Naked DNA delivery to whole pig cardiac tissue by coronary sinus retrograde injection employing non-invasive catheterization.

BACKGROUND: Hydrodynamic injection has demonstrated to be very efficient in the liver of small animals, although this procedure must be translated to the clinical practice in a milder but no less efficient way. The present study evaluates the capacity of non-invasive interventional catheterization as a procedure for naked DNA delivery to the heart in large animals. METHODS: Two catheters were placed in the coronary sinus: one of them to block blood circulation and the other to retrogradely inject 50 ml of a saline solution of DNA (20 µg/ml) containing the enhanced green fluorescent protein (EGFP) gene, at a flow rate of 5 ml/s. RESULTS: The results obtained show that EGFP protein, identified by immunohistochemistry, was present and widely distributed throughout the atrial and ventricular cardiac tissue. This observation agrees with the efficiency of EGFP gene delivery resulting in 1-200 EGFP gene copies per endogenous haploid genome. However, the transcription efficiency of the exogenous EGFP gene was at a ratio of 0.2-10 copies with respect to the endogenous GAPDH gene, suggesting that optimized gene constructs for expression in cardiac tissue could increase the final efficacy of gene transfer. CONCLUSIONS: We conclude that the retrovenous injection of naked DNA in the coronary sinus employing the catheterization technique is an easy and probably safe method for whole cardiac gene transfer.

Requirement and postoperative outcomes of abdominal panniculectomy alone or in combination with other procedures in a bariatric surgery unit.

BACKGROUND: A high percentage of patients present with redundant skin folds after bariatric surgery. This study aims to quantify the need for panniculectomy after open bariatric surgery and to analyze the postoperative outcomes. METHODS: A retrospective cohort study was performed. The patients were divided into 2 groups: group DLP, patients who underwent an abdominal panniculectomy alone and group DLP+, those who underwent panniculectomy in association with another surgical procedure. RESULTS: Four hundred forty-six patients underwent open bariatric surgery and 130 patients (29%) subsequently required an abdominal dermolipectomy. Seventy-six percent presented also incisional hernia and 8% presented cholelithiasis. Forty-six percent of patients presented postoperative complications: wound seroma/infection (21%), wound dehiscence due to skin necrosis (13%), and hemorrhage/hematoma (10%) were the most frequent. There were no major complications or mortality. DLP+ was not associated with an increase in complications. CONCLUSIONS: After open bariatric surgery, an abdominal panniculectomy is often required. This procedure has a high postoperative morbidity in these patients, although complications are usually mild. There is not an increase in the rate of complications when panniculectomy is associated with other procedures.

Rotura hepática espontánea en el síndrome HELLP: tratamiento mediante packing / Spontaneous hepatic rupture in HELLP syndrome: treatment through hepatic packing

La rotura hepática espontánea asociada a síndrome de HELLP (hemólisis, elevación de enzimas hepáticas y plaquetopenia) es extremadamente rara y se acompaña de una elevada tasa de complicaciones y mortalidad maternofetal. Es necesario un tratamiento urgente basado en la finalización del embarazo, reposición de hemoderivados y hemostasia hepática.Presentamos el caso de una paciente con síndrome HELLP y rotura hepática espontánea tratada mediante cesárea urgente y packing hepático (AU)

Spontaneous hepatic rupture associated with HELLP syndrome (hemolysis, elevated liver enzyme levels and low platelet count) is a very rare phenomenon that is frequently associated with a substantial rate of complications and mortality. In these cases, urgent management based on prompt delivery, blood transfusion and hepatic hemostasis is required.We report the case of a patient with spontaneous hepatic rupture caused by HELLP syndrome, which was treated with urgent cesarean section and hepatic packing (AU)

Relaxation by beta 3-adrenoceptor agonists of the isolated human internal anal sphincter.

