Clinical characterization of patients with anal fistula during follow-up of anorectal abscess: a large population-based study.

PURPOSE: Approximately 15-50% of patients with an anorectal abscess will develop an anal fistula, but the true incidence of this entity is currently unknown. The aim of the study was to determine the incidence of anorectal abscess and development of a fistula in a specific population area and to identify potential risk factors associated with demographic, socioeconomic and pre-existing disease (e.g. diabetes and inflammatory bowel disease). METHODS: A longitudinal observational study was designed including a large cohort study in an area with 7,553,650 inhabitants in Spain 1st january 2014 to 31st december 2019. Adults who attended for the first time with an anorectal abscess and had a minimum of 1-year follow-up were included. The diagnosis was made using ICD-10 codes for anorectal abscess and anal fistula. RESULTS: During the study period, we included 27,821 patients with anorectal abscess. There was a predominance of men (70%) and an overall incidence of 596 per million population. The overall incidence of anal fistula developing from abscesses was 20%, with predominance in men, and a lower incidence in the lowest income level. The cumulative incidence of fistula was higher in men and in younger patients (p < 0.0001). On multivariate analysis, patients aged 60-69 years (hazard ratio 2.0) and those with inflammatory bowel disease (hazard ratio 1.8-2.0) had a strong association with fistula development (hazard ratio 2.0). CONCLUSIONS: One in five patients with an anorectal abscess will develop a fistula, with a higher likelihood in men. Fistula formation was strongly associated with inflammatory bowel disease.

[Identification and review of low-value clinical practices in General and Digestive Surgery]. / Identificación y revisión de prácticas clínicas de poco valor clínico en Cirugía General y Digestiva.

INTRODUCTION: There are currently widespread clinical practices that, because they do not have been supported by available scientific evidence, are inappropriate for most patients. The objective of the present study was to identify and review these low-value clinical practices in General Surgery. MATERIAL AND METHODS: A systematic review of the specialized databases and the published guidelines with identification of low-value practices in General Surgery was carried out. Of the low-value practices selected for a tertiary and university hospitals through the consensus of expert surgeons, those that do not provide clinical value were identified. RESULTS: In a first search, 4,019 recommendations were found, of which 60 were selected because they were focused on General Surgery. After evaluation by the experts, a total of 29 clinical recommendations were selected to be implemented in a specialty service, which were divided into those corresponding to diagnostic processes (n=9), procedures and surgical technique (n=10) and of perioperative care and medication (n=10). CONCLUSIONS: There is evidence in the literature of some clinical practices that provide little value in General Surgery. The changes referring to do-not-do these practices should be implemented in current clinical practice of this specialty.

Monitorización de la respuesta a la terapia neoadyuvante en el carcinoma de mama localmente avanzado mediante métodos de imagen / No disponible

Objetivo: Establecer la validez diagnóstica de la mamografía, de la resonancia magnética y de la gammagrafía 99mTc-sestamibi en la valoración de la respuesta terapéutica de pacientes diagnosticadas de carcinoma de mama localmente avanzado. Pacientes y métodos: Estudio prospectivo observacional aprobado por el Comité Ético de nuestra institución en el que se han incluido 75 pacientes diagnosticadas de carcinoma de mama localmente avanzado por core biopsia (edad media: 52 años, rango: 26-80 años). Las pacientes fueron valoradas clínicamente, por mamografía, resonancia magnética y gammagrafía 99mTc-sestamibi antes de iniciar la terapia neoadyuvante y una vez finalizada la misma. Se han administrado regímenes terapéuticos basados en antraciclinas excepto en siete pacientes que recibieron hormonoterapia con inhibidores de la aromatasa. Para la valoración de la respuesta clínica se utilizaron los criterios RECIST y los mismos criterios, adaptados y consensuados, se emplearon para la valoración de la respuesta mediante técnicas de imagen e histología. Resultados: Tras cirugía se constató respuesta histológica, bien sea parcial o completa, en 61 pacientes (81,3%). Se evidenció conformidad entre la respuesta clínica y los hallazgos histológicos en el 80% de los casos, entre mamografía e histología en el 79,7% de casos, y esta fue del 78,9 % para la resonancia magnética y del 86,4% para la gammagrafía. La sensibilidad y especificidad fueron del 64,3 y del 83,8% para la mamografía, del 61,5 y 82,8% para la resonancia magnética, y del 58,3 y 92,6%, para la gammagrafía. Se pudo observar una concordancia del 88,8% entre resonancia y gammagrafía, del 75,7% entre esta y la mamografía y del 77,3 % entre gammagrafía y mamografía. Conclusiones: La resonancia magnética y la gammagrafía 99mTc-sestamibi demuestran su utilidad en la valoración de la respuesta tras la terapia neoadyuvante, si bien persiste la dificultad en la valoración de focos microscópicos de tumor o del componente in situ, y por tanto, en la definición de respuesta completa(AU)

