Alberto Titos García

Are there intra-operative hemodynamic differences between the Coliseum and closed HIPEC techniques in the treatment of peritoneal metastasis? A retrospective cohort study

BackgroundAlthough two main methods of intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) are currently accepted, the superiority of one over the other has not yet been demonstrated. The purpose of this study was to determine whether there are hemodynamic and temperature differences between patients who received HIPEC in two different techniques, open versus closed abdomen.MethodsThis retrospective study was conducted in our center between 2011–2015 in 30 patients who underwent surgery for peritoneal carcinomatosis secondary to colorectal cancer, in whom cytoreduction and HIPEC were performed by the Coliseum (15) or closed techniques (15). The main end points were morbidity, mortality, hemodynamic changes, and abdominal temperature. The comparative analysis of quantitative variables at different times was done with the parametric repeated measure ANOVA for those variables that fulfilled the suppositions of normality and independence and the Friedman non-parametric test for the variables that did not fulfill either of these suppositions.ResultsThere were no deaths in either group. The incidence of postoperative complications in the Coliseum group was 53% (8 patients), grade II–III. The incidence of complications in the closed group was 13% (2 patients), grade II–III. The intra-operative conditions regarding the systolic and diastolic pressures were more stable using the closed abdomen technique (but not significantly so). We found statistically significant differences in abdominal temperature in favor of the closed technique (p = 0.009).ConclusionsBoth HIPEC procedures are similar. In our series, the closed technique resulted in a more stable intra-abdominal temperature.

Eficacia de la estimulación del asa eferente previa al cierre de ileostomía

We have read with great interest the article by Abrisqueta, entitled Afferent loop stimulation prior to ileostomy closure. We report the case of a 55-year-old female patient who, during the diagnostic process of rectal tenesmus and bleeding, was diagnosed with a rectal adenocarcinoma measuring 3 cm, located 5 cm from the anal margin with concentric involvement, and 3 nodules in the mesorectal fat (UT3N1-2). After neoadjuvant treatment (radiotherapy to 50.4 Gy with concurrent capecitabine), a low anterior resection was performed in July 2012 with protective ileostomy in the right flank. During adjuvant treatment, a barium enema was used to confirm the integrity of the anastomosis; after chemotherapy, an extension study was performed to rule out the presence of tumor disease. In the month of November, treatment with efferent stimulation was begun. In our case, we began with 300 cm of warm saline introduced through a Foley catheter. We repeated the process each week, increasing the stimulation to 500 cm. After the online publication of the Abrisqueta article, we continued by including a thickener in the saline solution (Resource Thickener, Nestlé Healthcare Nutrition, Vevey, Switzerland). One week before surgery for the reconstruction of the intestinal tract, stimulation was done daily, while including in the solution the contents of a container of sodium lauryl sulfoacetate and trisodium citrate for anterograde preparation of the excluded segment. Throughout the process, the patient was asymptomatic except for the need for anal evacuation. We proceeded with the stoma closure, finding an efferent loop with a size similar to the afferent loop and performing a mechanical side-to-side anastomosis. The patient progressed satisfactorily, initiating peristalsis 24 h after surgery, and was discharged on the fourth day post-op. We believe that stimulation of the efferent loop is essential to prevent atrophy of the excluded intestinal segment and, therefore, postoperative ileus while also preventing complications. In our case, despite having used an osmotic laxative, there was evidence of contrast enema on a plain abdominal radiograph after 72 h. We concur with Abrisqueta about reeducating patients for sphincter control; in our case, we also recommended Kegel exercises for this patient. The future demonstration of the usefulness of this procedure using comparative prospective studies to analyze the benefits of intestinal stimulation prior to ileostomy closure would require establishing protocols for patients to do each day at home to stimulate the excluded segment.