AIMS: In this study, responses of beta(3)-adrenoceptor agonists were examined on human isolated internal anal sphincter (IAS) in order to explore their relaxant effects on hypertonicity of IAS. MAIN METHODS: The relaxant efficacy (E(max)) and potency (-logIC(50)) of BRL37344 and SR58611A, beta(3)-adrenoceptor agonists, were examined in contracted IAS muscle strips. The presence of beta(3)-adrenoceptors, and changes in intracellular calcium and cyclic nucleotide levels in IAS muscle were tested by Western blotting, epifluorescence microscopy and enzyme immunoassay, respectively. KEY FINDINGS: BRL37344 and SR58611A relaxed contracted IAS muscle (E(max)=27+/-3% and 35+/-3%; -logIC(50)=6.26+/-0.24 and 4.87+/-0.13; respectively). These relaxant responses were blocked by SR59230A, a selective beta(3)-antagonist but not by beta(1)/beta(2)-selective antagonists, neuronal inhibitor or inhibition of nitric oxide synthase. The E(max) of beta(3)-agonists was similar to that of beta(2)-selective agonists but smaller than that of isoprenaline (nonselective agonist) or beta(1)-selective agonists. BRL37344 (100 microM) increased cAMP (1.5-fold) without cGMP change, and depressed intracellular calcium signal. beta(3)-Adrenoceptor expression was smaller than that of beta(1)- and beta(2)-adrenoceptors. SIGNIFICANCE: This is the first study demonstrating the presence of beta(3)-adrenoceptor in human IAS muscle and beta(3)-mediated relaxation of augmented sphincter tone. However, direct beta(3)-relaxation appears smaller than that obtained for nonselective agonists which may limit their potential use in the treatment of anorectal hypertonicity disorders.

Neoplasias de páncreas y periampulares: morbimortalidad, resultados funcionales y supervivencia a largo plazo / Pancreatic and periampullary tumors: Morbidity, mortality, functional results and long-term survival

Objetivos Evaluar la morbimortalidad postoperatoria, el estado funcional y la supervivencia a largo plazo de pacientes con tumores de páncreas o periampulares a los que se intervino quirúrgicamente. Pacientes y métodos Cohorte de 160 pacientes a los que se intervino consecutivamente: 80 duodenopancreatectomías cefálicas (DPC), 30 resecciones corporocaudales (RCC), 7 duodenopancreatectomías totales, 4 resecciones centrales y 3 ampulectomías; en 36 pacientes no se realizó resección. La función pancreática se evaluó mediante test de sobrecarga oral a la glucosa, grasas en heces y elastasa fecal. Resultados La tasa de resecabilidad fue del 77,5%. En los pacientes resecados (n = 124) la morbilidad fue del 38,7% (con una tasa de fístulas pancreáticas del 6,4%) y la mortalidad del 4%. En las DPC la función endocrina pancreática ha empeorado en el 41%, con esteatorrea en el 58,6% de los casos; en las RCC estos valores fueron del 53,6 y del 21,7%. En los 36 pacientes no resecados la morbilidad fue del 27,7% y la mortalidad del 8,3%. La supervivencia a 2 a 5 años en los pacientes resecados por adenocarcinoma ductal fue del 42 y del 9%; en los ampulomas del 71 y del 53%; en los adenocarcinomas mucinosos, del 83 y del 33%; en los adenocarcinomas duodenales, del 100 y del 75%, y en el colangiocarcinoma distal, del 50 y del 50%.ConclusionesLa morbilidad de la cirugía resectiva pancreática continúa siendo alta, aunque la mortalidad perioperatoria es baja. Las alteraciones de la función exocrina y endocrina son muy frecuentes y dependen del tipo de resección. A pesar de estar gravada con frecuentes complicaciones y alteraciones funcionales, la cirugía resectiva ofrece una posibilidad de supervivencia a largo plazo en determinados casos (AU)

Aims To evaluate postoperative morbidity and mortality, pancreatic function and long-term survival in patients with surgically treated pancreatic or periampullar tumours. Patients and methods Cohort study including 160 patients consecutively operated on: 80 pancreaticoduodenectomies (PD), 30 distal pancreatectomies (DP), 7 total pancreatectomies, 4 central pancreatic resections and 3 ampullectomies. The tumour was not resected in 36 patients. Pancreatic function was evaluated by oral glucose tolerance test, faecal fat excretion and elastase. Results Resectability rate was 77.5%. In resected patients (n=124), 38.7% had complications with a pancreatic fistula rate of 6.4% and a mortality rate of 4%. In PD, endocrine function worsened in 41% and 58.6% had steatorrhoea; these figures in DP were 53.6% and 21.7% respectively. In the 36 non-resected patients, postoperative morbidity was 27.7% and mortality 8.3%. Two and five-year survival rates in resected patients with pancreatic cancer were 42% and 9% respectively; in malignant ampulloma 71% and 53%; in mucinous adenocarcinomas 83% and 33%; in duodenal adenocarcinoma 100% and 75%; and in distal cholangiocarcinoma 50% and 50%.ConclusionsMorbidity associated with resective pancreatic surgery is still high, but perioperative mortality is low. Endocrine and exocrine disturbances are very common depending on the type of resection. Despite the associated morbidity and functional disorders, surgery provides long-term survival in selected cases (AU)

[Pancreatic and periampullary tumors: morbidity, mortality, functional results and long-term survival]. / Neoplasias de páncreas y periampulares: morbimortalidad, resultados funcionales y supervivencia a largo plazo.