Aim: To establish diagnostic validity of mammography, mammary magnetic resonance and 99mTc-sestamibi scintimammography to assess response to neoadjuvant therapy in patients with locally advanced breast cancer. Patients and methods: A prospective observational study was approved at our institution which included 75 women with core biopsy diagnostic of locally advanced breast cancer (mean age: 52 y, range 26-80 y). All patients had clinical, mammography, mammary magnetic resonance and 99mTc-sestamibi scintimammography assessment before and after receiving neoadjuvant therapy. Primary chemotherapy based on anthracyclines was administered except in seven patients who received endocrine therapy with aromatase inhibitors. RECIST criteria were considered for clinical response assessment, and the same criteria were adapted for imaging methods and pathologic response. Results: After surgery, 61 patients (81,3%) showed histologic response (complete or partial). Clinical assessment of tumour response was in concordance with histologic study in 80% of patients. Mammography, magnetic resonance and scintimammography agreed with pathology in 79,7, 78,9 and 86,4% of patients, respectively. Based on histologic response, sensitivity and specificity were 64,3 and 83,8% for mammography, 61,5 and 82,8% for magnetic resonance, and 58,3 and 92,6% for scintimammography, respectively. Agreement between magnetic resonance and scintimammography was 88,8%, between magnetic resonance and mammography 75,7%, and 77,3% between scintimammography and mammography. Conclusion: Magnetic resonance and scintimammography should be added to the diagnostic arsenal since they have shown more reliability than conventional methods for predicting histopathologic response to neoadjuvant therapy. Nevertheless, tumour size is critical for the detection of residual small lesions, usually microscopic and DCIS foci, or in others words, there is a limitation to define complete response(AU)

[Comparison between intratumoral and peritumoral injection of radiotracer for locating and biopsying the sentinel lymph node in nonpalpable breast cancer]. / Comparación entre la inyección intratumoral y peritumoral del radiotrazador para la localización y biopsia del ganglio centinela en cáncer de mama no palpable.

OBJECTIVE: To determine whether there are differences in the technical efficacy in detecting and biopsying the sentinel node after intratumoral or peritumoral administration of the radiotracer in patients with nonpalpable early-stage breast cancer. MATERIAL AND METHODS: This prospective, randomized study included 80 patients with nonpalpable breast cancer without axillary adenopathies who were scheduled for primary surgical treatment. Patients were randomized to one of two groups: the INTRA group (intratumoral radiotracer administration, n=35) or the PERI group (peritumoral radiotracer administration, n=45). Patients with suspicious axillary lymph nodes at clinical or ultrasonographic examination that had positive results after fine-needle aspiration cytology were excluded. RESULTS: The rates of sentinel node detection were 97.1% (34/35) for intratumoral injection and 84.4% (38/45) for peritumoral injection. Radiotracer migration failure occurred in 8 cases (one in the INTRA group and 7 in the PERI group). The sentinel node was detected in an extra-axillary location in 21.9% of cases (11/59 in the INTRA group and 16/64 in the PERI group). CONCLUSIONS: Our study found no statistically significant differences in the detection rates of axillary or extra-axillary sentinel lymph nodes between the two groups; however, we observed greater technical efficacy with intratumoral radiotracer administration.

