Influence of Preoperative Muscle Mass Assessed by Computed Tomography on Prognosis After Liver Transplantation.

BACKGROUND: Sarcopenia (SP) and preoperative muscle mass are independent predictive factors for short- and long-term outcome of liver transplantation. OBJECTIVE: To assess the influence of muscle mass index (MMI) and preoperative SP on the prognosis of patients who underwent liver transplantation in our hospital. METHODS: Ninety-seven patients who underwent liver transplantation in the Regional University Hospital of Málaga from September 2013 to March 2016 were analyzed. SP was determined based on the MMI, as assessed by psoas muscle area at the L4 level measured by computed tomography (CT), with adjustment for patient sex. Two cohorts were differentiated: 54 patients without SP and 42 patients with SP. Postoperative complications, graft survival, and patient survival were assessed. A 3-year follow-up was carried out. RESULTS: Recipient characteristics were similar in both cohorts, except for MMI ± SD (group without SP: 94.03 ± 15.43 cm2/m2 vs group with SP: 56.99 ± 13.59 cm2/m2; P = .001). The incidence of postoperative complications (Clavien ≥ 3) in patients with and without SP was 39.5% and 24.1%, respectively (P = .08). SP was not associated with poorer long-term graft or patient survival. CONCLUSIONS: SP, determined by preoperative measurement of MMI, was identified as a predictive factor associated with a higher incidence of postoperative complications. Since MMI can be easily determined by CT, it should be assessed in all candidates for liver transplantation.

Acute abdomen in patients with systemic lupus erythematosus and antiphospholipid syndrome. Importance of early diagnosis and treatment.

Systemic lupus erithematosus (SLE) is an autoimmune disease with multiorgan involvement caused principally by vasculitis of small vessels. The gastrointestinal tract is one of the most frequently affected by SLE, with abdominal pain as the most common symptom. An early diagnosis and treatment of lupus enteritis is essential to avoid complications like hemorrhage or perforation, with up to 50 % of mortality rate. However, differential diagnosis sometimes is difficult, especially with other types of gastrointestinal diseases as digestive involvement of antiphospholipid syndrome (APS), moreover when both entities may coexist. We describe the case of a patient with both diseases that was diagnosed with lupus enteritis and treated with steroid therapy; the patient had an excellent response.

Abdomen agudo en paciente con lupus eritematoso sistémico y síndrome antifosfolípido. Importancia del diagnóstico y tratamiento precoz / Acute abdomen in patients with systemic lupus erythematosus and antiphospholipid syndrome. Importance of early diagnosis and treatment

El lupus eritematoso sistémico es una enfermedad autoinmune con afectación multivisceral causada principalmente por vasculitis de pequeño vaso. El tracto gastrointestinal es uno de los órganos más frecuentemente afectados, siendo el dolor abdominal el síntoma predominante. La enteritis lúpica requiere un diagnóstico y tratamiento precoces para evitar complicaciones como la hemorragia digestiva y la perforación intestinal, que pueden alcanzar una mortalidad de hasta el 50 %. Su diagnóstico a veces se ve dificultado por la presencia de otras patologías con afectación gastrointestinal similar como ocurre en el síndrome antifosfolípido. Presentamos el caso de una paciente con ambas enfermedades que fue diagnosticada de enteritis lúpica y tratada de forma conservadora con terapia corticoidea de choque. La paciente tuvo una respuesta excelente al tratamiento

Systemic lupus erithematosus (SLE) is an autoimmune disease with multiorgan involvement caused principally by vasculitis of small vessels. The gastrointestinal tract is one of the most frequently affected by SLE, with abdominal pain as the most common symptom. An early diagnosis and treatment of lupus enteritis is essential to avoid complications like hemorrhage or perforation, with up to 50 % of mortality rate. However, differential diagnosis sometimes is difficult, especially with other types of gastrointestinal diseases as digestive involvement of antiphospholipid syndrome (APS), moreover when both entities may coexist. We describe the case of a patient with both diseases that was diagnosed with lupus enteritis and treated with steroid therapy; the patient had an excellent response

Acute necrotizing pancreatitis: Surgical indications and technical procedures.