AIMS: To evaluate postoperative morbidity and mortality, pancreatic function and long-term survival in patients with surgically treated pancreatic or periampullar tumours. PATIENTS AND METHODS: Cohort study including 160 patients consecutively operated on: 80 pancreaticoduodenectomies (PD), 30 distal pancreatectomies (DP), 7 total pancreatectomies, 4 central pancreatic resections and 3 ampullectomies. The tumour was not resected in 36 patients. Pancreatic function was evaluated by oral glucose tolerance test, faecal fat excretion and elastase. RESULTS: Resectability rate was 77.5%. In resected patients (n = 124), 38.7% had complications with a pancreatic fistula rate of 6.4% and a mortality rate of 4%. In PD, endocrine function worsened in 41% and 58.6% had steatorrhoea; these figures in DP were 53.6% and 21.7% respectively. In the 36 non-resected patients, postoperative morbidity was 27.7% and mortality 8.3%. Two and five-year survival rates in resected patients with pancreatic cancer were 42% and 9% respectively; in malignant ampulloma 71% and 53%; in mucinous adenocarcinomas 83% and 33%; in duodenal adenocarcinoma 100% and 75%; and in distal cholangiocarcinoma 50% and 50%. CONCLUSIONS: Morbidity associated with resective pancreatic surgery is still high, but perioperative mortality is low. Endocrine and exocrine disturbances are very common depending on the type of resection. Despite the associated morbidity and functional disorders, surgery provides long-term survival in selected cases.

Intraoperative real-time (99m)Tc-sestamibi scintigraphy with miniature gamma camera allows minimally invasive parathyroidectomy without ioPTH determination in primary hyperparathyroidism.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) is being widely accepted as the procedure of choice for the treatment of primary hyperparathyroidism (PHPT), which is caused by a parathyroid single adenoma in more than 80% of cases in some series. Preoperative location studies, like sestamibi scans, allow the proper identification of pathologic gland and intraoperative parathormone (ioPTH) assay is used to confirm the removal of the adenoma. We have studied the feasibility of a new miniature gamma camera (MGC) used intraoperatively to locate parathyroid adenomas and confirm its correct excision. MATERIALS AND METHODS: Twenty patients with PHPT positively diagnosed by preoperative sestamibi scans underwent a MIP. In the first five patients, both ioPTH assay and the new hand-held MGC were used consecutively to locate and confirm the excision of the pathologic gland. For the next 15 cases, PTH was measured but not used intraoperatively for diagnosis and the MGC was the only diagnostic tool employed to perform the operation. Concordance between preoperative and intraoperative scintigraphy, surgical time, success rate, and complications are analyzed. RESULTS: All cases were operated on successfully by a MIP. After 1 year follow-up, the drop of PTH and the normalization of calcium levels confirmed the excision of all pathologic tissue. The MGC proved its usefulness in all patients offering accurate real-time intraoperative images for location and confirming the success of the procedure. CONCLUSIONS: The MGC is a useful instrument in MIP for PHPT. It may be used as complementary to the standard tools used to date, or even replace them, at least in selected cases of single adenomas.

Prognostic heterogeneity of endosonographic T3 rectal cancer.

