Extended totally extraperitoneal (eTEP) treatment for lateral primary and incisional hernias. New approach to old problems.

PURPOSE: To describe the eTEP approach for treating lateral primary and incisional hernia and show its results in a prospective series of cases. METHODS: A descriptive prospective study with patients treated surgically for lateral hernias using eTEP approach. Every patient was operated by the same surgeon from November 2018 to December 2021. Inclusion criteria were primary and incisional hernia, lateral and W1 and W2 sized using the EHS classification. Exclusion criteria were W3 hernia, loss of domain, need to remove previous mesh, dystrophic or ulcerative skin, history of previous complex surgery. Details of the surgical technique are described. RESULTS: 34 patients were operated. Median age was 65 years old and BMI, 29.9 (22.1-47.1). There were several locations being the most frequent L3 in 18 patients. The median length was 41 mm (10-129) and width, 44 mm (10-97). The median of defect-mesh ratio was 5.05 (0.9-447.64). TAR was practised in 21 patients (61.8%). Only one patient suffered a clinically relevant complication, being a hematoma (Dindo-Clavien II). 50% of patients were operated in ambulatory surgery. After a median follow-up of 13.5 months, only one recurrence has been reported (2.9%). CONCLUSION: eTEP to treat lateral hernias is feasible and reproducible showing good results in terms of hernia recurrence and complications. A further prospective randomized clinical trial is needed to support these results.

Is it always necessary to perform an axillary lymph node dissection after neoadjuvant chemotherapy for breast cancer?

INTRODUCTION: Recent prospective studies support the feasibility of performing sentinel lymph node biopsy following neoadjuvant chemotherapy in initially fine-needle aspiration cytology or ultrasound-guided biopsy-proven node-positive breast cancer. The main aid is to identify preoperative features that help us predict a complete axillary response to neoadjuvant chemotherapy in these patients and thus select the candidates for sentinel lymph node biopsy post-neoadjuvant chemotherapy to avoid unnecessary axillary lymphadenectomy. MATERIALS AND METHODS: A retrospective observational study with a total of 150 patients, biopsy-proven node-positive breast cancer who underwent neoadjuvant chemotherapy followed by breast surgery and axillary lymphadenectomy were included and retrospectively analysed. A predictive model was generated by a multivariate logistic regression analysis for pathological complete response-dependent variable. RESULTS: The response of the primary lesion to neoadjuvant chemotherapy according to post-treatment magnetic resonance imaging, Her2/neu overexpression and a low estrogen receptor expression are associated with a higher rate of nodal pathologically complete response. The multivariant model generated a receiver operating characteristic curve with an area under the curve of 0.79 and a confidence interval of 0.72-0.87 at a 95% level of significance. CONCLUSIONS: This model could be a helpful tool for the surgeon to help in predicting which cases have a higher likelihood of achieving a pathologically complete response and therefore selecting those who may benefit from a post-neoadjuvant chemotherapy sentinel lymph node biopsy and avoid unnecessary axillary lymphadenectomy.

[Risk factors for acute respiratory failure after liver transplantation]. / Factores pronósticos de insuficiencia respiratoria aguda en el postoperatorio del trasplante hepático.

OBJECTIVES: To study the risk factors for acute respiratory failure during recovery after liver transplantation. PATIENTS AND METHODS: We prospectively studied 340 consecutive liver transplant operations. Patient data was grouped according to whether acute respiratory failure developed (group I) or not (group II). Acute respiratory failure was defined by the need for mechanical ventilation longer than 5 days after transplantation or by the need for an inspired oxygen fraction of over 50% for 72 hours. We evaluated demographic characteristics, stage of liver disease before the transplant, comorbidity, immunosuppressant treatment administered, and complications during and after surgery. RESULTS: Sixty-six patients were placed in group I and 274 in group II. Univariate analysis showed significant differences between the groups for age, sex, Child-Pugh functional stage, preoperative renal failure, type of immunosuppression, and postoperative complications such as atrial fibrillation, pleural effusion, pulmonary edema, ascites, postoperative acute renal failure, brain dysfunction, early graft dysfunction, and respiratory infection. Multivariate analysis by logistic regression, taking the development or not of acute respiratory failure as the dependent variable, gave a model with 6 variables that accounted for 94% of the cases. The variables entering into the model, with their respective odds ratios (OR) were female sex (OR, 5.5), stage C liver function (OR, 3.9), pulmonary edema (OR, 16.3), postoperative acute renal failure (OR, 9), cerebral dysfunction (OR, 4.5), and respiratory infection (OR, 62). CONCLUSIONS: The development of acute respiratory failure after liver transplantation is affected by the following factors: female sex, Child-Pugh class, pulmonary edema, postoperative acute renal failure, cerebral dysfunction, and respiratory infection.