Necrosis of pancreatic parenchyma or extrapancreatic tissues is present in 10%-20% of patients with acute pancreatitis, defining the necrotizing presentation frequently associated with high morbidity and mortality rates. During the initial phase of acute necrotizing pancreatitis the most important pillars of medical treatment are fluid resuscitation, early enteral nutrition, endoscopic retrograde colangiopancreatography if associated cholangitis and intensive care unit support. When infection of pancreatic or extrapancreatic necrosis occurs, surgical approach constitutes the most accepted therapeutic option. In this context, we have recently assited to changes in time for surgery (delaying the indication if possible to around 4 wk to deal with "walled-off" necrosis) and type of access for necrosectomy: from a classical open approach (with closure over large-bore drains for continued postoperative lavage or semiopen techniques with scheduled relaparotomies), trends have changed to a "step-up" philosophy with initial percutaneous drainage and posterior minimally invasive or endoscopic access to the retroperitoneal cavity for necrosectomy if no improvement has been previously achieved. These approaches are progressively gaining popularity and morbidity and mortality rates have decreased significantly. Therefore, a staged, multidisciplinary, step-up approach with minimally invasive or endoscopic access for necrosectomy is widely accepted nowadays for management of pancreatic necrosis.

Infección de sitio quirúrgico tras apendicectomía urgente: tasa global y tipo según la vía de abordaje (abierta/laparoscópica) / Postappendectomy surgical site infection: Overall rate and type according to open/laparoscopic approach

OBJETIVO: Evaluar la incidencia y el perfil de la infección de sitio quirúrgico (ISQ) postapendicectomía en relación con la vía de abordaje (abierta [AA] vs laparoscópica [AL]).Material y método Estudio observacional analítico de cohortes, con pacientes > 14 años intervenidos por sospecha de apendicitis aguda a lo largo de 4 años (2007-2010) en un hospital de tercer nivel (n = 868), divididos en 2 grupos según la vía de abordaje para la apendicectomía (AL, grupo de estudio, 135; AA, grupo control, 733). Variable resultado: ISQ, global y por tipos. Estratificación del riesgo infeccioso mediante: a) índice NNIS (bajo riesgo: NNIS 0E, 0 y 1; alto riesgo: NNIS 2 y 3); b) estadio evolutivo apendicular (bajo riesgo: normal o flemonoso; alto riesgo: gangrenoso o perforado). Análisis estadístico: software SPSS. Resultado principal y análisis estratificado con el test de χ2. Parámetros de riesgo: OR cruda y de Mantel-Haenszel respectivamente, con su IC 95% y aceptando significación estadística con p < 0,05.ResultadosAmbos grupos fueron homogéneos en cuanto a edad, género, ASA y formas evolucionadas. ISQ global: 13,4% (más de la mitad detectadas en el seguimiento tras el alta). Distribución: AA, 13% (superficial 9%, profunda 2%, órgano-espacio 2%); AL, 14% (superficial 5%, profunda 1%, órgano-espacio 8%) (global: n.s.; distribución: p < 0,000). El análisis estratificado mostró asociación entre ISQ parietal/acceso abierto e ISQ órgano-espacio/abordaje laparoscópico y que resulta especialmente evidente en pacientes de alto riesgo de ISQ postoperatoria (NNIS alto o presentación evolucionada).Conclusión La AA conlleva un mayor riesgo de ISQ parietal y la AL de órgano-espacio. Esta asociación es especialmente evidente en pacientes con especial riesgo de ISQ