PURPOSE: This study aimed to assess the prognostic implications of uT3 rectal carcinomas according to the tumor thickness and to analyze the correlation between this ultrasound-based parameter and other prognostic factors. METHODS: Seventy-four patients with uT3(pM0) rectal tumors underwent primary surgery from 1996 to 2003. Preoperative endorectal ultrasound was used to assess uN stage, maximum tumor perimeter, and maximum tumor thickness. An ultrasound maximum tumor thickness cutoff point for local recurrence subdividing T3 tumors into uT3a and uT3b was established. RESULTS: Median follow-up was 41 months (range, 24-59). The 5-year actuarial local and overall recurrence rates were 9.82 percent (n = 7) and 42.46 percent (n = 23), respectively. uN stage(P = 0.05), circumferential resection margin involvement (P = 0.002), an ultrasound maximum tumor thickness (P = 0.01), and locally advanced tumors (P = 0.001) were related to a significantly increased risk of local recurrence. An ultrasound maximum tumor thickness (hazard ratio, 1.15; 95 percent confidence interval, 1.0-1.2) and locally advanced tumor (hazard ratio, 17.21; 95 percent confidence interval, 2.99-98.84) were preoperative independent variables for predicting local recurrence. Locally advanced tumor was the only preoperative independent prognostic factor for overall recurrence (P = 0.004; hazard ratio, 1.09; 95 percent confidence interval, 1.0-1.1). An ultrasound maximum tumor thickness with a 19-mm cutoff point, subdividing the T3 tumors into uT3a and uT3b, can be used to predict local recurrence. Locally advanced tumors (P = 0.02) and circumferential resection margin involvement (P = 0.005) showed a significant association with an ultrasound maximum tumor thickness >19 mm. CONCLUSIONS: A maximum tumor thickness measured by endorectal ultrasound in pT3 rectal cancer is an independent prognostic factor for local and overall recurrence. An ultrasound maximum tumor thickness cutoff point of 19 mm may be useful to classify patients preoperatively and to select them for primary surgery or neoadjuvant therapy.

Macroscopic assessment of mesorectal excision in rectal cancer: a useful tool for improving quality control in a multidisciplinary team.

BACKGROUND: High quality of surgical technique and the use of descriptive measures to assess and report surgical proficiency have been shown to influence locoregional tumor control in patients with rectal cancer. In this study, the authors have aimed to audit the implementation of a macroscopic assessment of mesorectal excision (MAME) and to investigate factors that influenced surgical quality and disease recurrence. METHODS: All curative resections for rectal cancer were prospectively evaluated for MAME between 1998 and 2007. Mesorectal specimens were graded into 3 types: complete, nearly complete, and incomplete categories. Univariate and multivariate analyses identified independent risk factors for noncomplete mesorectum categories as well as local and overall tumor recurrence. RESULTS: Of 359 specimens, 294 (81.9%) underwent evaluation; 82.3% were "complete." Abdominoperineal resection (APR) was the sole covariate associated with inadequate mesorectal excision (odds ratio [OR]=2.7; P=.003). Independent predictors of local recurrence were circumferential resection margin (CRM) involvement (OR=3.6; P=.027) and noncomplete mesorectum (OR=4.4; P=.008). CRM+ (OR=3.1; P=.004), poorly differentiated tumors (OR=14.2; P=.010), nodal involvement (OR=2.9; P=.010), and APR (OR=2.9; P=.006) were independent risk factors for overall recurrence. In lower third tumors, noncomplete mesorectum occurred more frequently in APR compared with sphincter-saving procedures (31.1% vs 18.8%; P=.088). CONCLUSIONS: This study demonstrates the value of auditing MAME. Good proficiency of mesorectal excision is associated with lower tumor recurrences after curative surgery, and is a morphological tool found to be useful in clinical practice.

Importancia de la exploración física y técnicas de imagen en la valoración diagnóstica de las fístulas de ano / Importance of physical examination and imaging techniques in the diagnosis of anorectal fistulae

Objetivos: Se diseña un estudio para valorar el papel de exploración clínica y métodos de imagen en el diagnóstico de la fístula de ano. Material y métodos: Efectuamos un estudio observacional con recogida prospectiva de datos en 120 pacientes, mediante evaluación clínica por un explorador experimentado (EE), un cirujano sin especial dedicación a la coloproctología (EC) y una exploración con anestesia (EQ), ultrasonografía endoanal (UEA) y resonancia magnética (RM), usando como referencia los hallazgos durante la cirugía. Resultados: La EQ fue significativamente mejor que la del EE o EC para detección de orificio interno (OFI), trayecto primario y cavidades abscesuales (CA). La UEA fue significativamente más sensible y exacta que el EE para identificar OFI y CA, pero no respecto a la EQ. La RM fue más sensible que el EE en la identificación de OFI, trayectos transesfinterianos, supraesfinterianos y CA sin diferencias significativas con la UEA, y más sensible que la EQ para detectar CA. Conclusiones: La exploración bajo anestesia sigue teniendo un importante lugar en la evaluación de pacientes con fístula de ano. Los métodos de imagen son complemento ocasional de una valoración clínica que puede ayudar a los menos experimentados a decidir el tratamiento apropiado y fundamentalmente cuando se sospecha de una fístula compleja (AU)