Comparación entre la inyección intratumoral y peritumoral del radiotrazador para la localización y biopsia del ganglio centinela en cáncer de mama no palpable / Comparison between intratumoral and peritumoral injection of radiotracer for locating and biopsying the sentinel lymph node in nonpalpable breast cancer

Objetivo. Determinar si existen diferencias en la eficacia técnica en la detección y biopsia del ganglio centinela tras la administración del radiotrazador por vía intratumoral respecto a la vía peritumoral, en pacientes con cáncer de mama inicial no palpable. Material y métodos. Se realizó un estudio prospectivo y aleatorizado que incluyó a 80 pacientes con cáncer de mama no palpable, sin adenopatías axilares, programadas para tratamiento quirúrgico primario. Las pacientes fueron aleatorizadas en dos grupos según la vía de administración del radiotrazador: grupo INTRA (intratumoral, n = 35) y grupo PERI (peritumoral, n = 45). Fueron excluidas pacientes con ganglios axilares clínica o ecográficamente sospechosos con punción con aguja fina positiva. Resultados. Los índices de detección del ganglio centinela fueron del 97,1% (34/35) en la técnica de inyección intratumoral y 84,4% (38/45) en la vía peritumoral. Se dieron 8 fracasos de migración del radiotrazador (uno en el grupo INTRA y 7 en el PERI). En el 21,9% de casos se detectó el ganglio centinela en localización extraaxilar (11/59 en el gru - po INTRA y 16/64 en el grupo PERI). Conclusiones. Nuestro estudio no ha mostrado diferencias estadísticamente significativas en los índices de detección de los ganglios centinelas axilares ni extraaxilares entre los dos grupos, pero observó una mayor eficacia de la técnica en la administración intratumoral del radiotrazador

Objective. To determine whether there are differences in the technical efficacy in detecting and biopsying the sentinel node after intratumoral or peritumoral administration of the radiotracer in patients with nonpalpable early-stage breast cancer. Material and methods. This prospective, randomized study included 80 patients with nonpalpable breast cancer without axillary adenopathies who were scheduled for primary surgical treatment. Patients were randomized to one of two groups: the INTRA group (intratumoral radiotracer administration, n = 35) or the PERI group (peritumoral radiotracer administration, n = 45). Patients with suspicious axillary lymph nodes at clinical or ultrasonographic examination that had positive results after fine-needle aspiration cytology were excluded. Results. The rates of sentinel node detection were 97.1% (34/35) for intratumoral injection and 84.4% (38/45) for peritumoral injection. Radiotracer migration failure occurred in 8 cases (one in the INTRA group and 7 in the PERI group). The sentinel node was detected in an extra-axillary location in 21.9% of cases (11/59 in the INTRA group and 16/64 in the PERI group). Conclusions. Our study found no statistically significant differences in the detection rates of axillary or extra-axillary sentinel lymph nodes between the two groups; however, we observed greater technical efficacy with intratumoral radiotracer administration

Ablación del cáncer de mama mediante técnica de radiofrecuencia. Experiencia inicial / No disponible

Objetivo: Valorar la efectividad de la ablación por radiofrecuencia(ARF) en el tratamiento local del cáncer de mama enestadios iniciales.Pacientes y métodos: La ARF guiada por imagen ecográficase practicó en 4 pacientes (de los 30 inicialmente previstoscomo objeto de reclutamiento) en quirófano bajo anestesia general.La resección del lecho tumoral se llevó a cabo 2-3 semanasdespués. La valoración pre- y post-ARF se efectuó medianteimagen ecográfica, mamográfica y resonanciamagnética (RM).Resultados: El análisis anatomo-patológico determinó presenciade tejido tumoral en todos los casos, mientras que laRM informó tejido viable en 1 de los 3 casos en que se efectuó.Estos resultados no permitieron continuar el reclutamientode pacientes.Discusión: La radiofrecuencia es la técnica actualmentemás atractiva para la realización de la ablación no quirúrgicaen el tratamiento primario del cáncer de mama. El presentetrabajo pretende aportar una visión real, basada tanto en laexperiencia propia como en la literatura publicada. Con estaspremisas discutimos nuestros resultados, desalentadores aunquepreliminares, así como la bondad de la técnica en cuantoa eficacia de ablación tumoral y la posibilidad futura de sustituirla exéresis quirúrgica de la tumoración, principal motivaciónde los estudios actuales(AU)