OBJECTIVE: To compare the incidence and profile of surgical site infection (SSI) after laparoscopic (LA) oropen (OA) appendicectomy. MATERIAL AND METHOD: Observational and analytical study was conducted on patients older than 14 years old with suspected acute appendicitis operated on within a 4-year period (2007-2010) at a third levelhospital (n = 868). They were divided in two groups according to the type of appendicectomy (LA, study group, 135; OA, control group, 733). The primary endpoint was a surgical site infection (SSI), and to determine the overall rate and types (incisional/organ-space). The risk of SSI was stratified by: i) National Nosocomial Infection Surveillance (NNIS) index (low risk: 0E, 0 and 1; high risk: 2 and 3); ii) status on presentation (low risk: normal or phlegmonous; high risk: gangrenous or perforated). The statisticalanalysis was performed using the software SPSS. The main result and stratified analysis was determined with 2, and the risk parameters using OR and Mantel-Haenszel OR with 95%CI, accepting statistical significance with P < .05. RESULTS: Age, gender, ASAindex and incidence of advanced cases were similar in both groups. The overall lSSI rate was 13.4% (more than a half of them detected during follow-up after discharge). Type of SSI: OA,13% (superficial 9%, deep 2%, organ-space 2%); AL, 14% (superficial 5%, deep 1%, organ-space 8%) (overall:not significant; distribution: P < .000). Stratified analysis showed that there is an association between incisional SSI/OA and organ-space SSI/LA, and is particularly stronger in those patients with high risk of postoperative SSI (high risk NNIS or gangrenous-perforated presentation).CONCLUSION: OA and LA are associated with a higher rate of incisional and organ-space SSI respectively. This is particularly evident in patients with high risk of SSI

[Post-appendectomy surgical site infection: overall rate and type according to open/laparoscopic approach]. / Infección de sitio quirúrgico tras apendicectomía urgente: tasa global y tipo según la vía de abordaje (abierta/laparoscópica).

OBJECTIVE: To compare the incidence and profile of surgical site infection (SSI) after laparoscopic (LA) or open (OA) appendicectomy. MATERIAL AND METHOD: Observational and analytical study was conducted on patients older than 14years-old with suspected acute appendicitis operated on within a 4-year period (2007-2010) at a third level hospital (n=868). They were divided in two groups according to the type of appendicectomy (LA, study group, 135; OA, control group, 733). The primary endpoint was a surgical site infection (SSI), and to determine the overall rate and types (incisional/organ-space). The risk of SSI was stratified by: i)National Nosocomial Infection Surveillance (NNIS) index (low risk: 0E, 0 and 1; high risk: 2 and 3); ii)status on presentation (low risk: normal or phlegmonous; high risk: gangrenous or perforated). The statistical analysis was performed using the software SPSS. The main result and stratified analysis was determined with χ(2), and the risk parameters using OR and Mantel-Haenszel OR with 95%CI, accepting statistical significance with P<.05. RESULTS: Age, gender, ASA index and incidence of advanced cases were similar in both groups. The overall SSI rate was 13.4% (more than a half of them detected during follow-up after discharge). Type of SSI: OA, 13% (superficial 9%, deep 2%, organ-space 2%); AL, 14% (superficial 5%, deep 1%, organ-space 8%) (overall: not significant; distribution: P<.000). Stratified analysis showed that there is an association between incisional SSI/OA and organ-space SSI/LA, and is particularly stronger in those patients with high risk of postoperative SSI (high risk NNIS or gangrenous-perforated presentation). CONCLUSION: OA and LA are associated with a higher rate of incisional and organ-space SSI respectively. This is particularly evident in patients with high risk of SSI.

Empleo, eficacia y repercusión clínica del apoyo radiológico al diagnóstico de la apendicitis aguda / Radiological support for diagnosis of acute appendicitis: Use, effectiveness and clinical repercussions

OBJETIVO: Analizar el incremento del apoyo radiológico solicitado para el diagnóstico de la apendicitis aguda (AA), su justificación a partir de su repercusión clínica así como los parámetros de rentabilidad diagnóstica de ECO y TAC para esta enfermedad. MATERIAL Y MÉTODO: Estudio observacional analítico de cohortes, con pacientes intervenidos por sospecha de AA en un hospital de tercer nivel, excluyendo menores de 14 años y gestantes. Grupo de estudio: enero de 2010-diciembre de 2011 (n1 = 419). Grupo control: muestra de pacientes entre 18 y 65 años intervenidos entre octubre de 2001 y septiembre de 2003 (n2 = 237). Variables de estudio en ambas muestras: 1) porcentaje de exploraciones realizadas como apoyo radiológico al diagnóstico de la apendicitis; 2) sensibilidad y valor predictivo positivo (VPP) de ECO y TAC; 3) tasa de cirugías en blanco y con diagnósticos diferentes de AA. Análisis estadístico: software SPSS, con test de la χ2, aceptando como significativos niveles de p < 0,05 y calculando la odds ratio (OR) con su intervalo de confianza al 95% (IC95%). RESULTADOS: Ambas muestras fueron homogéneas en cuanto a edad, género o porcentaje de localizaciones atípicas y formas evolucionadas. El número de exploraciones solicitadas durante el periodo de estudio fue significativamente mayor que en el control (78,8 vs. 30,4%; p < 0,000). La sensibilidad de la TAC fue superior a la de la ECO (97 vs. 86%), aunque ambas pruebas presentaron valores similares de VPP (92 vs. 94%). El porcentaje de intervenciones con diagnóstico certero de AA fue significativamente mayor en el grupo de estudio (94,5 vs. 88,6%; p < 0,006; OR: 2,2; IC95% 1,25-4). CONCLUSIÓN: El incremento de solicitudes de apoyo radiológico al diagnóstico de AA conlleva un significativo aumento de intervenciones con diagnóstico certero