Effectiveness of efferent loop stimulation: looking for a suitable protocol.

that we inaccurately categorized 3 studies as not being funded by industry. the fourth article referred to does not document industrial support. the implication of this correspondence is that this review was not compiled by the authors with independence from input by industry. this was not the case. Both authors had complete independence in performing the literature search, identifying articles for inclusion, data extraction, drafting the article, and decision to submit for publication. the final document did not undergo review by an industrial partner explaining why privileged documents, referenced by the correspondent, were not available to us and mitigates against concerns regarding unacknowledged publications. our search strategy complies with the Preferred reporting items for systematic reviews and Meta-Analyses guidelines. our exclusion criteria clearly state that a meeting abstract would not be considered for inclusion. in addition, this systematic review was limited to studies in digestive tract surgery in humans, and evidence referenced in this correspondence relating to animal studies or gynecological surgery was not considered. the study by Cornish et al published in Diseases of the Colon & Rectum in 2006 is indeed an influential study. the authors of the recent Cochrane review recognized that the inclusion of a subgroup of patients (90 of 1791 patients operated on for bowel obstruction rather than having an open digestive tract resection) in meta-analysis significantly affected the point estimate of effect on time to recurrent surgery for intestinal obstruction. We have published a systematic review without such meta-analysis, and whether this subgroup is a distinct patient group that warrants separate consideration is a moot point. We feel strongly that we provide an objective and comprehensive systematic review with well-balanced and conservative conclusions, which are unchanged by this correspondence. We reiterate that more evidence is needed regarding the efficacy of all antiadhesion strategies in reducing chronic abdominal symptoms, avoiding repeated operative interventions, and improving quality of life.

Tratamiento endovascular de una hemorragia digestiva grave por aneurisma de la arteria hepática derecha secundaria al decúbito de una prótesis biliar endoscópica

A 55-year-old male with obstructive jaundice associated with alcoholic hepatopathy and chronic pancreatitis underwent ERCP with sphincterotomy and plastic biliary stent placement. He was readmitted due to hematemesis and jaundice. Another ERCP was performed, during which we observed papillary bleeding and migration of the prosthesis, which was exchanged for a coated stent. He was readmitted once again due to hematemesis and shock, and a gastroscopy revealed hemorrhage originating in the bile duct and migration of the stent, which was removed. Arteriography showed evidence of bleeding due to an aneurism of the right hepatic artery secondary to decubitus erosion of the prosthesis. Coil embolization resolved the hemorrhage (Fig. 1). c i r e s p . 2 0 1 4 ; 9 2 ( 9 ) : e 5 3

Apendicectomía laparoscópica por apendicitis aguda asociada a malrotación intestinal

limitada por los efectos secundarios que conllevan en relación con el beneficio clı́nico del trasplante. Se han utilizado a dosis bajas, o administrados durante cortos periodos, aunque no está clara la supervivencia del injerto en estos casos. Algunos pacientes han precisado mú ltiples trasplantes por persistencia de la hipocalcemia. Existen investigaciones encaminadas a inducir tolerancia mediante técnicas de modulación de la expresión de los antı́genos de histocompatibilidad de la clase I y II. Otra estrategia pasa por el aislamiento del tejido implantado con microencapsulación, realizándose estudios en modelos animales y algunas experiencias en humanos. Otra lı́nea de investigación serı́a el cultivo de tejido paratiroideo. Sin embargo, con todas estas técnicas el porcentaje de éxito es bajo. Finalmente, hay descritos en la bibliografı́a casos similares al que presentamos, en los que el hipoparatiroidismo aparece en un paciente ya inmunosuprimido, por lo que el riesgo de dicho tratamiento ya no supone una contraindicación para la realización del alotrasplastante. En estos casos, los resultados fueron buenos, salvo un paciente que desarrolló un rechazo agudo. Por tanto, en pacientes con hipoparatiroidismo permanente que ya reciben tratamiento inmunosupresor, deberı́a plantearse como tratamiento definitivo el alotrasplante de paratiroides, ya que los resultados a largo plazo muestran recuperación de la función paratiroidea y reversión de las alteraciones clı́nicas y analı́ticas de la entidad.