Objective: To evaluate the efficacy of radiofrequency ablation(RFA) therapy for breast cancer.Patients and methods: Only four of the 30 initially scheduledpatients underwent ultrasound-guided RFA under generalanesthesia. Lumpectomy was performed 2-3 weeks after theRFA procedure.Results: Post-RFA MRI scans revealed lesion enhancementin 1 of 3 patients, however residual tumor was confirmedhistopathologically in all four patients. Because of such discouragingresults we decided to stop patient enrollment.Discussion: Nowadays, RFA is the most promising ablationtechnique for primary breast cancer treatment. Based on publishedstudies and on our own experience, an overview ofbreast cancer RFA is presented. We discuss both technicalRFA issues and pros compared with standard surgical treatment(AU)

Syngeneic islet transplantation into seminal vesicles of diabetic rats.

Pancreatic islet transplantation has been proposed as an attractive option for the treatment of type I diabetes. Transplantation into different sites has been investigated, among them those that are immuno-logically privileged (e.g., thymus, uterus, brain, anterior eye chamber, and testicle). Because of their characteristics, seminal vesicles could be considered as immunologically privileged organs, but there is no worldwide experience that can confirm it. The purpose of the present study is to assess the viability and functionality of islet transplantation into seminal vesicles of diabetic rats. One hundred ninety inbred adult male syngeneic Lewis rats were used as donors (n = 72), receptors (n = 36), and controls(n = 11). Diabetes was chemically induced through a single intraperitoneal injection of streptozotocin. Groups of 1200 purified islets were introduced in the right seminal vesicle of diabetic rats. Diabetic control rats were sham transplanted. Body weight and glycemia were monitored every 2 d. Of transplanted rats, 16.7% achieved a good function due to islet engraftment, while 30.6% achieved a partially good response, and 52.7% were considered as nonresponding. This is the first report about islet transplantation into seminal vesicles of diabetic animals. Our results indicate that islet transplantation into rat seminal vesicles is technically possible, and that islets can function normally after engraftment into the wall of the seminal vesicle.

Engraftment of islets obtained by collagenase and Liberase in diabetic rats: a comparative study.

INTRODUCTION: Islet transplantation is an attractive solution for type I diabetes, but the results are at the present discouraging. Collagenase, the enzyme used to obtain islets for transplantation, presents interbatch variability and endotoxin contamination that induces inflammatory cytokine production. Liberase (Roche, Basel, Switzerland), a new mixture of purified enzymes, has the same composition in all batches and is endotoxin-free. AIMS: To compare the engraftment of islets obtained using either enzyme in streptozotocin-induced diabetic rats. METHODOLOGY: Collagenase- or Liberase-isolated islets were transplanted under the kidney capsule of diabetic rats. Collagenase islets restored glycemia and insulinemia in all animals at 24 hours, and both parameters were maintained in 45% of rats over 90 days; however, Liberase islets failed to reverse diabetes in all subjects. RESULTS: In vitro experiments showed that Liberase islets did not maintain active insulin secretion. Cytotoxicity assays showed toxicity of Liberase to islets; both enzymes induced inflammatory cytokine production by macrophages. CONCLUSION: In summary, in our model, Liberase is not a good substitute for collagenase as an islet-isolating reagent. A major effort and investment in developing enzymes for tissue dispersion is needed to improve the outcome of islet transplantation.

Vascular complications following bladder drained, simultaneous pancreas-kidney transplantation: the University of Miami experience.

