Reconstrucción mamaria diferida con colgajo de dorsal ancho: aportación de la ecografía Doppler-Dúplex / Delayed breast reconstruction with latissimus dorsi fiap: contribution of Doppler-Duplex ultrasound

Introducción y objetivo: Para obtener buenos resultados en reconstrucción mamaria autóloga con colgajo de dorsal ancho se requiere verificar la presencia de una vascularización tóracodorsal adecuada. En el presente trabajo evaluamos la aportación de la ecografía Doppler-Dúplex para la localización de la arteria torácodorsal, previa a la reconstrucción mamaria diferida con colgajo de dorsal ancho. Material y método: Revisión de 51 pacientes con antecedentes de cirugía axilar por cáncer de mama candidatas a reconstrucción diferida con colgajo homolateral del músculo dorsal ancho. La exploración ecográfica la realizó un solo radiólogo utilizando la modalidad ecográfica Doppler-Dúplex. Resultados: Entre las 51 pacientes, se localizó la arteria tóracodorsal mediante ecografía en 39 casos (76.47%). En 12 casos no se pudo localizar o bien su identificación resultó dudosa. Entre estos 12 casos, en 8 se realizó angio-tomografía computarizada o bien angio-resonancia magnética que identificaron la arteria en 5 casos. En los otros 3, las pacientes rechazaron las exploraciones y no se sometieron a reconstrucción mediante la técnica estudiada o bien no se reconstruyeron. Se dispone de datos confirmados en 47 casos, entre los cuales no se ha visualizado vascularización tóracodorsal en 3 casos, lo que supone un 6.38%. Los parámetros diagnósticos resultantes fueron: sensibilidad 88.63%; especificidad 100%; valor predictivo positivo 100%;y valor predictivo negativo 37.50%, con una exactitud del 89.36%. Conclusiones: En base a nuestra experiencia podemos concluir que, siempre que se disponga de la experiencia y los medios técnicos adecuados, la ecografía Doppler-Dúplex debería ser el primer procedimiento a utilizar para la evaluación de la vascularización tóracodorsal. y en el caso de no reunir tales requisitos o bien si la ecografía fuera dudosa/negativa, realizar otros métodos como la angio-tomografía computarizada o la angio-resonancia magnética(AU).

Background and objective: To obtain good results with autologous latissimus dorsi flap in breast reconstruction it's necessary to verify the presence of adequate thoracodorsal vascularity. In this paper we evaluate the contribution of Doppler-Duplex ultrasound for the localization of the thoracodorsal vessels prior to delayed breast reconstruction with a dorsal fap. Methods: Review of 51 patients with a history of axillary surgery for breast cancer, candidates for delayed breast reconstruction with an ipsilateral flap of the latissimus dorsi muscle. The ultrasound examination was performed by a single radiologist using the Doppler-Duplex ultrasound modality. Results: Among the 51 patients, the thoracodorsal artery was located by ultrasound in 39 cases (76.47%). In 12 cases it could not be located or its identification was doubtful. Among these 12 cases, 8 underwent computed tomography angiography or magnetic resonance angiography, which identified the artery in 5 cases. In the remaining 3 cases the patients refused such examinations and did not undergo reconstruction. Confirmed data are available in 47 cases, among which thoracodorsal vasculature was not visualized in 3 cases, which represents 6.38%,The resulting diagnostic parameters were: sensitivity 88.63%; specificity 100%; positive predictive value 100%; and negative predictive value 37.50%, with an accuracy of 89.36%. Conclusions: From our experience we can conclude that,when the appropriate experience and equipment are available, Doppler-Duplex ultrasound should be the first procedure to be used for the evaluation of the thoracodorsal vasculature. And in the case of not meeting these requirements or the ultrasound was doubtful/negative, perform other methods such as computed tomography angiography or magnetic resonance angiography. Level of evidence 5c Diagnostic.(AU)