Aim: The study was designed to determine the role of clinical examination and imaging techniques in the diagnosis of anorectal fistula. Material and methods: We performed an observational study with prospective recruiting using the data of 120 patients, by means of clinical evaluation by an experienced coloproctologist surgeon (EE), a surgeon without special training in coloproctology (CE), and examination under anaesthesia (SE), endoanal ultrasound (EAU) and magnetic resonance (MR), using the surgical findings as a reference. Results: SE was significantly better than EE or CE for detecting an internal opening (IO), primary track and abscess cavities (AC). EAU was significantly more sensitive and accurate than the EE in identifying an IO, and AC, but not compared to the SE. MR was more sensitive than the EE in the identification of the IO, transphincter and suprasphincter tracks and AC with no significant differences compared to EAU, and more sensitive than the SE to detect AC. Conclusions: Examination under anaesthesia still has a place in the evaluation of anorectal fistula. Imaging methods are an occasional complement to a clinical evaluation that can help the less experienced to decide the appropriate treatment, particularly when a complex fistula is suspected (AU)

[Importance of physical examination and imaging techniques in the diagnosis of anorectal fistulae]. / Importancia de la exploración física y técnicas de imagen en la valoración diagnóstica de las fístulas de ano.

AIM: The study was designed to determine the role of clinical examination and imaging techniques in the diagnosis of anorectal fistula. MATERIAL AND METHODS: We performed an observational study with prospective recruiting using the data of 120 patients, by means of clinical evaluation by an experienced coloproctologist surgeon (EE), a surgeon without special training in coloproctology (CE), and examination under anaesthesia (SE), endoanal ultrasound (EAU) and magnetic resonance (MR), using the surgical findings as a reference. RESULTS: SE was significantly better than EE or CE for detecting an internal opening (IO), primary track and abscess cavities (AC). EAU was significantly more sensitive and accurate than the EE in identifying an IO, and AC, but not compared to the SE. MR was more sensitive than the EE in the identification of the IO, transphincter and suprasphincter tracks and AC with no significant differences compared to EAU, and more sensitive than the SE to detect AC. CONCLUSIONS: Examination under anaesthesia still has a place in the evaluation of anorectal fistula. Imaging methods are an occasional complement to a clinical evaluation that can help the less experienced to decide the appropriate treatment, particularly when a complex fistula is suspected.

The occlusive tourniquet: a simple method for rectal stump washout during open and laparoscopic surgery.

Rectal stump washout with cytolytic agents is recommended and usually performed during anterior rectal or rectosigmoid resection. The use of a linear stapler instrument during ultralow anterior resection makes the placement of pelvic clamps difficult for rectal stump washout prior to resection. The objective of this work is to demonstrate the use of a simple procedure, the occlusive tourniquet for rectal stump washout. Occlusive tourniquet applied to open technique: after complete dissection of the rectum and sigmoid colon according to the usual technique, a simple piece of tubing from an intravenous line is passed behind and around the rectum/sigmoid colon at some point distal to the tumor to form an occlusive tourniquet. Occlusive tourniquet applied to laparoscopic technique: similar to the open technique, tubing is passed through the left iliac fossa trocar and passed behind the sigmoid mesocolon. This simple procedure allows easy exposure and dissection of the mesorectum, without traumatizing the rectum/sigmoid colon or the tumor and lavage can be performed without the need for clamps or other instruments which may traumatize the rectum and provoke anastomotic failure. In conclusion, the occlusive tourniquet is a simple method for rectal stump washout so this step can be done.

[Effect of neoadjuvant chemotherapy on the results of resection of colorectal liver metastases]. / Efecto de la quimioterapia neoadyuvante en los resultados de la cirugía de resección de las metástasis hepáticas de origen colorrectal.

