Treatment of esophageal perforation: A review of our experience at a tertiary referral hospital spanning the past 19 years.

INTRODUCTION AND AIMS: Esophageal perforation is an uncommon event that is a medical/surgical emergency, with a 15-30% mortality rate. The aim of the present study was to communicate our experience in the management of esophageal perforation, evaluating the different strategies utilized, in an effort to establish measures to guide decision-making in selecting treatment. MATERIALS AND METHODS: A retrospective descriptive study was conducted on patients diagnosed with esophageal perforation at our hospital center, within the time frame of 2000 and 2019. RESULTS: Over the past 19 years, 15 patients were diagnosed with esophageal perforation. Surgical treatment was carried out in 80% of the cases. Primary closure, reinforced with plasty, was performed in 67% of the patients, of whom 62.5% had early diagnosis and a 100% survival rate. Diagnosis was late in 37.5% of the cases, with a 33.3% survival rate. Esophagectomy and gastric pull-up were performed on 25% of the patients, 66.6% of whom had early diagnosis and a 100% survival rate. In the 33.3% that had late diagnosis, the mortality rate was 100%. Esophagectomy, with cervical esophagostomy and feeding jejunostomy, was performed on one of the patients (8.3%) that had early diagnosis and a 100% survival rate. CONCLUSIONS: The main survival predictor in esophageal perforation is the interval of time between the injury and its diagnosis, and in turn, the resulting treatment. Each patient with esophageal perforation should have individualized treatment to adequately manage the condition.

Egg consumption and cardiovascular disease according to diabetic status: The PREDIMED study.

BACKGROUND: Eggs are a major source of dietary cholesterol and their consumption has been sometimes discouraged. A relationship between egg consumption and the incidence of cardiovascular disease (CVD) has been suggested to be present exclusively among patients with type2 diabetes. AIMS: To assess the association between egg consumption and CVD in a large Mediterranean cohort where approximately 50% of participants had type 2 diabetes. METHODS: We prospectively followed 7216 participants (55-80 years old) at high cardiovascular risk from the PREDIMED (PREvención con DIeta MEDiterránea) study for a mean of 5.8 years. All participants were initially free of CVD. Yearly repeated measurements of dietary information with a validated 137-item food-frequency questionnaire were used to assess egg consumption and other dietary exposures. The endpoint was the rate of major cardiovascular events (myocardial infarction, stroke or death from cardiovascular causes). RESULTS: A major cardiovascular event occurred in 342 participants. Baseline egg consumption was not significantly associated with cardiovascular events in the total population. Non-diabetic participants who ate on average >4 eggs/week had a hazard ratio (HR) of 0.96 (95% confidence interval, 0.33-2.76) in the fully adjusted multivariable model when compared with non-diabetic participants who reported the lowest egg consumption (<2 eggs/week). Among diabetic participants, the HR was 1.33 (0.72-2.46). There was no evidence of interaction by diabetic status. HRs per 500 eggs of cumulative consumption during follow-up were 0.94 (0.66-1.33) in non-diabetics and 1.18 (0.90-1.55) in diabetics. CONCLUSIONS: Low to moderated egg consumption was not associated with an increased CVD risk in diabetic or non-diabetic individuals at high cardiovascular risk. This trial was registered at controlled-trials.com as ISRCTN35739639.

Efectos a corto plazo en la pérdida de peso de una dieta vegetariana baja en grasa / Short term effects on weight loss of a low-fat vegetarian diet

