported to have immunomodulatory and neurotrophic effects in spinal cord injury (SCI). We report a subject with complete C2 SCI who received three anatomically targeted intrathecal infusions of BMSCs under a single-patient expanded access investigational new drug (IND). She underwent intensive physical therapy and was followed for >2 years. At end-point, her American Spinal Injury Association Impairment Scale (AIS) grade improved from A to B, and she recovered focal pressure touch sensation over several body areas. We conducted serial neurophysiological testing to monitor changes in residual connectivity. Motor, sensory, and autonomic system testing included motor evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), electromyography (EMG) recordings, F waves, galvanic skin responses, and tilt-table responses. The quality and magnitude of voluntary EMG activations increased over time, but remained below the threshold of clinically obvious movement. Unexpectedly, at 14 months post-injury, deep inspiratory maneuvers triggered respiratory-like EMG bursting in the biceps and several other muscles. This finding means that connections between respiratory neurons and motor neurons were newly established, or unmasked. We also report serial analysis of MRI, International Standards for Neurological Classification of SCI (ISNCSCI), pulmonary function, pain scores, cerebrospinal fluid (CSF) cytokines, and bladder assessment. As a single case, the linkage of the clinical and neurophysiological changes to either natural history or to the BMSC infusions cannot be resolved. Nevertheless, such detailed neurophysiological assessment of high cervical SCI patients is rarely performed. Our findings indicate that electrophysiology studies are sensitive to define both residual connectivity and new plasticity.

Dichotomous Locomotor Recoveries Are Predicted by Acute Changes in Segmental Blood Flow after Thoracic Spinal Contusion Injuries in Pigs.

Neuroimaging facilitates the translation of animal pre-clinical research to human application. The large porcine spinal cord is useful for testing invasive interventions. Ideally, the safety and efficacy of a delayed intervention is tested in pigs that have recovered sufficiently after spinal cord injury (SCI) to allow either deterioration or improvement of function to be detected. We set out to create moderate severity T9 injuries in Yucatan minipigs by conducting a bridging study adapting methods previously developed in infant piglets. The injury severity was varied according to two pneumatic impactor parameters: the piston compression depth into tissue or the velocity. To stratify locomotor recovery, a 10-point scale used in prior piglet studies was redefined through longitudinal observations of spontaneous recovery. Using hindlimb body weight support to discriminate injury severity, we found that end-point recovery was strongly bimodal to either non-weight-bearing plegia with reciprocating leg movements (<5/10) or recovery of weight bearing that improved toward a ceiling effect (≥ 8/10). No intermediate recovery animals were observed at 2 months post-injury. The ability of intra-operative ultrasound and acute magnetic resonance imaging (MRI) to provide immediate predictive feedback regarding tissue and vascular changes following SCI was assessed. There was an inverse association between locomotor outcome and early gray matter hemorrhage on MRI and ultrasound. Epicenter blood flow following contusion predicted recovery or non-recovery of weight-bearing. The depth of the dorsal cerebrospinal fluid space, which varied between animals, influenced injury severity and confounded the results in this fixed-stroke paradigm.

Intraoperative radiotherapy with the Intrabeam® device for the treatment of resectable pancreatic adenocarcinoma. / Radioterapia intraoperatoria con Intrabeam® para el tratamiento del adenocarcinoma de páncreas resecable.

INTRODUCTION: The application of intraoperative radiation therapy to the tumor bed after resection of pancreatic cancer has been shown to be beneficial in the local control of the disease. The objective of this study was to evaluate the preliminary outcomes after the application of a single intraoperative dose to the tumor bed with a new intraoperative radiotherapy device (Intrabeam®) in terms of viability, safety and short-term results. METHODS: We studied 5 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer in which a radiotherapy boost (5Gy) was intraoperatively applied to the tumoral bed using the portable Intrabeam® device, a low-energy point-source X-ray. Postoperative complications, hospital stay and mortality, recurrences and short-term survival were analyzed. RESULTS: Mean patient age was 68 years. All patients had a T3-stage tumor and one of them N1. In 3 patients, R0 resection was performed, while R1 resection was conducted in 2. Perioperative mortality was 0%. The only complications included delayed gastric emptying and postoperative hemorrhage. There were no pancreatic fistulas. During follow-up (mean: 11.2 months), there was a relapse in the patient who had undergone R1 resection. CONCLUSIONS: The application of radiotherapy with the Intrabeam® device in selected patients has not resulted in increased perioperative morbidity or mortality; therefore, this is a safe procedure for the treatment of resectable cancer.