Ganglioneuroma como causa infrecuente de tumor suprarrenal

Ganglioneuroma (Gn) is a benign tumor of the sympathetic nervous system that may occur along the paravertebral sympathetic ganglia, from the neck to the pelvis, and occasionally in the adrenal medulla. Adrenal Gn (AGn) usually occurs asymptomatically in patients under 20 years of age and is incidentally diagnosed in imaging tests requested for other reasons. Despite its benign nature, conversion to a malignant schwannoma has been documented in some cases, and it has been associated with tumors such as pheochromocytoma. Gn is treated by surgical resection and has an excellent prognosis. We report two patients with AGn diagnosed and operated on at our hospital. Case 1. This was an 18-year-old female outpatient with an unremarkable history who attended for non-specific abdominal pain and was found to have a solid left adrenal mass in an ultrasound examination. A computed tomography (CT) scan confirmed the presence of a homogeneous, solid adrenal tumor 6 cm in diameter showing peripheral enhancement. Laboratory tests and functional hormone screening tests were normal. Based on the diagnosis of a nonfunctioning adrenal mass, laparoscopic left adrenalectomy was performed. The patient was discharged 24 h after surgery, and a 7 cm tumor pathologically diagnosed as Gn was found in the surgical specimen. Case 2. This was a 28-year-old male patient with no remarkable history except for recurrent episodes of gastroenteritis and non-specific abdominal pain. An outpatient ultrasonography revealed a suspected right adrenal tumor. An abdominal CT scan confirmed the presence of a 5.8 cm × 4 cm adrenal mass with a mixed low density. As with the previous patient, routine laboratory tests and blood hormone profile were normal. A non-functioning incidental adrenal tumor was diagnosed, and laparoscopic right adrenalectomy was performed. The patient was also discharged at 24 h with no postoperative complications, and the pathological department reported a ganglioneuroma.

Carta científicaGanglioneuroma como causa infrecuente de tumor suprarrenalGanglioneuroma as an uncommon cause of adrenal tumor

Ganglioneuroma (Gn) is a benign tumor of the sympathetic nervous system that may occur along the paravertebral sympathetic ganglia, from the neck to the pelvis, and occasionally in the adrenal medulla. Adrenal Gn (AGn) usually occurs asymptomatically in patients under 20 years of age and is incidentally diagnosed in imaging tests requested for other reasons. Despite its benign nature, conversion to a malignant schwannoma has been documented in some cases, and it has been associated with tumors such as pheochromocytoma. Gn is treated by surgical resection and has an excellent prognosis. We report two patients with AGn diagnosed and operated on at our hospital. Case 1. This was an 18-year-old female outpatient with an unremarkable history who attended for non-specific abdominal pain and was found to have a solid left adrenal mass in an ultrasound examination. A computed tomography (CT) scan confirmed the presence of a homogeneous, solid adrenal tumor 6 cm in diameter showing peripheral enhancement. Laboratory tests and functional hormone screening tests were normal. Based on the diagnosis of a nonfunctioning adrenal mass, laparoscopic left adrenalectomy was performed. The patient was discharged 24 h after surgery, and a 7 cm tumor pathologically diagnosed as Gn was found in the surgical specimen. Case 2. This was a 28-year-old male patient with no remarkable history except for recurrent episodes of gastroenteritis and non-specific abdominal pain. An outpatient ultrasonography revealed a suspected right adrenal tumor. An abdominal CT scan confirmed the presence of a 5.8 cm × 4 cm adrenal mass with a mixed low density. As with the previous patient, routine laboratory tests and blood hormone profile were normal. A non-functioning incidental adrenal tumor was diagnosed, and laparoscopic right adrenalectomy was performed. The patient was also discharged at 24 h with no postoperative complications, and the pathological department reported a ganglioneuroma.