Introducción: Diversos estudios han demostrado la eficacia de las dietas vegetarianas en la reducción del riesgo de obesidad, aunque se dispone de escasos datos en población mediterránea española acerca del efecto de la dieta vegetariana en la reducción de peso a corto plazo, en individuos previamente no vegetarianos. Objetivo: Nuestro objetivo ha sido estudiar el efecto en población mediterránea de una dieta vegetariana baja en grasas en la reducción del peso corporal y en otras medidas antropométricas y de composición corporal, tras su administración durante 15 días en condiciones estrictas de internado. Métodos: Se ha llevado a cabo un estudio de intervención nutricional en voluntarios administrando un menú completo diario. Para ello, se instauró en régimen de internado estricto durante 15 días una dieta lacto-vegetariana baja en grasa (20%) y que aportaba unas 1900 Kcal/día en una muestra de 168 individuos (44 hombres, 124 mujeres) cuya ingesta basal de grasa era superior al 30%. Se valoró la influencia de esta dieta en los parámetros antropométricos y de composición corporal (peso, talla, IMC, perímetro de cintura y cadera, ICC y masa grasa). Resultados: La intervención dietética produjo reducciones estadísticamente significativas, tanto en hombres como en mujeres, en el peso (2,15+/-1,2 kg), IMC (0,77+/-0,4), perímetro de cintura (2,90+/-2,6 cm), perímetro de cadera (2,04+/-1,9 cm) e ICC (0,01+/-0,0). Conclusión: La dieta lacto-vegetariana a corto plazo produce una pérdida significativa de peso y grasa abdominal y es más saludable que otros tipos de dietas con mayor riesgo cetogénico y menor aporte de antioxidantes (AU)

To study the effect on a Mediterranean population of a low-fat (20%) vegetarian diet on reducing body-weight and other anthropometrical measurements and body composition following a fifteen-day administration in strict interned conditions. Methods: We have carried out a nutritional intervention study in volunteers consisting on the administration of a whole dietary menu. A strict internment was imposed for fifteen days. A low-fat lacto-vegetarian diet of 1900 Kcal per day was administered on a sample of 168 individuals (44 men, 124 women) whose baseline intake of fat was greater than 30% of energy. The influence of this diet was evaluated on the anthropometric parameters and body composition (weight, height, BMI, waist and hip circumference, waist-to-hip ratio and body fat mass). Results: The dietary intervention produced statistically significant reductions both in men and in women, in weight (2,15+/-1,2 kg), BMI (0,77+/ -0,4 kg/m2), waist circumference (2,90+/-2,6 cm), hip circumference (2,04+/-1,9 cm) and waist-to-hip ratio (0,01+/-0,0). Conclusion: The lacto-vegetarian diet model used in this dietary intervention probed useful in tackling overweight and obesity and presents advantages over other types of diet with greater ketogenic risk and lesser antioxidant contribution (AU)

[Coffee and tea consumption in a high cardiovascular risk Mediterranean population]. / Consumo de café y té en población mediterránea de alto riesgo cardiovascular.

INTRODUCTION: Coffee and tea consumption recommendations for a healthy diet have been changing in recent years as it has increased the level of evidence on their benefits has increased. OBJECTIVE: To know the frequency of coffee and tea consumption of in a high cardiovascular risk Mediterranean population (CVR) and to analyze whether there are differences between the consumption of these drinks by cardiovascular risk factors. METHODS: A cross-sectional study was carried out on 945 people (340 males, 605 females) (67.4+/-6.2 years old) with high CVR recruited in primary care centres of Valencia, included in the PREDIMED study. Coffee and tea consumption has been determined through a validated questionnaire. We analyzed biochemical, clinical and anthropometric variables by standard methods. RESULTS: Tea consumption is very low in this Mediterranean population (0.4+/-1.6 cups/weeks). By contrast, coffee consumption averaged nearly one cup per day (6.5+/-5.2 cups/weeks). Hypertensive patients showed a lower overall consumption of coffee than in non-hypertensive patients (6.6+/-5.1 vs 7.3+/-5.9; P=0.023 respectively). These differences were greatest when caffeinated coffee consumption is analyzed (2.9+/-4.5 vs 4.3+/-5.3, P<0001). Moreover, diabetics consumed significantly less coffee and tea than non-diabetics (P=0.015 and P=0.022 respectively), these differences being greater for caffeinated coffee (P<0.025). CONCLUSIONS: In conclusion, in this high cardiovascular risk Mediterranean population a coffee consumption pattern, based on traditional recommendations, is observed, that as a result of new scientific evidence should be update.

