Daniel Díaz-Gómez

Appropriate management of common bile duct stones: A RAND Corporation/UCLA Appropriateness Method statistical analysis

BackgroundBile duct stones affect 10% of patients who undergo a cholecystectomy and therefore represent a major health problem. Laparoscopic common bile duct exploration, endoscopic sphincterotomy, and open surgical choledocholithotomy are the three available methods for dealing with choledocholithiasis. Though many trials and reviews have compared all three strategies, a list of indications for defined patient profiles is lacking.MethodsWe employed the RAND Corporation/UCLA Appropriateness Method (RAM) to evaluate the three procedures for bile duct stone clearance. An expert panel judged appropriateness after a comprehensive bibliography review, a first-round private rating of 108 different clinical situations, a consensus meeting, and a second round of definitive rating. A list of indications for each procedure was statistically calculated.ResultsA consensus was reached for 41 indications (38%). The endoscopic approach was always appropriate for preoperatively diagnosed bile duct stones and inappropriate for patients with single intraoperative detected stones causing cholangitis and bile duct dilatation. Laparoscopic bile duct exploration was appropriate for preoperatively diagnosed choledocholithiasis if patients had not undergone a previous cholecystectomy and no signs of cholangitis were detected. The laparoscopic approach was also appropriate for intraoperatively incidentally detected stones, except for septic patients with poor performance status and multiple calculi. Laparoscopic bile duct clearance was judged inappropriate for septic patients with poor performance status and absence of bile duct dilatation. Open surgery was appropriate in all patients with intraoperative diagnosis of choledocholithiasis and cholangitis and in septic patients with bile duct dilatation. There was no clinical situation in which open surgery was appropriate when bile duct stones were preoperatively diagnosed.ConclusionsThere is still uncertainty with respect to the management of choledocholithiasis, showing the need for further investigation. The RAM helps to elucidate appropriateness for the different treatment options in specific clinical settings.

Experiencia con la técnica de la bolsa de Bogotá para el cierre temporal del abdomen

Resumen Introduccion La bolsa de Bogota es uno de los dispositivos que se han descrito para el cierre temporal del abdomen. El objetivo de este trabajo ha sido describir nuestra experiencia con la tecnica de la bolsa de Bogota. Material y metodo Analizamos retrospectivamente nuestra experiencia entre enero de 2000 y marzo de 2006. Se aplico estadistica descriptiva con calculo de porcentajes y medias. Resultados En un total de 12 pacientes se empleo la bolsa de Bogota. En 11 (91,66%) se coloco de forma preventiva por presentar riesgos de hipertension intraabdominal y sindrome compartimental abdominal. En un paciente (8,34%) la descompresion con bolsa de Bogota se realizo una vez el sindrome compartimental se habia instaurado. No hemos tenido ninguna complicacion en relacion con la colocacion ni la retirada de la bolsa de Bogota. En ningun caso aparecieron fistulas intestinales ni colecciones infectadas intraabdominales. La estancia media hospitalaria fue de 46,33 dias y en la unidad de cuidados intensivos, de 16,58 dias. En la actualidad 7/12 (58,34%) han fallecido y 5/12 (41,66%) viven. Conclusiones La bolsa de Bogota para el open abdomen en nuestra serie ha sido un metodo util para evitar o tratar el sindrome compartimental abdominal. La gran mortalidad descrita viene dada por el proceso inicial que presentan los pacientes y no por las complicaciones derivadas de la colocacion de la bolsa de Bogota.

A vacuum assisted closure system in complex wounds: a retrospective study

Abstract Introduction Vacuum-assisted closure (V.A.C.) therapy is a dynamic and non-invasive system for improving wound healing. This novel therapy is based on applying air suction at a controlled sub-atmospheric pressure. The most important benefits of this therapy include a reduction in the wound area together with induction of new granulation tissue formation, effective wound cleansing (removal of small tissue by suction), and the continuous removal of wound exudate. The aim of this study is to describe our experience with V.A.C. therapy for complex wounds. Material and methods We retrospectively evaluated our experiences with V.A.C. therapy between April 2007 and August 2008. We employed a “suprafascial” V.A.C. system and an open abdomen V.A.C. system. Descriptive statistical techniques were applied and percentages and means were calculated. Results V.A.C. therapy was applied in 20 patients, of whom 16 (80%) had complex abdominal wounds and 4 (20%) had wounds in other locations. We employed a “suprafascial” V.A.C. system in 17 patients (85%) and an “intra-abdominal” V.A.C. system in 3 patients (15%). Two patients (10%) developed fistula during interabdominal V.A.C. therapy (urinary and enteric) but closure was achieved before therapy was finished. Mean hospital stay was 38.3 days (7–136). No mortality was directly due to the V.A.C. system. Two patients (10%) died due to their septic condition and the rest are still alive. Mean therapy length was 29.17 days (1–77) in the suprafascial group and 18 days (7–49) in the abdominal group. Average costs were €3197.97 (119.1–10780.25) per patient. Conclusions V.A.C. therapy can improve and accelerate abdominal wound healing even in the presence of infection and bowel fistula.