Biopsia con aguja gruesa para la determinación del perfil de expresión génica tumoral, mediante la plataforma de 70 genes / Core needle biopsy for determining tumour gene expression profile through the 70 gene signature

Objetivos Evaluar la utilidad de la biopsia ecoguiada con aguja gruesa diagnóstica (BAG1) para la determinación del perfil de expresión génica tumoral (PEG), en los tumores malignos de mama. Materiales y métodos Revisión de 130 biopsias ecoguiadas con aguja gruesa (BAG), con resultado de malignidad. Se consideraron «aptas» las muestras con, al menos, un 30% de células tumorales. Se estudió la influencia del tamaño tumoral (menor de 1 cm, entre 1-2 cm y mayor de 2 cm) y se analizaron las causas que motivaron muestras no aptas. Se utilizó la plataforma MammaPrint® (70 genes). Se evaluó la influencia del grado histológico y del riesgo genómico en los resultados. Resultados En la BAG1 se obtuvieron muestras aptas en 100 biopsias (76,92%). Entre los 36 casos en los que se utilizó la BAG para obtener el PEG, en 32 (88,89%) se realizó a partir de la BAG1. Entre los 30 casos en los que la BAG1 no resultó apta, en 26 casos no se obtuvo el porcentaje mínimo de células tumorales en la muestra. Ni el grado histológico ni el riesgo genómico influyeron en los resultados. Conclusiones Las muestras diagnósticas de la biopsia ecoguiada con aguja gruesa (BAG1) pueden ser válidas para la determinación del perfil de expresión génica. Ello facilita y acelera el proceso de evaluación pronóstica en los tumores infiltrantes de mama. Por ello, proponemos que, de manera rutinaria y ante el diagnóstico de tumor maligno infiltrante, conste el porcentaje de células tumorales en los informes anatomopatológicos. (AU)

Objectives To assess the utility of diagnostic ultrasound-guided core needle biopsy (CNB1) for determining tumour gene expression profile (GEP) in malignant breast tumours. Materials and Methods Review of 130 diagnostic ultrasound-guided core needle biopsies (CNB1) indicating malignancy. Samples with at least 30% tumour cells were considered suitable. The influence of tumour size (less than 1 cm, between 1-2 cm and greater than 2 cm) was studied and the causes of unsuitable samples were analysed. The MammaPrint® platform (70 genes) was used. The influence of histological grade and genomic risk was evaluated. Results Suitable CNB1 samples were obtained in 100 biopsies (76.92%). Among the 36 cases in which CNB was used to obtain the GEP, in 32 (88.89%) it was performed using the CNB1. Among the 30 cases in which CNB1 was not suitable, the minimum percentage of tumour cells in the sample was not obtained in 26 cases. Neither histological grade nor genomic risk influenced the results. Conclusions Diagnostic samples from ultrasound-guided biopsy (CNB1) can be valid to determine GEP. This facilitates and accelerates the prognostic evaluation process in infiltrating breast tumours. Therefore, we propose that, when diagnosing an infiltrating malignant tumour, the percentage of tumour cells should be routinely recorded in the pathology reports. (AU)

Biopsia con aguja gruesa para la determinación del perfil de expresión génica tumoral, mediante la plataforma de 70 genes / Core needle biopsy for determining tumour gene expression profile through the 70 gene signature