Consumo de café y té en población mediterránea de alto riesgo cardiovascular / Coffee and tea consumption in a high cardiovascular risk mediterranean population

Introducción: Las recomendaciones de consumo de café y té en una alimentación saludable han ido variando en los últimos años a medida que ha aumentado el nivel de evidencia acerca de los beneficios de los mismos. Objetivo: Conocer la frecuencia de consumo actual de café y té en población mediterránea de alto riesgo cardiovascular (RCV) y analizar, si hay diferencias entre el consumo de estas bebidas por factores de RCV. Material y métodos: Se ha realizado un estudio transversal en 945 personas (340 hombres, 605 mujeres) (67,4 ± 6,2 años) de alto RCV reclutados en centros de atención primaria de la Comunidad Valenciana incluidos en el estudio PREDIMED. Se ha determinado el consumo de café y de té mediante un cuestionario validado. Se han analizado variables bioquímicas, clínicas y antropométricas por métodos estándar. Resultados: El consumo de té es muy bajo en esta población mediterránea (0,4 ± 1,6 tazas/sem). Por el contrario, el consumo de café casi alcanza en promedio una taza al día (6,5 ± 5,2 tazas/sem). En los hipertensos se observa un menor consumo global de café que en los no hipertensos (6,6 ± 5,1 vs 7,3 ± 5,9; P = 0,023 respectivamente), siendo estas diferencias de consumo limitadas al café con cafeína (2,9 ± 4,5 vs 4,3 ± 5,3; P < 0,001). También los diabéticos consumen significativamente menos café y té que los no diabéticos (P = 0,015 y P = 0,022 respectivamente), siendo mayores estas diferencias para el café con cafeína (P < 0,025).Conclusión: En conclusión en esta población mediterránea de alto riesgo cardiovascular se observa un patrón de consumo de café basado en las recomendaciones clínicas tradicionales, que debería revisarse en base a las nuevas evidencias científicas (AU)

Introduction: Coffee and tea consumption recommendations for a healthy diet have been changing in recent years as it has increased the level of evidence on their benefits has increased. Objective: To know the frequency of coffee and tea consumption of in a high cardiovascular risk Mediterranean population (CVR) and to analyze whether there are differences between the consumption of these drinks by cardiovascular risk factors. Methods: A cross-sectional study was carried out on 945 people (340 males, 605 females) (67.4 ± 6.2 years old) with high CVR recruited in primary care centres of Valencia, included in the PREDIMED study. Coffee and tea consumption has been determined through a validated questionnaire. We analyzed biochemical, clinical and anthropometric variables by standard methods. Results: Tea consumption is very low in this Mediterranean population (0,4 ± 1,6 cups/weeks). By contrast, coffee consumption averaged nearly one cup per day (6,5 ± 5,2 cups/weeks). Hypertensive patients showed a lower overall consumption of coffee than in non-hypertensive patients (6,6 ± 5,1 vs 7,3 ± 5,9; P = 0,023 respectively). These differences were greatest when caffeinated coffee consumption is analyzed (2.9 ± 4.5 vs 4 3 ± 5.3, P < 0001). Moreover, diabetics consumed significantly less coffee and tea than non-diabetics (P = 0,015 and P = 0,022 respectively), these differences being greater for caffeinated coffee (P < 0,025). Conclusions: In conclusion, in this high cardiovascular risk Mediterranean population a coffee consumption pattern, based on traditional recommendations, is observed, that as a result of new scientific evidence should be update (AU

Iontoforesis en el abordaje del paciente con dolor crónico / Iontophoresis in the approach to patients with chronic pain