OBJECTIVE: The aim of this study is to analyze the increasing need of radiological support in the diagnosis of acute appendicitis (AA), the clinical repercussions associated, and the parameters of diagnostic accuracy of ultrasound and computed tomography (CT) scan for AA. MATERIAL AND METHODS: Observational and analytical study. Cohort, patients operated on for suspected AA at a tertiary referral hospital. Pregnancy and < 14 years were exclusion criteria. Study group: January 2010-December 2011 (n1 = 419). CONTROL GROUP: set of patients aged 18 to 65 years old operated between October 2001-September 2003 (n2 = 237). Variables analyzed in both groups: 1) percentage of radiological support for diagnosis of acute appendicitis; 2) sensitivity and positive predictive value (PPV) of ultrasound and CT scan; 3) rate of surgical explorations with negative result or with diagnosis other than acute appendicitis. Statistical analysis: SPSS software, χ2 test, statistical significance accepted with P<.05, 95% confidence interval (95% CI) for the odds ratio (OR). RESULTS: Age, gender, percentage of atypical locations and gangrenous/perforated episodes were similar in both groups. The number of radiological examinations needed for diagnosis was significantly higher in the study group (78.8% vs. 30.4%, P < .0,000). Sensitivity was significantly superior for CT than for ultrasound scan (97% vs. 86%), but PPV was similar in both tests (92% vs. 94%). Surgical exploration percent values with diagnosis of acute appendicitis was significantly higher in the study group (94.5% vs. 88.6%; P < .006, OR 2.2; CI 95% 1.25-4). CONCLUSIONS: CT and ultrasound scan are excellent diagnostic tools for acute appendicitis, and have contributed to a significant increase in surgical explorations with correct diagnosis

[Radiological support for diagnosis of acute appendicitis: use, effectiveness and clinical repercussions]. / Empleo, eficacia y repercusión clínica del apoyo radiológico al diagnóstico de la apendicitis aguda.

OBJECTIVE: The aim of this study is to analyze the increasing need of radiological support in the diagnosis of acute appendicitis (AA), the clinical repercussions associated, and the parameters of diagnostic accuracy of ultrasound and computed tomography (CT) scan for AA. MATERIAL AND METHODS: Observational and analytical study. Cohort, patients operated on for suspected AA at a tertiary referral hospital. Pregnancy and <14 years were exclusion criteria. STUDY GROUP: January 2010-December 2011 (n1=419). CONTROL GROUP: set of patients aged 18 to 65 years old operated between October 2001-September 2003 (n2=237). Variables analyzed in both groups: 1) percentage of radiological support for diagnosis of acute appendicitis; 2) sensitivity and positive predictive value (PPV) of ultrasound and CT scan; 3) rate of surgical explorations with negative result or with diagnosis other than acute appendicitis. STATISTICAL ANALYSIS: SPSS software, χ(2) test, statistical significance accepted with P<.05, 95% confidence interval (95% CI) for the odds ratio (OR). RESULTS: Age, gender, percentage of atypical locations and gangrenous/perforated episodes were similar in both groups. The number of radiological examinations needed for diagnosis was significantly higher in the study group (78.8% vs. 30.4%, P<.0,000). Sensitivity was significantly superior for CT than for ultrasound scan (97% vs. 86%), but PPV was similar in both tests (92% vs. 94%). Surgical exploration percent values with diagnosis of acute appendicitis was significantly higher in the study group (94.5% vs. 88.6%; P<.006, OR 2.2; CI 95% 1.25-4). CONCLUSIONS: CT and ultrasound scan are excellent diagnostic tools for acute appendicitis, and have contributed to a significant increase in surgical explorations with correct diagnosis.