Factores pronósticos de insuficiencia respiratoria aguda en el postoperatorio del trasplante hepático / Risk factors for acute respiratory failure after liver transplantation

OBJETIVOS: Estudiar los factores pronósticos que determinanel desarrollo de insuficiencia respiratoria aguda(IRA) durante el postoperatorio del trasplante hepático.PACIENTES Y MÉTODO: Estudiamos retrospectivamente340 trasplantes hepáticos consecutivos. Los pacientes fuerondistribuidos en dos grupos según desarrollasen (GrupoI) o no (Grupo II) IRA, definida por la necesidad deventilación mecánica durante más de 5 días tras el trasplanteo por precisar una FiO2 superior al 50% durante 72h. Evaluamos las características demográficas, estadio funcionalhepático previo, indicación del trasplante, patologíaasociada, tratamiento inmunosupresor administrado ycomplicaciones intra y postoperatorias.RESULTADOS: El Grupo I lo constituyeron 66 pacientes yel Grupo II 274. El análisis univariante obtuvo diferenciassignificativas para las variables: edad, sexo, estadio funcionalde Child-Pugh, insuficiencia renal preoperatoria,tipo de tratamiento inmunosupresor y complicaciones postoperatoriascomo fibrilación auricular, derrame pleural,edema pulmonar, ascitis, fracaso renal agudo postoperatorio,disfunción cerebral, disfunción inicial del injerto einfecciones respiratorias. Con el análisis multivariantemediante regresión logística, tomando el desarrollo o no deIRA como variable dependiente, obtuvimos un modelo con6 variables que discriminaba correctamente al 94% de loscasos. Las variables incluidas en el modelo, con sus respectivasOdds Ratios (OR), fueron: sexo mujer (OR 5,5),estadio funcional C (OR 3,9), edema pulmonar (OR 16,3),fracaso renal agudo postoperatorio (OR 9), disfuncióncerebral (OR 4,5) e infección respiratoria (OR 62).CONCLUSIONES: El desarrollo de IRA en el postoperatoriodel trasplante hepático está determinado por: sexofemenino, estadio funcional Child, edema pulmonar, fracasorenal agudo postoperatorio, disfunción cerebral einfección respiratoria

OBJECTIVES: To study the risk factors for acute respiratoryfailure during recovery after liver transplantation.PATIENTS AND METHODS: We prospectively studied340 consecutive liver transplant operations. Patientdata was grouped according to whether acute respiratoryfailure developed (group I) or not (group II). Acuterespiratory failure was defined by the need for mechanicalventilation longer than 5 days after transplantationor by the need for an inspired oxygen fraction ofover 50% for 72 hours. We evaluated demographiccharacteristics, stage of liver disease before the transplant,comorbidity, immunosuppressant treatmentadministered, and complications during and after surgery.RESULTS: Sixty-six patients were placed in group Iand 274 in group II. Univariate analysis showed significantdifferences between the groups for age, sex,Child-Pugh functional stage, preoperative renal failure,type of immunosuppression, and postoperative complicationssuch as atrial fibrillation, pleural effusion, pulmonaryedema, ascites, postoperative acute renal failure,brain dysfunction, early graft dysfunction, and respiratoryinfection. Multivariate analysis by logisticregression, taking the development or not of acute respiratoryfailure as the dependent variable, gave amodel with 6 variables that accounted for 94% of thecases. The variables entering into the model, with theirrespective odds ratios (OR) were female sex (OR, 5.5),stage C liver function (OR, 3.9), pulmonary edema(OR, 16.3), postoperative acute renal failure (OR, 9),cerebral dysfunction (OR, 4.5), and respiratory infection(OR, 62).CONCLUSIONS: The development of acute respiratoryfailure after liver transplantation is affected by the followingfactors: female sex, Child-Pugh class, pulmonaryedema, postoperative acute renal failure, cerebral dysfunction,and respiratory infection

[Effects of positive end expiratory pressure on oxygen transport]. / Efectos de la presión positiva telespiratoria sobre el transporte de oxígeno.

Fifteen patients admitted at the ICU of our hospital suffering from respiratory failure and submitted to mechanical ventilation were included in a study upon the influence of positive end expiratory pressure (PEEP) on oxygen transport. When the PaO2/FiO2 index was less than 300, 200, and 150, PEEP of +5, +10, and +15 cmH2O respectively was introduced. A Swan-Ganz catheter in the pulmonary artery and a catheter in a radial artery were inserted with the aim to obtain mixed venous blood samples and determine cardiac output, and vascular pulmonary resistances for each PEEP value. When PEEP increased from 5 cmH2O to 15 cmH2O, oxygen supply decreased a 12.4% (p less than 0.05), oxygen extraction from the tissues increased a 21.4% (p less than 0.025) and cardiac output decreased a 7.9% (p less than 0.02) while vascular pulmonary resistances increased a 6.6% (p = NS). We conclude that a PEEP of 5 cmH2O impairs tissue oxygenation when compared with PEEP of 5 cmH2O and that oxygen supply decrease with cardiac output.

[Correlation between the concentration of plasma lactic acid and other cardiorespiratory parameters in hypoxic patients]. / Correlación entre la concentración plasmática de ácido láctico y otros parámetros cardiorrespiratorios en pacientes hipóxicos.

We carried out a study in a group of 20 patients; this group was made up of 16 women and 4 men. All patients were under controlled ventilation and the relation between partial pressure of oxygen and the fraction of oxygen to be inhaled was equal or less than 150. A Swan-Ganz catheter was implanted in the pulmonary artery and another catheter in a radial artery. We determined the cardiac output, oxygen saturation in mixed venous blood and blood levels of lactic acid. We calculated the oxygen supply, oxygen consumption and tissue extraction of oxygen. We could to point out that there is a positive and significative correlation between lactic acid blood levels and cardiac output, oxygen consumption and oxygen extraction (p less than 0.001); negative and significative between acid blood levels and oxygen supply (p less than 0.025) and oxygen saturation in mixed venous blood (p less than 0.001). Finally we observed that when the lactic acid blood levels went up, decrease in oxygen saturation in mixed venous blood is more acute that increase in cardiac output.