Objetivos: Con este trabajo se pretende evaluar la técnica en los diferentes diagnósticos en los que se ha empleado durante un año en nuestra unidad. Material y métodos: Se realizó un estudio retrospectivo analizando las historias clínicas de 50 pacientes que, durante el año 2005, recibieron tratamiento con iontoforesis y que cumplían los criterios de inclusión/exclusión. Se evaluó la efectividad analgésica del tratamiento mediante la escala analógica visual (EVA) al inicio del tratamiento y una vez finalizado este. Para la evaluación de la técnica se calculó la media, con un intervalo de confianza (IC) del 95% pretratamiento y postratamiento, y se compararon los resultados, valorando su consistencia con la prueba de la t de Student (mediante el programa informático SPSS v.13.1). Resultados: Valorando la consistencia de los datos, comparando la EVA pretratamiento y postratamiento con la prueba de la t de Student para datos apareados, podemos afirmar que el tratamiento con iontoforesis consigue una reducción de la EVA estadísticamente significativa en las siguientes afecciones: osteoartritis (media + desviación estándar [DE] pretratamiento 7,28 ± 1,69 y postratamiento 4,80 ± 2,64) y síndrome del túnel carpiano (media + DE pretratamiento 7,57 ± 0,83 y postratamiento 6,35 ± 0,74). Conclusiones: La iontoforesis parece ser una técnica apropiada y muy segura para el tratamiento del dolor crónico en afecciones como la osteoartritis o el síndrome del túnel carpiano (AU)

Objective: To evaluate the technique of iontophoresis in the distinct entities in which it was used during a 1-year period in our unit. Material and method: We performed a retrospective study. The medical records of 50 patients who received iontophoresis in 2005 and who met the inclusion and exclusion criteria were analyzed. The analgesic effectiveness of treatment was evaluated through a visual analog scale (VAS) at the beginning and end of treatment. To evaluate the technique, the pre-treatment and post-treatment means of VAS scores were calculated with 95% confidence intervals and the results were compared. Student’s t-test was used to evaluate the consistency of the data (the SPSS v. 13.1 statistical package was used). Results: Evaluation of the consistency of the data by comparing pre-treatment and posttreatment VAS results through Student’s t-test for paired data showed that treatment with iontophoresis produced statistically significant reductions in VAS scores for the following entities: osteoarthritis (pretreatment mean ± standard deviation 7.28 ± 1.69,post-treatment mean ± standard deviation 4.80 ± 2.64) and carpel tunnel syndrome(pretreatment mean ± standard deviation 7.57 ± 0.83, post-treatment mean ± standard deviation 6.35 + 0.74). Conclusions: Iontophoresis seems to be an appropriate and highly safe technique for the treatment of chronic pain in diseases such as osteoarthritis and carpel tunnel syndrome (AU)

Tratamiento de la neuropatía diabética grave medianteestimulación medular / Treatment of severe diabetic neuropathy through spinal cord stimulation

La diabetes mellitus (DM) es una patología ampliamente extendidaen la población general que, por el efecto perjudicial que ejerce lahiperglucemia sobre estructuras nerviosas o vasculares, puede generarcomplicaciones, en muchas ocasiones difíciles de tratar. Laalteración nerviosa secundaria a la DM ocasiona, por lo general, procesosdolorosos graves. Existen multitud de guías de práctica clínicaque realizan recomendaciones sobre el uso de diferentes fármacosen monoterapia o combinados, con distintos grados de evidencia.Sin embargo, hay situaciones clínicas en las que no se produce respuestaa las terapias farmacológicas, por lo que se buscan otrosrecursos para obtener la analgesia. Presentamos un caso resistenteal tratamiento convencional farmacológico, en el que se obtiene elcontrol analgésico mediante sistemas de estimulación medular (AU)

Diabetes mellitus (DM) is a widespread disease among the generalpopulation which, because of the damaging effect of hyperglycemiaon the nervous or vascular structures, may lead to complicationswhich in many cases are difficult to treat. In general, neurologicaldisorders secondary to DM cause severe, painful processes. A greatmany clinical practice guidelines are available providing recommendationsabout different drugs to be used as a monotherapy or incombination, with varying degrees of evidence. Nevertheless, certainclinical situations show no response to pharmacological therapiesand, therefore, other resources have to be found and implementedto achieve analgesia. We present a case that was resistant to traditionalpharmacological treatments, in which analgesic control wasachieved through spinal cord stimulation systems (AU)

Strangulated small bowel evisceration after intraperitoneal drainage.

We report an exceptional case of strangulated small bowel evisceration through an intraperitoneal drainage after open cholecystectomy. It is a recognized but rare complication of surgical procedures. The drainage must be sited carefully and when necessary. If possible, drains of less than 10 mm external diameter should generally be used.