Vascular complications remain a significant nonimmunologic source of pancreas allograft loss. From February 1993 through January 1998, we performed 98 simultaneous pancreas-kidney transplantations (SPK) using pancreatic exocrine bladder drainage in patients with type 1 insulin-dependent diabetes mellitus and end-stage renal disease. They originally received quadruple immunosuppression, and since May 1997 triple immunosuppression protocol (tacrolimus, mycophenolate mofetil, and steroids). The patients' mean age was 37 years (range 24-53 years), including 50 women and 48 men with a mean follow-up of 42 months. The overall rate of vascular complications was 6% (5 patients). The vascular complications were as follows: late thrombosis of the Y with persistent pancreas allograft function (n = 1), rupture of a pseudoaneurysm of the superior mesenteric artery (PSMA) with an arteriovenous fistula (AVF) (n = 1), thrombosis of the splenic vein (SV) (n = 3), complete thrombosis of the superior mesenteric vein (SMV) and splenic vein (n = 1). The patient with PSMA underwent surgical correction of the AVF and PSMA with preservation of the allograft pancreas function. The other patient with late thrombosis of the Y-graft required no treatment. All 3 patients with SV thrombosis were systemically heparinized followed by oral anticoagulation. The patient with complete thrombosis required surgical thrombectomy of the SMV and SV followed by heparinization and oral anticoagulation. All 6 patients including the 4 with thrombosis had preservation of the pancreas function. Serial pancreas ultrasound showed resolution and improvement with recanalization of the splenic vein and superior mesenteric vein in those patients with thrombosis. We describe our vascular experience with salvage of the pancreatic allograft function. Surgery seems to be the best treatment option in the case of AVF or complete thrombosis of the allograft. Intravenous heparin followed by oral anticoagultion could be a conservative approach for SV thrombosis.

Successful surgical salvage of pancreas allografts after complete venous thrombosis.

BACKGROUND: Complete venous thrombosis of the pancreas after simultaneous pancreas-kidney (SPK) transplantation usually results in graft loss. We describe a technique that allows salvage of the graft after complete venous thrombosis. METHODS: A total of 150 patients with insulin dependent diabetes mellitus/end stage renal disease underwent SPK over the past decade at the University of Miami. Of these, three patients developed complete venous thrombosis after induction therapy with antiinterleukin-2R antibody and i.v. tacrolimus. These three patients underwent surgical thrombectomy followed by heparinization and oral anticoagulation. The splenic vein was opened distally at the tail of the pancreas and the superior mesenteric vein at the level of the mesentery or head of the pancreas. Thrombectomy was performed with a Fogarty catheter. The portal anastomosis was not opened or manipulated. The arterial "Y" graft was not clamped and the right iliac vein was controlled proximally with a double wrapped vessel-loop to contain possible thrombus. In one patient, the partially thrombosed splenic artery was opened at the tail of the pancreas and thrombectomy was performed in the same fashion. There were no apparent technical problems. A pancreatic biopsy was not performed, nor was acute rejection treated empirically. RESULTS: Intraoperative and serial Doppler ultrasound showed good flow through the allograft. In all three patients the exocrine and endocrine function of the pancreas was preserved with a mean follow-up of 15 months. CONCLUSIONS: The described surgical thrombectomy followed by systemic anticoagulation may be useful in the salvage of the allograft pancreas in case of complete venous thrombosis.

[Selective biopsy of the sentinel ganglion in patients with breast cancer. Initial results]. / Biopsia selectiva del ganglio centinela en pacientes con cáncer de mama. Primeros resultados.

BACKGROUND: Sentinel-node biopsy is meant to excise the first-echelon node from a primary tumor, which is the one that most probably harbors early metastases. PATIENTS AND METHODS: We report our results in 35 patients with breast cancer, using a radiotracer by peri-tumoral injection, pre-surgical scintigraphy and intraoperative mapping with a gamma probe. RESULTS: The technical success rate was 97%, negative predictive value 95.2%, accuracy 97%, and added value to staging 40%. CONCLUSION: Compared with the conventional lymph-node staging procedure for breast cancer, sentinel-node biopsy with pre-surgical scintigraphy seems a good practical choice.

Platelet count and survival in patients with colorectal cancer--a preliminary study.