Association of retroperitoneal lymphangioleiomyomatosis with endosalpingiosis: a case report.

Lymphangioleiomyomatosis is a rare disorder of unknown origin that usually presents pulmonary symptoms. Retroperitoneal lymphangioleiomyomatosis without lung involvement has rarely been reported. We present a 38-year-old woman, the fourth case reported of retroperitoneal lymphangioleiomyomatosis with endosalpingiosis in the literature.Lymphangioleiomyomatosis is a rare disorder of unknown origin that usually presents pulmonary symptoms. Retroperitoneal lymphangioleiomyomatosis without lung involvement has rarely been reported. We present a 38-year-old woman, the fourth case reported of retroperitoneal lymphangioleiomyomatosis with endosalpingiosis in the literature.

Leiomioma de localización perineal

Los tumores perianales primarios son raros en adultos y generalmente se presentan en personas de mediana edad, con predominio en mujeres en caso de ser benignos. La literatura es escasa y la mayoria de las publicaciones hacen referencia a casos aislados o series muy cortas. La forma mas frecuente de presentacion es como una masa proxima al ano e indolora. La histopatologia de estos tumores suele ser diversa, la mayoria de alto grado de malignidad. La exeresis es la primera opcion terapeutica. El principal objetivo es la obtencion de margenes negativos sin danar las funciones esfinterianas, ya que la extirpacion completa esta asociada con menores tasas de recurrencia local1,2. Los leiomiomas son comunes en el utero y la piel, y hasta hace relativamente poco tiempo se consideraba que no existian o que eran raros en las partes blandas profundas. Presentamos el caso de una mujer de 48 anos, fumadora importante y asmatica, que consulta por una tumoracion perianal indolora, de 6-7 cm de diametro, de pocos dias de evolucion (fig. 1). La paciente fue sometida a exeresis mediante abordaje perineal en posicion de Jack-Knife. El diagnostico anatomopatologi175.941 Cartas al director

Supervivencia prolongada tras resección de metástasis hepáticas de adenocarcinoma de páncreas

The prognosis for pancreatic adenocarcinoma has changed very little in recent decades and still continues to be dismal. It has been demonstrated that surgical resection is the only therapeutic option that is able to achieve greater long-term survival (18% 5-years post-pancreaticoduodenectomy [PD], and only 12% when there are metastases in the regional lymph nodes). Using these data, pancreatic resection is traditionally considered contraindicated when there are synchronous liver metastases at the time of surgery. We present a case of long-term survival after PD with simultaneous resection of synchronous liver metastases and deferred surgery for multiple metachronous liver metastases. A 38-year-old male with no prior medical history came to our emergency department in December 2006 with weight loss, jaundice and abdominal pain in the upper right abdominal quadrant. Computed tomography (CT) detected a space-occupying lesion measuring 15 mm 9 mm at the head of the pancreas, with no suspicion of extra-pancreatic disease. A malignant lesion was suspected, and a PD was proposed. During the surgery, a solitary superficial lesion in the liver was biopsied. As the intraoperative histopathologic study ruled out malignancy, we proceeded with the standard Whipple procedure. The postoperative period was uneventful, and the definitive pathology analysis reported ductal adenocarcinoma of the head of the pancreas measuring 25 mm with moderate differentiation (pT2), and absence of pathologic lymph nodes (pN0). The differed study of the biopsied liver nodule revealed the presence of pancreatic metastatic tumor cells. In a follow-up control in June 2007, 7 hepatic metastases were detected in segments II ( 1), III ( 3), IV ( 1), V ( 1) and VIII ( 1) (Fig. 1), and chemotherapy was therefore initiated with gemcitabine and capecitabine as palliative treatment. The patient presented good response to the protocol, with partial regression of the hepatic metastases and persistence of only 2 lesions in a CT done in November 2008. Given this situation, we re-considered the therapeutic strategy, and rescue surgery was proposed. During laparotomy, 6 subcentimeter metastases (segments II, III, IV, V, VIII) were identified and resected. In addition, a larger lesion was detected in the IVb-V segment, which was treated by means of radiofrequency ablation. The pathology study demonstrated the presence of pancreatic adenocarcinoma in all the resected lesions. The patient remained disease-free for 50 months after the pancreatic resection, 28 months after the second hepatic surgery (Fig. 2). In April 2011, a follow-up CT detected multiple bilateral c i r e s p . 2 0 1 3 ; 9 1 ( 6 ) : 3 9 0 – 3 9 9