Microanastomosis venosas directas mediante cuff extraluminal / Direct venous microanastomoses with an extraluminal cuff

Introducción. Las microanastomosis venosas son más difíciles de realizar que las arteriales debido a las características de la pared venosa. La técnica habitual es la sutura con puntos sueltos, pero presenta los inconvenientes de una duración excesiva y la presencia de gran cantidad de material de sutura desde el punto de vista anastomótico. La técnica del cuff extraluminal para la realización de estas microanastomosis puede evitar estas complicaciones. Materiales y métodos. Se realizan 30 microanastomosis en la vena yugular interna de la rata Sprague-Dawley mediante la colocación de un cuff extraluminal de silicona, y se determina la duración, la permeabilidad inmediata (tanto en la primera hora como al mes) y sus posibles complicaciones. Se realiza además un estudio histológico a los quince días y al mes de su realización. Resultados. Duración media de las anastomosis: 6,77 minutos. Permeabilidad al mes del 83,3 por ciento. Destaca la presencia de tres trombosis y dos dehiscencias.El estudio histológico revela una escasa alteración parietal con una marcada hiperplasia subendotelial. Conclusiones. La técnica de microanastomosis venosas con un cuff extraluminal es una técnica rápida y fácil de realizar, y presenta unas tasas de permeabilidad altas (83,3 por ciento), a pesar de que se genera una tensión excesiva dentro de la línea de anastomosis debido al acortamiento vascular que se produce (AU)

Microanastomosis venosa yuguloyugular contralateral. Un nuevo modelo experimental / Contralateral jugular-jugular venous microanastomosis. A new experimental model

Introducción. Las microanastomosis venosas son de difícil realización, fundamentalmente por las características de la pared venosa. Objetivo. Ofrecer una técnica que evite las frecuentes complicaciones, y diseñar un nuevo modelo experimental. Materiales y métodos. Se utiliza la rata albina Sprague-Dowley. Tras cervicotomía en T invertida y disección de las dos venas yugulares externas, se mide la longitud de ambas desde sus extremos mandibular y clavicular. Se procede a la ligadura del extremo proximal de una yugular y el extremo distal de la contralateral, y se mide la longitud de las venas yugulares, así como la distancia entre las dos secciones vasculares. Se realiza una microanastomosis terminoterminal yuguloyugular contralateral en 10 animales, cinco mediante la técnica habitual de puntos sueltos y otros cinco con la utilización de un cuff extraluminal. Resultados. Longitud de cada vena yugular externa de 18 mm (ñ 1 mm). La distancia entre ambas secciones venosas fue de 25 mm. Se consiguió 5 mm de longitud añadida, útil para la microanastomosis.Todas las microanastomosis fueron permeables. Discusión. Con este nuevo modelo experimental se consigue una longitud venosa suficiente para realizar anastomosis directas fácilmente movilizables, permitiendo técnicas que obliguen a acortamiento de los segmentos venosos, y que se eviten los fallos anastomóticos secundarios a la tensión longitudinal y lesión de la pared vascular. Si se emplea un cuff extraluminal la anastomosis queda sin tensión, a pesar de la eversión y del telescopaje necesario (AU)

[Venous microanastomoses by extraluminal cuff versus standard technique]. / Microanastomosi venosa diretta con cuff extraluminale versus sutura standard.

AIM: Venous microanastomoses are more difficult to carry out in comparison with the arterial ones, because of the characteristics of the vascular wall. The suture with loose stitches is the usual surgical technique, but it has 2 disadvantages: a long time of execution and the presence of foreign material in the anastomosis. To avoid these complications, we an extraluminal silicone cuff has been used. METHODS: We performed 70 microanastomoses on the internal jugular vein of Sprague-Dawley rats with these 2 techniques, estimating the immediate and late permeability and postoperative complications. Moreover, a histological study of all the anastomoses was carried out on the 15th day and after 1 mo from the intervention. RESULTS: The mean time requested to perform the microanastomosis is significatively shorter when using the extraluminal cuff. The late permeability with standard suture is 97% and 77% with the cuff. The number of complications with standard suture is significatively lower than with cuff, where rates of 20% of dehiscence and 14% of trombosis were observed. The histological study showed a poor alteration of the vascular wall, with important subendothelial hypertrophy on cuff microanastomosis and a great permanent histopatologic alteration if the standard technique had been used. CONCLUSIONS: The suture with loose stiches is a very good technique to use for this type of microanastomosis, even if the extraluminal cuff can be used in microanastomosis of a free graft or when it is necessary to perform more than 1 microanastomosis.