Experiencia de un programa de fast-track en la duodenopancreatectomía cefálica / Experience of a cephalic pancreatoduodenectomy fast-track program

Introducción La Fast-track surgery se ha planteado recientemente como un programa eficaz en la cirugía pancreática. Aunque la morbimortalidad tras la duodenopancreatectomía cefálica ha mejorado en la última década, la prevalencia de complicaciones postoperatorias continúa siendo elevada. El objetivo de este trabajo es examinar los resultados de un programa de Fast-track en este tipo de intervenciones. Resultados Ochenta y dos pacientes fueron intervenidos de duodenopancreatectomía cefálica dentro de un protocolo de recuperación precoz. La mediana de edad fue 63 años. El 65% fueron varones. La mediana de estancia hospitalaria fue de 9 días, con un 14,6% de reingresos. Se aplicó la clasificación de Clavien-DeOliveira para evaluar la severidad de las complicaciones. La morbilidad global fue del 47,6%. La complicación más frecuente correspondió al grupo que englobaba las generales, seguidas por la infección de la herida quirúrgica y complicaciones cardiorrespiratorias. Teniendo en cuenta que solo el 32% de los pacientes tuvieron drenaje desde la cirugía, la frecuencia de fístula pancreática fue del 8,5%, y esta se situaba en los grupos de mayor morbilidad (grados III, IV y V). La mortalidad postoperatoria fue del 4,9%. La cirugía asociada constituyó un factor de riesgo para la mortalidad. Conclusiones La Fast-track surgery en la duodenopacreatectomía cefálica realizada en centros de alto volumen es un programa seguro y eficaz que permite además mejorar los resultados de morbimortalidad (AU)

Introduction Fast-track surgery has been proposed as a valid method in pancreatic surgery. Although morbidity and mortality has improved in the last decade, the prevalence of postoperative complications is still high. The aim of this study is to analyse the results of a programme of Fast-track surgery in this context. Results A total of 82 patients who underwent a cephalic pancreatoduodenectomy with a programme of early recovery after surgery, were analysed. There were 53 men, with a median age of 63 years old. The median hospital stay was 9 days, with 14.6% of readmissions. The Clavien-DeOliveira Classification was applied to evaluate the severity of postoperative complications. The overall morbidity was 47.6%. The most common complications were general, followed by infection of surgical wound and cardiopulmonary events. Taking into account that a surgical drain was used in 32% of patients, the prevalence of pancreatic fistula was 8.5%, and were classified in the most severity grades (III, IV and V). The postoperative mortality was 4.9%. The associated surgery was a risk factor of mortality. Conclusions The Fast-track programme after pancreatoduodenectomy in high volume centres is a safe and effective method, that can improve the morbidty and mortality results (AU)

[Experience of a cephalic pancreatoduodenectomy fast-track program]. / Experiencia de un programa de fast-track en la duodenopancreatectomía cefálica.

INTRODUCTION: Fast-track surgery has been proposed as a valid method in pancreatic surgery. Although morbidity and mortality has improved in the last decade, the prevalence of postoperative complications is still high. The aim of this study is to analyse the results of a programme of Fast-track surgery in this context. RESULTS: A total of 82 patients who underwent a cephalic pancreatoduodenectomy with a programme of early recovery after surgery, were analysed. There were 53 men, with a median age of 63 years old. The median hospital stay was 9 days, with 14.6% of readmissions. The Clavien-DeOliveira Classification was applied to evaluate the severity of postoperative complications. The overall morbidity was 47.6%. The most common complications were general, followed by infection of surgical wound and cardiopulmonary events. Taking into account that a surgical drain was used in 32% of patients, the prevalence of pancreatic fistula was 8.5%, and were classified in the most severity grades (III, IV and V). The postoperative mortality was 4.9%. The associated surgery was a risk factor of mortality. CONCLUSIONS: The Fast-track programme after pancreatoduodenectomy in high volume centres is a safe and effective method, that can improve the morbidty and mortality results.