INTRODUCTION: Surgery is the treatment of choice in patients with colorectal liver metastases. However, only 10% to 20% of these cases are resectable. The use of neoadjuvant chemotherapy may allow surgery in patients with tumors initially considered unresectable. The aim of this study was to compare the results of liver resection due to colorectal liver metastases in patients with and without neoadjuvant chemotherapy. PATIENTS AND METHOD: We studied 105 patients who underwent surgery for liver metastases from colorectal cancer. The patients were divided into two groups according to treatment: surgery in patients with initially resectable tumors (group 1) and neoadjuvant chemotherapy plus surgery (group 2) in patients with initially irresectable tumors, who were considered for surgery after response to chemotherapy. Age, sex, origin of primary tumor, time of presentation, number, maximum size and location of metastases, CEA, resection margin, postoperative morbidity and mortality, length of hospital stay, recurrence rate, survival and disease-free survival were compared between the 2 groups of patients. RESULTS: When group 1 was compared with group 2, statistically significant differences were observed in synchronicity (30.8% vs 77.4%), bilobarity (13.5% vs 58.5%), number and size of metastases (1 vs 3 nodules and 4 cm vs 2 cm), resectability rate (96.1% vs 81.1%), disease-free interval (25 vs 11 months) and long-term survival at 1, 3 and 5 years (93%, 67% and 36% vs 78%, 26% and 12%). However, no statistically significant differences were found in postoperative morbidity and mortality (28.8% and 0% in group 1 and 22.6% and 1.8% in group 2, respectively). CONCLUSIONS: Neoadjuvant chemotherapy was not associated with greater postoperative morbidity and mortality after resection of colorectal liver metastases, but long-term survival was lower in the group of patients receiving this treatment modality than in those with tumors initially considered resectable.

['Same-day' thyroid surgery. Results after 805 thyroidectomies in a fast-track program]. / Cirugía tiroidea con menos de 24 horas de hospitalización. Resultados tras 805 tiroidectomías consecutivas en un programa de alta precoz tipo fast-track.

INTRODUCTION: The aim of this study was to analyze the validity of a fast-track surgery program with less than 24-hour admission for all thyroid disease treated in an endocrine surgery unit. MATERIAL AND METHOD: Between January 2000 and January 2006, 805 consecutive patients underwent thyroid surgery in a fast-track program. Data on type of disease, procedure, operating time, length of hospital stay, postoperative morbidity, and the number of reinterventions and readmissions were gathered. RESULTS: After a minimum follow-up of 6 months, transitory hypocalcemia occurred in 4.8%, permanent hypocalcemia in 0.2%, transitory dysphonia in 2.5%, and permanent dysphonia in 1.1%. Only 7 patients required emergency reintervention in the first 6 hours after surgery, in all patients due to hemorrhage. Most of these complications occurred in patients undergoing surgery for hyperthyroidism or in those undergoing total thyroidectomy with modified radical neck dissection. Most patients were discharged within 24 hours with a mean length of hospital stay of 23.9 hours, excluding patients who underwent cervical lymphadenectomy. There were only three readmissions, all of which were due to correction of symptomatic hypocalcemia. CONCLUSIONS: Except for total thyroidectomy with modified radical neck dissection due to cancer, all thyroid surgery can be performed in a fast-track program with less than 24-hour admission, within a specialized endocrine surgery unit.

Efecto de la quimioterapia neoadyuvante en los resultados de la cirugía de resección de las metástasis hepáticas de origen colorrectal / Effect of neoadjuvant chemotherapy on the results of resection of colorectal liver metastases

Introducción. La cirugía es el tratamiento de elección de los pacientes con metástasis hepáticas de cáncer colorrectal, pero sólo un 10-20% de los casos son resecables. El uso de quimioterapia neoadyuvante puede rescatar para la cirugía a pacientes inicialmente considerados irresecables. El objetivo de este trabajo es comparar los resultados de la resección de metástasis hepáticas de origen colorrectal en pacientes con y sin quimioterapia neoadyuvante. Pacientes y método. Se ha estudiado a 105 pacientes intervenidos por metástasis hepáticas de cáncer colorrectal, divididos en dos grupos según la estrategia de tratamiento: cirugía en los pacientes inicialmente considerados resecables (grupo C) y quimioterapia neoadyuvante más cirugía (grupo QT+C) en los que inicialmente se consideró irresecables y que tras quimioterapia se convirtieron en resecables. Se ha comparado la edad y el sexo, el origen del tumor primario, el tiempo de aparición, el número, el tamaño máximo y la localización de las metástasis, CEA, el margen de resección, la morbilidad y la mortalidad postoperatorias, el tiempo de ingreso, la tasa de recidivas y la supervivencia en general y la libre de enfermedad. Resultados. Al comparar a los dos grupos, C y QT+C, han resultado significativas la presencia de metástasis sincrónicas (el 30,8 y el 77,4%), la distribución bilobar (el 13,5 y el 58,5%), el número y el tamaño de las metástasis (1 contra 3 nódulos y 4 contra 2 cm), la tasa de resecabilidad (el 96,1 y el 81,1%), el intervalo libre de enfermedad (25 y 11 meses) y la supervivencia actuarial a 1, 3 y 5 años (el 93, el 67 y el 36% contra el 78, el 26 y el 12%). Sin embargo, no hemos encontrado diferencias en cuanto a la morbilidad y la mortalidad postoperatorias, que fueron del 28,8 y el 0%, respectivamente, en el grupo C y del 22,6 y el 1,8% en el grupo QT+C. Conclusiones. La quimioterapia neoadyuvante no tuvo relación con mayor morbimortalidad postoperatoria tras la resección de metástasis hepáticas de origen colorrectal, pero la supervivencia general a largo plazo en el grupo de pacientes que recibieron este tratamiento fue inferior a la del grupo de pacientes considerados inicialmente resecables (AU)