Objetivos Evaluar la utilidad de la biopsia ecoguiada con aguja gruesa diagnóstica (BAG1) para la determinación del perfil de expresión génica tumoral (PEG), en los tumores malignos de mama. Materiales y métodos Revisión de 130 biopsias ecoguiadas con aguja gruesa (BAG), con resultado de malignidad. Se consideraron «aptas» las muestras con, al menos, un 30% de células tumorales. Se estudió la influencia del tamaño tumoral (menor de 1 cm, entre 1-2 cm y mayor de 2 cm) y se analizaron las causas que motivaron muestras no aptas. Se utilizó la plataforma MammaPrint® (70 genes). Se evaluó la influencia del grado histológico y del riesgo genómico en los resultados. Resultados En la BAG1 se obtuvieron muestras aptas en 100 biopsias (76,92%). Entre los 36 casos en los que se utilizó la BAG para obtener el PEG, en 32 (88,89%) se realizó a partir de la BAG1. Entre los 30 casos en los que la BAG1 no resultó apta, en 26 casos no se obtuvo el porcentaje mínimo de células tumorales en la muestra. Ni el grado histológico ni el riesgo genómico influyeron en los resultados. Conclusiones Las muestras diagnósticas de la biopsia ecoguiada con aguja gruesa (BAG1) pueden ser válidas para la determinación del perfil de expresión génica. Ello facilita y acelera el proceso de evaluación pronóstica en los tumores infiltrantes de mama. Por ello, proponemos que, de manera rutinaria y ante el diagnóstico de tumor maligno infiltrante, conste el porcentaje de células tumorales en los informes anatomopatológicos. (AU)

Objectives To assess the utility of diagnostic ultrasound-guided core needle biopsy (CNB1) for determining tumour gene expression profile (GEP) in malignant breast tumours. Materials and Methods Review of 130 diagnostic ultrasound-guided core needle biopsies (CNB1) indicating malignancy. Samples with at least 30% tumour cells were considered suitable. The influence of tumour size (less than 1 cm, between 1-2 cm and greater than 2 cm) was studied and the causes of unsuitable samples were analysed. The MammaPrint® platform (70 genes) was used. The influence of histological grade and genomic risk was evaluated. Results Suitable CNB1 samples were obtained in 100 biopsies (76.92%). Among the 36 cases in which CNB was used to obtain the GEP, in 32 (88.89%) it was performed using the CNB1. Among the 30 cases in which CNB1 was not suitable, the minimum percentage of tumour cells in the sample was not obtained in 26 cases. Neither histological grade nor genomic risk influenced the results. Conclusions Diagnostic samples from ultrasound-guided biopsy (CNB1) can be valid to determine GEP. This facilitates and accelerates the prognostic evaluation process in infiltrating breast tumours. Therefore, we propose that, when diagnosing an infiltrating malignant tumour, the percentage of tumour cells should be routinely recorded in the pathology reports. (AU)

El modelo Acute Care Surgery en el mundo y la necesidad e implantación de unidades de trauma y cirugía de urgencia en España / The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain

El modelo Acute Care Surgery agrupa bajo una misma disciplina el trauma, la cirugía de urgencias y los cuidados intensivos posquirúrgicos. Concebido y extendido durante las 2 últimas décadas por territorio norteamericano, la magnitud e idiosincrasia clínica de la urgencia quirúrgica han hecho que este modelo se haya asumido en muchos otros puntos de la geografía mundial. En nuestro país, el reflejo ha sido la creación e implantación de las denominadas unidades de trauma y cirugía de urgencias, cuyos objetivos son comunes a las publicadas para el modelo original: evitar la nocturnidad en las urgencias quirúrgicas, liberar a los profesionales vinculados a la cirugía electiva en horario laboral y convertirse en el eslabón y referente perfectos de la continuidad asistencial. En el presente artículo se resumen el nacimiento y la expansión del modelo original, la evidencia aportada en cuanto a resultados y la situación actual en nuestro país

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country

The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain. / El modelo Acute Care Surgery en el mundo y la necesidad e implantación de unidades de trauma y cirugía de urgencia en España.

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

[Leiomyosarcoma of the inferior vena cava. Case report and literature review]. / Leiomiosarcoma de vena cava inferior. Caso clínico y revisión bibliográfica.