Subtotal thyroidectomy with transposition of the remnant gland to the subcutaneous space. A new alternative technique in benign thyroid disease.

BACKGROUND: Thyroidectomy is the preferred surgical option for the treatment of benign disease of the thyroid in a wide rage of indications. Controversy exists concerning the extent of the primary excision for optimal results. A subtotal thyroidectomy with transposition of the thyroid remnant to the subcutaneous space prevents thyroid hormone supplementation for life and laryngeal nerve damage during a re-operation. METHODS: We present the case of a 42-year-old female with nontoxic multinodular goitre who underwent subtotal thyroidectomy in which a thyroid remnant of the left upper pole was placed subcutaneously through a buttonhole incision at the junction of the left sternocleidomastoid and the pre-thyroidal muscles. The remnant of thyroid nourished by the vascular pedicle of the superior pole vessels was sutured to the pre-thyroidal muscles. RESULTS: One month after operation, the remnant was palpated as a small well-limited mass without signs of inflammation and thyroid function tests were normal. A contrast-enhanced computed tomography (CT) scan confirmed the subcutaneous position of the thyroid tissue without pathological signs. The scintigraphy showed uptake radioactivity by the transported thyroid remnant. One year after operation the patient was clinically euthyroid with TSH and T4 levels within normal limits. CONCLUSIONS: This report documents the feasibility and efficacy of subtotal thyroidectomy with transposition of the thyroid remnant to the subcutaneous space in multinodular goitre.

Nuevo modelo experimental de trasplante esplénico en la región cervical mediante anastomosis venosa tutorizada / New experimental model of cervical spleen transplantation through a gided venous anastomosis

Introducción. Nuestro grupo de trabajo ha desarrollado un nuevo modelo de trasplante esplénico vascularizado basado en la utilización de la región cervical del donante y la tutorización temporal de la microanastomosis venosa. El objetivo de nuestro trabajo es simplificar la técnica quirúrgica y reducir la incidencia de complicaciones con respecto al modelo clásico de trasplante esplénico en la cavidad abdominal. Material y métodos. Se han realizado 25 trasplantes esplénicos cervicales en ratas tipo Lewis isogénicas y consanguíneas de 12 semanas de edad y un peso medio de 250 g. La técnica quirúrgica se basó en la utilización de la región cervical de la rata receptora, practicándose la anastomosis arterial T-L del brazal de aorta de la donante con la arteria carótida de la receptora. Además, se realizó la anastomosis venosa T-T mediante la tutorización temporal con un Abbocath del número 24 del brazal de porta de la donante con la vena yugular externa de la receptora. Resultados. La incidencia de complicaciones relacionadas con la técnica quirúrgica ha sido del 8 por ciento (una trombosis y una hemorragia). El tiempo quirúrgico medio total del trasplante ha sido de 80 min (ñ 10 min).Conclusiones. Nuestro modelo de trasplante esplénico cervical en ratas basado en la tutorización temporal de la anastomosis venosa consigue simplificar la técnica quirúrgica, reducir el tiempo operatorio y disminuir la incidencia de complicaciones (AU)

[Biliary tract cancer following bilioenteric anastomosis]. / Cáncer de vía biliar después de anastomosis biliodigestivas.

Two cases of carcinoma of bile ducts after bilioenteric anastomosis are presented. The first one arose in the gallbladder eleven years after cholecystojejunostomy; the second, in the common bile duct three years after cholecystectomy and choledocoduodenostomy. The reflux into the bile duct and recurrent infections can be risk factors in tumor development. Although palliative resection was feasible in one case, the early tumor spread and the invasion of the enteric structure, resulted in a poor outcome in the second case.