Introduction. Surgery is the treatment of choice in patients with colorectal liver metastases. However, only 10% to 20% of these cases are resectable. The use of neoadjuvant chemotherapy may allow surgery in patients with tumors initially considered unresectable. The aim of this study was to compare the results of liver resection due to colorectal liver metastases in patients with and without neoadjuvant chemotherapy. Patients and method. We studied 105 patients who underwent surgery for liver metastases from colorectal cancer. The patients were divided into two groups according to treatment: surgery in patients with initially resectable tumors (group 1) and neoadjuvant chemotherapy plus surgery (group 2) in patients with initially irresectable tumors, who were considered for surgery after response to chemotherapy. Age, sex, origin of primary tumor, time of presentation, number, maximum size and location of metastases, CEA, resection margin, postoperative morbidity and mortality, length of hospital stay, recurrence rate, survival and disease-free survival were compared between the 2 groups of patients. Results. When group 1 was compared with group 2, statistically significant differences were observed in synchronicity (30.8% vs 77.4%), bilobarity (13.5% vs 58.5%), number and size of metastases (1 vs 3 nodules and 4 cm vs 2 cm), resectability rate (96.1% vs 81.1%), disease-free interval (25 vs 11 months) and long-term survival at 1, 3 and 5 years (93%, 67% and 36% vs 78%, 26% and 12%). However, no statistically significant differences were found in postoperative morbidity and mortality (28.8% and 0% in group 1 and 22.6% and 1.8% in group 2, respectively). Conclusions: Neoadjuvant chemotherapy was not associated with greater postoperative morbidity and mortality after resection of colorectal liver metastases, but long-term survival was lower in the group of patients receiving this treatment modality than in those with tumors initially considered resectable (AU)

Multiple intrahepatic pseudocysts in acute pancreatitis.

Liver pseudocysts are a very rare complication in acute pancreatitis with only a few cases previously described. The lack of experience and literature on this condition leads to difficulties in the differential diagnosis and management. We report herein a case of acute pancreatitis who developed multiple intrahepatic pseudocysts. After complete imaging evaluation, the diagnosis was still unclear and the patient was operated on. The presence of liver lesions in patients with acute pancreatitis should raise the possibility of intrahepatic pseudocysts.

Cirugía tiroidea con menos de 24 horas de hospitalización. Resultados tras 805 tiroidectomías consecutivas en un programa de alta precoz tipo fast-track / “Same-day” thyroid surgery. Results after 805 thyroidectomies in a fast-track program