BACKGROUND: Large vessel sarcomas are rare tumours. Leiomyosarcoma of the inferior vena cava is the most common. About 300 cases have been reported in the literature. They tend to be large, and not develop metastasis. The prognosis of these tumours is poor. CLINICAL CASE: An 81 year-old woman who complained of pain in the right flank, with no other symptoms. Abdominal computed tomography showed a large retroperitoneal mass, which affected the inferior vena cava, with signs of thrombosis inside. It also encompassed the right renal vein and the right kidney. Excision of the tumour was performed in block, performing an autologous saphenous vein bypass between left the renal vein and proximal segment of inferior vena cava. DISCUSSION: Leiomyosarcomas of the inferior vena cava are classified according to their relationship with adjacent structures. The clinical signs and symptoms are generally non-specific. Diagnosis is made using computed tomography or magnetic resonance imaging, and biopsy of the retroperitoneal mass. Surgery is the only treatment capable of providing prolonged survival. The surgical management is determined by: the level of involvement, the extension, and the presence or absence of collateral veins. The role of adjuvant therapy is controversial. CONCLUSIONS: Inferior vena cava leiomyosarcomas remain a challenge for surgeons. At present, radical resection with negative margins, offers the highest survival rate. The best results are obtained with a multidisciplinary approach by experienced teams in the management of these tumours.

[Colonic gallstone ileus: A rare cause of intestinal obstruction]. / Íleo biliar colónico: una rara causa de obstrucción intestinal.

BACKGROUND: A gallstone colonic ileus is a very rare condition. CLINICAL CASE: The case is reported of an 87 year-old patient who came to the Emergency Department due to an intestinal obstruction of several days onset, which was caused by a gallstone affected sigmoid colon. CONCLUSION: Colonic gallstone ileus is a rare disease that usually occurs in older patients due to the passage of large gallstone directly from the gallbladder to colon, through a cholecystocolonic fistula. It has a high morbidity and mortality.

[Role of care surgery in the treatment of pseudomembranous colitis]. / Papel de la cirugía en el tratamiento de la colitis pseudomembranosa.

BACKGROUND: Pseudomembranous colitis, caused by Clostridium difficile, has seen an increased incidence in recent years, driven mainly by the indiscriminate use of antibiotics. Although initial treatment is medical, the role of emergency surgery has gained ground due to high mortality and the emergence of increasingly virulent strains. In our country the prevalence is still low so that sometimes our experience in handling is limited. AIM: To analyze our surgical experience in treatment of this disease and to remember the role of surgery as well as some technical aspects of it. CLINICAL CASES: We present 2 cases of patients who have suffered a fulminant pseudomembranous colitis unresponsive to initial medical treatment and requiring urgent surgical intervention with a good response to it. CONCLUSIONS: It is important to keep in mind the surgical option in treatment of pseudomembranous colitis, especially when it presents as fulminant colitis, there are associated complications or failure to respond to medical treatment.

Enfermedad de Hirschsprung en el adulto que debuta como obstrucción intestinal aguda. A propósito de un caso / Hirschsprung disease with debut in adult age as acute intestinal obstruction: case report

La enfermedad de Hirschsprung consiste en la ausencia de células ganglionares en los plexos submucosos y mientérico del intestino. Suele diagnosticarse en el periodo neonatal, siendo muy poco frecuente que se descubra en el adulto. Suele presentarse como estreñimiento severo con dilatación cólica proximal al segmento agangliónico. El tratamiento es quirúrgico, extirpando el segmento agangliónico y restableciendo la continuidad del tubo digestivo. En muy raras ocasiones, esta enfermedad se presenta como un cuadro de obstrucción intestinal aguda. Presentamos el caso de un paciente, no diagnosticado previamente, que debutó como un cuadro de dilatación cólica masiva, con un diámetro máximo de 44 cm, con riesgo de perforación inminente, lo que motivó la realización de una cirugía urgente. Incluimos una revisión de la literatura existente al respecto (AU)