Radioterapia intraoperatoria con Intrabeam(R) para el tratamiento del adenocarcinoma de páncreas resecable / Intraoperative radiotherapy with the Intrabeam(R) device for the treatment of resectable pancreatic adenocarcinoma

INTRODUCCIÓN: La aplicación de radioterapia intraoperatoria en el lecho tumoral tras la resección de un cáncer de páncreas ha demostrado ser beneficiosa en el control local de la enfermedad. El objetivo de este estudio fue valorar los resultados iniciales obtenidos tras la aplicación de una nueva modalidad de radioterapia intraoperatoria (Intrabeam(R)) en términos de viabilidad, seguridad y resultados a corto plazo. MÉTODOS: Se estudiaron 5 pacientes sometidos a duodenopancreatectomía cefálica por cáncer de páncreas resecable, en los que se aplicó intraoperatoriamente un boost de radioterapia (5Gy) en el lecho tumoral mediante la utilización del dispositivo portátil Intrabeam(R), fuente puntual de rayos X de baja energía. Se analizaron las complicaciones, estancia y mortalidad postoperatorias, recidivas y superviviencia a corto plazo. RESULTADOS: La edad media fue de 68 años. Todos los pacientes presentaban un estadio tumoral T3 y uno de ellos N1. En 3 pacientes se realizó una resección R0 y en 2 casos resultó ser una resección R1. La mortalidad peroperatoria fue del 0%. Solo se presentaron como complicaciones un retraso en el vaciamiento gástrico y una hemorragia postoperatoria. No hubo fístulas pancreáticas. Durante el seguimiento (media: 11,2 meses) se constató una recidiva en el paciente en el que se había practicado una resección R1. CONCLUSIONES: La aplicación de radioterapia con el dispositivo Intrabeam(R) en pacientes seleccionados no ha supuesto un aumento de la morbimortalidad peroperatoria, mostrándose como un procedimiento seguro en el tratamiento del cáncer resecable

INTRODUCTION: The application of intraoperative radiation therapy to the tumor bed after resection of pancreatic cancer has been shown to be beneficial in the local control of the disease. The objective of this study was to evaluate the preliminary outcomes after the application of a single intraoperative dose to the tumor bed with a new intraoperative radiotherapy device (Intrabeam(R)) in terms of viability, safety and short-term results. METHODS: We studied 5 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer in which a radiotherapy boost (5Gy) was intraoperatively applied to the tumoral bed using the portable Intrabeam(R) device, a low-energy point-source X-ray. Postoperative complications, hospital stay and mortality, recurrences and short-term survival were analyzed. RESULTS: Mean patient age was 68 years. All patients had a T3-stage tumor and one of them N1. In 3 patients, R0 resection was performed, while R1 resection was conducted in 2. Perioperative mortality was 0%. The only complications included delayed gastric emptying and postoperative hemorrhage. There were no pancreatic fistulas. During follow-up (mean: 11.2 months), there was a relapse in the patient who had undergone R1 resection. CONCLUSIONS: The application of radiotherapy with the Intrabeam (R) device in selected patients has not resulted in increased perioperative morbidity or mortality; therefore, this is a safe procedure for the treatment of resectable cancer

Intraspinal Delivery of Schwann Cells for Spinal Cord Injury.

Cell transplant-mediated tissue repair of the damaged spinal cord is being tested in several clinical trials. The current candidates are neural stem cells, stromal cells, and autologous Schwann cells (aSC). Due to their peripheral origin and limited penetration of astrocytic regions, aSC are transplanted intralesionally as compared to neural stem cells that are transplanted into intact spinal cord. Injections into either location can cause iatrogenic injury, and thus technical precision is important in the therapeutic risk-benefit equation. In this chapter, we discuss how we bridged from transplant studies in large animals to human application for two Phase 1 aSC transplant studies, one subacute and one chronic. Preclinical SC transplant studies conducted at the University of Miami in 2009-2012 in rodents, minipigs, and primates supported a successful Investigational New Drug (IND) submission for a Phase 1 trial in subacute complete spinal cord injury (SCI). Our studies optimized the safety and efficiency of intralesional cell delivery for subacute human SCI and led to the development of new simpler techniques for cell delivery into subjects with chronic SCI. Key parameters of delivery methodology include precision localization of the injury site, stereotaxic devices to control needle trajectory, method of entry into the spinal cord, spinal cord motion reduction, the volume and density of the cell suspension, rate of delivery, and control of shear stresses on cells.

Obesity Surgery Score (OSS) for Prioritization in the Bariatric Surgery Waiting List: a Need of Public Health Systems and a Literature Review.

BACKGROUND: In the last decades, we have experienced an increase in the prevalence of obesity in western countries with a higher demand for bariatric surgery and consequently prolonged waiting times. Currently, in many public hospitals, the only criterion that establishes priority for bariatric surgery is waiting time regardless of obesity severity. METHODS: We propose a new, simple, and homogeneous clinical prioritization system, the Obesity Surgery Score (OSS), which takes into account simultaneously and equitably the time on surgical waiting list and the obesity severity based on three variables: body mass index, obesity-related comorbidities, and functional limitations. We have reviewed the current literature related to obesity clinical staging systems, and we have carried out an analysis of our patients in waiting list and divided their characteristics according to their degree of severity (A, B, or C) in the OSS. Patients with OSS grade C have a higher mean BMI, greater severity in comorbidities, and greater socio-labor impact. The current surgery waiting time of our series is of 26 months. Currently, 27 patients (51.9%) with OSS grade B and 15 patients (51.7%) with OSS grade C have been on our waiting list for more than 1 year. CONCLUSION: Since the obesity severity, the waiting time and its clinical consequences are associated with an increase in morbidity and mortality, it is important to apply a structured prioritization system for bariatric surgery waiting list. This allows prioritization of patients at greater risk, improves patient prognosis, and optimizes costs and available health resources.

Estallido postraumático de metástasis suprarrenal por hepatocarcinoma / Post-traumatic rupture of a suprarenal metastasis of hepatocarcinoma

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