Introducción. El objetivo del estudio ha sido analizar la validez de un programa de alta precoz, tipo fast-track, de cirugía con ingreso de menos de 24 h, para todas las enfermedades tiroideas tratadas en una unidad de cirugía endocrina. Material y método. Entre enero de 2000 y enero de 2006, se intervino del tiroides consecutivamente a 805 pacientes en régimen de alta precoz. Se recogieron los datos sobre el tipo de afección, la intervención realizada y su duración, la estancia hospitalaria, la morbilidad postoperatoria, el número de reintervenciones y el número de reingresos. Resultados. Tras un seguimiento mínimo de 6 meses, el 4,8% de los pacientes sufrió hipocalcemia transitoria; el 0,2%, hipocalcemia permanente; el 2,5%, disfonía transitoria, y el 1,1%, disfonía definitiva. Sólo 7 pacientes precisaron reintervención urgente en las primeras 6 h postoperatorias, en todos los casos por hemorragia. La mayor parte de dichas complicaciones se produjo en pacientes intervenidos por hipertiroidismo o en aquellos en los que se realizó una tiroidectomía total con vaciamiento radical modificado. La mayoría de los pacientes recibió el alta hospitalaria en las primeras 24 h, con una estancia media de 23,9 h excluyendo a los pacientes sometidos a una linfadenectomía cervical. Únicamente hubo 3 reingresos, en todos los casos para corrección de hipocalcemia sintomática. Conclusiones. Con excepción de la tiroidectomía total con vaciamiento cervical por cáncer, toda la cirugía del tiroides se puede realizar con un modelo de alta precoz tipo fast-track, en un régimen de estancia de menos de 24 h, en una unidad especializada en cirugía endocrina (AU)

Introduction. The aim of this study was to analyze the validity of a fast-track surgery program with less than 24-hour admission for all thyroid disease treated in an endocrine surgery unit. Material and method. Between January 2000 and January 2006, 805 consecutive patients underwent thyroid surgery in a fast-track program. Data on type of disease, procedure, operating time, length of hospital stay, postoperative morbidity, and the number of reinterventions and readmissions were gathered. Results. After a minimum follow-up of 6 months, transitory hypocalcemia occurred in 4.8%, permanent hypocalcemia in 0.2%, transitory dysphonia in 2.5%, and permanent dysphonia in 1.1%. Only 7 patients required emergency reintervention in the first 6 hours after surgery, in all patients due to hemorrhage. Most of these complications occurred in patients undergoing surgery for hyperthyroidism or in those undergoing total thyroidectomy with modified radical neck dissection. Most patients were discharged within 24 hours with a mean length of hospital stay of 23.9 hours, excluding patients who underwent cervical lymphadenectomy. There were only three readmissions, all of which were due to correction of symptomatic hypocalcemia. Conclusions. Except for total thyroidectomy with modified radical neck dissection due to cancer, all thyroid surgery can be performed in a fast-track program with less than 24-hour admission, within a specialized endocrine surgery unit (AU)

Computed tomographic diagnosis of obturator hernia and its surgical management: a case series.

The obturator hernia is a rare type of hernia which usually presents in thin, elderly women. The preoperative diagnosis is typically difficult, with non-specific signs and symptoms which result in a delay in the diagnosis. It can also be an incidental finding at exploratory laparotomy for a patient with intestinal obstruction. The treatment is surgical. A series of four females with obturator hernia is presented. All patients presented with a history of intestinal obstruction and the hernia was diagnosed preoperatively by computed tomography. All patients underwent a preperitoneal mesh repair with a favourable outcome. The diagnosis and the surgical approach are discussed.

Potential role of a new hand-held miniature gamma camera in performing minimally invasive parathyroidectomy.

PURPOSE: Sestamibi scans have increased the use of minimally invasive parathyroidectomy (MIP) to treat primary hyperparathyroidism (PHPT) when caused by a parathyroid single adenoma. The greatest concern for surgeons remains the proper identification of pathological glands in a limited surgical field. We have studied the usefulness of a new hand-held miniature gamma camera (MGC) when used intraoperatively to locate parathyroid adenomas. To our knowledge this is the first report published on this subject in the scientific literature. METHODS: Five patients with PHPT secondary to a single adenoma, positively diagnosed by preoperative sestamibi scans, underwent a MIP. A gamma probe for radioguided surgery and the new hand-held MGC were used consecutively to locate the pathological glands. This new MGC has a module composed of a high-resolution interchangeable collimator and a CsI(Na) scintillating crystal. It has dimensions of around 15 cmx8 cmx9 cm and weighs 1 kg. The intraoperative assay of PTH (ioPTH) was used to confirm the complete resection of pathological tissue. RESULTS: All cases were operated on successfully by a MIP. The ioPTH confirmed the excision of all pathological tissues. The MGC proved its usefulness in all patients, even in a difficult case in which the first attempt with the gamma probe failed. In all cases it offered real-time accurate intraoperative images. CONCLUSION: The hand-held MGC is a useful instrument in MIP for PHPT. It may be used to complement the standard tools used to date, or may even replace them, at least in selected cases of single adenomas.