Hirschsprung's disease is characterized by absence of ganglion cells in submucosal and myenteric plexus of distal bowel. Most cases become manifest during the neonatal period, but in rare instances, this disease is initially diagnosed in adult age. It usually presents as severe constipation with colonic dilatation proximal to the aganglionic segment. The treatment is surgical, removing the aganglionic segment and restoring continuity of digestive tract. The disease rarely presents as an acute intestinal obstruction. We report a case not previously diagnosed, which presented as a massive colonic dilatation with a maximum diameter of 44 cm, with imminent risk of drilling that forced to perform an emergency surgery. We include a review of existing literature (AU)

Tratamiento de la ingesta de cuerpos extraños / Treatment for ingested foreign bodies

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Hirschsprung disease with debut in adult age as acute intestinal obstruction: case report.

Hirschsprung's disease is characterized by absence of ganglion cells in submucosal and myenteric plexus of distal bowel. Most cases become manifest during the neonatal period, but in rare instances, this disease is initially diagnosed in adult age. It usually presents as severe constipation with colonic dilatation proximal to the aganglionic segment. The treatment is surgical, removing the aganglionic segment and restoring continuity of digestive tract. The disease rarely presents as an acute intestinal obstruction. We report a case not previously diagnosed, which presented as a massive colonic dilatation with a maximum diameter of 44 cm, with imminent risk of drilling that forced to perform an emergency surgery. We include a review of existing literature.

Distinct breast cancer stem/progenitor cell populations require either HIF1α or loss of PHD3 to expand under hypoxic conditions.

The heterogeneous nature of breast cancer is a result of intrinsic tumor complexity and also of the tumor microenvironment, which is known to be hypoxic. We found that hypoxia expands different breast stem/progenitor cell populations (cells with increased aldehyde dehydrogenase activity (Aldefluor+), high mammosphere formation capacity and CD44+CD24-/low cells) both in primary normal epithelial and tumor cells. The presence of the estrogen receptor (ER) limits hypoxia-dependent CD44+CD24-/low cell expansion.We further show that the hypoxia-driven cancer stem-like cell enrichment results from a dedifferentiation process. The enhanced mammosphere formation and Aldefluor+ cell content observed in breast cancer cells relies on hypoxia-inducible factor 1α (HIF1α). In contrast, the CD44+CD24-/low population expansion is HIF1α independent and requires prolyl hydroxylase 3 (PHD3) downregulation, which mimics hypoxic conditions, leading to reduced CD24 expression through activation of NFkB signaling. These studies show that hypoxic conditions expand CSC populations through distinct molecular mechanisms. Thus, potential therapies that combine current treatments for breast cancer with drugs that target CSC should take into account the heterogeneity of the CSC subpopulations.

Respuesta hormonal de las células madre de mama y resistencia a tamoxifeno / Hormone response of breast stem cells and tamoxifen resistance

Objetivo. Determinar la influencia a nivel celular y molecular de varios tratamientos hormonales (estrógeno, tamoxifeno y fulvestrant) sobre las células epiteliales y las células madre de la mama sana y tumoral. Métodos. Se emplearon muestras de tejido mamario sano y tumoral, así como líneas celulares de cáncer de mama y células resistentes a tamoxifeno, para analizar los efectos de las hormonas sobre la proliferación y diferenciación celular. Resultados. Las células epiteliales y las células madre de la mama respondieron de forma diferente a los tratamientos hormonales. Las células resistentes a tamoxifeno presentaban un mayor contenido de células madre cancerosas y expresaban niveles de Sox2 más elevados, mientras que los niveles de expresión del receptor de progesterona eran muy bajos. Las células resistentes a tamoxifeno eran, además, más resistentes al tratamiento con fulvestrant. Conclusiones. El desarrollo de resistencia a tamoxifeno está asociado con un incremento en el contenido de células madre cancerosas. El tratamiento con fulvestrant no parece disminuir la población de células madre cancerosas. Sox2 podría ser un biomarcador de resistencia a tamoxifeno en el cáncer de mama (AU)