In a previous report we found an inverse correlation between pre-operative platelet count (PlC) levels and the risk of post-operative pulmonary embolism in patients undergoing hip surgery. In the present study, we prospectively evaluated the prognostic significance of pre-operative PlC levels on survival in 180 consecutive patients undergoing surgery for colorectal cancer. Other major clinicopathological parameters studied were age, gender, Dukes' stage, duration of surgery, pre-operative haemoglobin levels and transfusion requirements. There were no significant differences in mean pre-operative PlC levels according to tumor stage. Thirty-three patients (18%) died during follow-up (3-23 months, median: 13 months). Univariate analysis (Kaplan-Meier estimates) showed that advanced tumor stage (p < 0.001), duration of surgery (p < 0.05) and a high pre-operative PlC level (p < 0.001) were significantly associated to a poor survival. The multivariate Cox analysis revealed that tumor stage (RR:5.734; 95%C.I.: 2.644-12.44), a high pre-operative PlC level (RR: 2.467; 95%C.I.: 1.117-5.452), and to a lesser extent the patients' age remained independent prognostic variables for mortality. The findings of this preliminary study may be of interest from the point of view of pathogenesis, but also clinically, since they might be used in the decision as to which patients or groups of patients should receive more aggressive therapeutic intervention.

Endotoxin contamination may be responsible for the unexplained failure of human pancreatic islet transplantation.

Clinical transplantation of human islets has a disappointingly low rate of success. We report here the identification of a possible causative factor: endotoxin present in the collagenase preparations used to disperse the pancreatic tissue before islet purification and transplantation. Supporting evidence includes (1) detection of unexpectedly high levels of endotoxin in most collagenase solutions currently used to digest human pancreases; (2) demonstration that supernatants generated during islet separation are able to induce the inflammatory cytokines interleukin (IL)-1, IL-6, and tumor necrosis factor-alpha (TNF-alpha) in macrophages; and (3) induction of IL-1, IL-6, and TNF-alpha in the islets during the separation procedure. Cytokine expression was assessed by reverse transcription-polymerase chain reaction and, for TNF-alpha, confirmed by enzyme-linked immunoabsorbent assay. It is proposed that endotoxin and locally induced cytokines carried over with the graft activate the endothelium and promote lymphomonocytic infiltration of grafted islets and surrounding liver tissue favoring primary nonfunction and early rejection. These results also have implications for the numerous experimental procedures that use collagenase, and they point to possible ways to improve islet preparation and transplantation protocols.

[Survey of residents on their satisfaction after obtaining a hospital post]. / Encuesta a residentes MIR sobre su satisfacción tras obtener una plaza hospitalaria.

BACKGROUND: To evaluate the degree of satisfaction of the resident physicians in an university hospital by the election of the speciality and the hospital, after the takeover of the workplace and in the course of their period of residence. SUBJECTS AND METHODS: An anonymous questionnaire was distributed to the 164 residents of the hospital to know the concordance between the initial expectations of the residents and the degree of current satisfaction, about the specialty and the chosen hospital. RESULTS: 149 out of 164 residents (90.8%) answered the survey. In what is referring to the elected speciality, 57% (85 residents) expressed to be satisfied or very satisfied by their election; 22% (33 residents) felt indifferent, and 21% (31 residents) were unsatisfied or very unsatisfied. In what concerns to the chosen hospital, 43% (64 residents) were satisfied or very satisfied; 29% (43 residents) indifferent, and 28% (42 residents) were unsatisfied or very unsatisfied. With respect to the degree of satisfaction by the exercise of the profession at the moment of accomplishing the survey, 98% (143/149) of the residents answered, and of these, 30% (43 residents) expressed to be satisfied or very satisfied; 28% (40 residents), indifferent, and 42% (60 residents), unsatisfied or very unsatisfied. In the degree of satisfaction influenced in a statistically significant way the group of speciality chosen (medical, surgical or central services) after the examination and the moment of accomplishing the survey; the number of order of the residents examination; to have or not to have a speciality wished before of the residents examination, and the year of residence underway. CONCLUSIONS: The degree of satisfaction of the resident physicians by the election of the speciality and of the hospital is relatively low. This fact outlines the suitability of the election system of the specialty.