Objective. To determine the influence of various hormones (estrogen, tamoxifen and fulvestrant) on cell proliferation and differentiation in normal and cancer breast stem cells. Methods. Primary tissue samples, breast cancer cell lines and tamoxifen-resistant cells were used to analyze the effects of hormones on cell proliferation and differentiation. Results. Breast epithelial cells and stem cells responded differentially to hormone treatments. Tamoxifen-resistant cells showed increased cancer stem cell content and expressed higher Sox2 levels, while progesterone receptor levels were very low. Tamoxifen-resistant cells were resistant to fulvestrant treatment. Conclusions. The development of tamoxifen resistance is associated with an increase in cancer stem cell content. Treatment with fulvestrant does not appear to reduce the cancer stem cell population. Sox2 could represent a biomarker of tamoxifen resistance in breast cancer (AU)

Evolución del abordaje quirúrgico de la colecistitis aguda en una unidad de cirugía de urgencias / Development of the surgical approach to acute cholecystitis in an emergency surgical unit

Objetivo La aplicación de la técnica laparoscópica en la colecistitis aguda es aún hoy un tema controvertido. El objetivo del estudio es valorar la aplicabilidad, seguridad, beneficios y complicaciones del abordaje laparoscópico en pacientes con colecistitis aguda, así como la evolución y desarrollo de dicha vía en la unidad de cirugía de urgencias de un hospital de tercer nivel, en comparación con la laparotómica. Material y método El estudio consta de 354 pacientes con cuadros de colecistitis aguda intervenidos por vía abierta o laparoscópica desde 2006 a 2009.ResultadosSe han intervenido 253 pacientes por vía laparoscópica, 101 por vía abierta, apreciándose un predominio del sexo masculino (57,67%) y una edad media de 62,83 años. El número de colecistectomía laparoscópica ha pasado del 60% en el 2006, al 79% en 2009. La estancia media (englobando complicadas y no complicadas) hablan a favor del abordaje laparoscópico frente al abierto (mostrando una diferencia de aproximadamente 6 al día). Las complicaciones postoperatorias a lo largo de estos cuatro años en la vía laparoscópica han experimentado un descenso, pasando de un 21,42 a un 11,3%. Las complicaciones locales y globales se correlacionaron significativamente con el tiempo transcurrido entre el inicio de los síntomas agudos y la cirugía, así como con el estado anatomopatológico de la vesícula biliar. Conclusiones El abordaje laparoscópico va adquiriendo un papel cada vez más primordial en el tratamiento de esta dolencia, convirtiéndose en nuestro hospital en la principal opción quirúrgica (AU)

Objective The application of the laparoscopic technique in acute cholecystitis is still subject to controversy. The aim of this study is to asses the applicability, safety, benefits and complications of the laparoscopic approach in patients with acute cholecystitis, as well as the development of this technique in the emergency surgery department of a tertiary hospital, compared to laparotomy. Material and method The study consisted of 354 patients with acute cholecystitis syndromes operated either by open or laparoscopic surgery, during the years 2006 to 2009.ResultsThe laparoscopic method was used in 253 patients, and 101 by the open route, with the slight majority being male (57.67%) and with a mean age of 62.83 years. The number of laparoscopic cholecystectomies increased from 60% in 2006, to 79% in 2009. The mean hospital stay (including those with and without complications) was shorter using the laparoscopic approach, compared to open surgery (showing a difference of approximately 6 days). The postoperative complications in laparoscopy during the four years studied decreased from 21.42 to 11.3%. The local and general complications were significantly associated with time since the start of the acute symptoms and the surgery, as well as the histopathological state of the gall bladder. Conclusions The laparoscopic approach continues to play an increasing role in the treatment of this disease, becoming the main surgical option in our hospital (AU)