J.M Lera

Infección de sitio quirúrgico en un servicio de cirugía general. Análisis de cinco años y valoración del índice National Nosocomial Infection Surveillance (NNIS)

Resumen Introduccion Se describe la tasa de infeccion de sitio quirurgico (ISQ) valorando la validez del sistema del indice National Nosocomial Infection Surveillance (NNIS) de estratificacion del riesgo y la influencia de los diferentes factores en la aparicion de una ISQ. Pacientes y metodo Registro prospectivo durante 5 anos de incidencia de ISQ segun el indice y categoria del NNIS, estancias postoperatorias y germenes aislados. Se realizaron pruebas de la χ2, de la t de Student y regresion logistica multiple. Resultados El numero de pacientes es de 6.218, y el de ISQ, de 513 (8,25%). La tasa de infecciones en cirugia limpia es del 2,27%, la de limpia-contaminada, del 9,17%, la de contaminada, del 11,40%, y la de sucia, del 19,14%. En pacientes con ASA I: 4,0%, ASA II: 8,23%, ASA III: 13,54%, ASA IV: 19,55% y ASA V: 33,33%; con un tiempo intervencion = percentil 75 del 6,97%, y > percentil 75 del 23,01%. Con indice NNIS 0: 3,95%, NNIS 1: 8,17%, NNIS 2: 22,08% y NNIS 3: 37,23%. La duracion de la intervencion es el factor del indice NNIS que mas influye en la tasa de infecciones (odds ratio [OR] = 3,43, frente a 2,60 del grado de contaminacion y 2,20 del nivel ASA). La tasa de infecciones en la categoria de la cirugia hepatobiliopancreatica es del 30,9%; la de intervenciones sobre el intestino delgado, del 24,3%; la de la cirugia colorrectal, del 16,1%; la de la cirugia gastroduodenal, del 15,4%; la de otras intervenciones en partes blandas, del 8,5%; la de laparotomias exploradoras, del 7,7%; la de apendicectomias por apendicitis, del 6,4%; la de colecistectomias, del 5,0%; la de otras intervenciones en el aparato digestivo, del 5,0%; la de la cirugia mamaria, del 3,3%; la de herniorrafias, del 1,5%, y la de intervenciones endocrinologicas, del 0,7%. Conclusiones El indice NNIS es valido en nuestros pacientes para estratificar el riesgo de presentar una ISQ. El factor tiempo es el que tiene mayor peso en el riesgo de infeccion, y el nivel ASA, el menor. La categoria NNIS tambien discrimina diferentes grados de riesgo.

Stent or surgery for incurable obstructive colorectal cancer: an individualized decisión

IntroductionIn the setting of stage-IV obstructive colorectal cancer, self-expanding metallic stents (SEMS) placement and palliative surgery may be appropriate options. The aim of the present study is to evaluate the long-term results of surgery compared with stent implantation and to identify patients in whom one of these options can provide more benefit.Materials and methodsFrom November 2000 to November 2008, 98 patients with incurable stage-IV colorectal cancer were treated with palliative surgery (n=53) or SEMS (n=45). Data were recorded with respect to age, gender, tumor location, carcinoembryogenic antigen, ASAclass, presence of metastatic disease in one or multiple organs, volume of liver metastases, urgency of the procedure and treatment with chemotherapy. Comparison between surgery and stent placement was performed for all group and for patients who received and did not receive chemotherapy.ResultsBoth groups were comparable regarding age, ASA-class, chemotherapy treatment, tumor location and presence of metastatic disease in one or multiple organs but not in gender, rate of urgent procedures, abnormal CEA and of volume of liver metastases >25%. Survival in surgical group was significantly higher (11.9 vs 7.3 months; log-rank test, p = 0.002). SEMS group had lower early morbidity, hospital stay and stoma creation. For patients who received chemotherapy, surgery provided benefit in survival (6.8 vs 3.9 months; log-rank test, p = 0.101); in this subgroup, long-term complications from the primary tumour were more common in stented group, and time to chemotherapy was longer in the group of surgery. No differences in survival were shown in patients who did not receive chemotherapy.ConclusionStent placement offers advantages regarding early morbidity, hospital stay and stoma creation. Surgery offers a benefit in survival in patients who receive chemotherapy but not in non-candidates to chemotherapy.

Differences and molecular immunohistochemical parameters in the subtypes of infiltrating ductal breast cancer.

Breast cancer is a heterogeneous disease, and patients are categorized into subtypes according to gene expression. We studied the associations among molecular, immunohistochemical, and clinicopathologic features and their distribution according to the subtypes luminal, HER2, basal, and normal-like in 60 patients with invasive ductal breast carcinoma without distant metastasis at the time of diagnosis (M0). We evaluated the hypermethylation of the CDH-1, RASSF1A, SIAH-1 and TSLC-1 genes by methylation-specific polymerase chain reaction and the expression of p53, bcl-2, cyclin D1, E-cadherin, and beta-catenin proteins in tissue microarrays by immunohistochemical analysis. Expression of bcl-2 was associated with the luminal subtype (P=.003), and CDH-1 hypermethylation was present preferentially in HER2 tumors (P=.038). The basal subtype was characterized by the expression of beta-catenin (P=.003). The hypermethylation of CDH-1 and the expression of bcl-2, cyclin D1, and beta-catenin proteins differ among breast cancer subtypes.

Pathologic Response of Primary Rectal Cancer to Oxaliplatin-Based Chemotherapy

Management of stage IV rectal cancer is controversial, and different strategies may be useful. Preoperative chemotherapy for liver metastases might cause pathologic changes over the primary rectal tumor. In this study, the authors show the pathologic regression of the primary rectal tumor after neoadjuvant chemotherapy treatment. Patients suffering stage IV rectal cancer underwent surgery after oxaliplatin-based chemotherapy. Age, gender, type of surgery, carcinoembryogenic antigen (CEA) level, presence of metastatic disease in one or multiple organs, ypT, ypN, and circumferential resection margin (CRM) were evaluated. Pathologic response of the primary tumor was estimated by using three conventional grading systems and a semiquantitative system assessed by the amount of viable cells out of the total tumor area macroscopically described. Fibrosis, necrosis, and colloid response were evaluated with a semiquantitative system. A complete pathologic response (ypTO) was found in one patient. A good response was observed in the 41.6% of the cases with all grading systems. Presence of fibrosis in the primary tumor was found in six cases. No patient showed CRM involvement. One patient developed a local recurrence. Oxaliplatin-based chemotherapy for stage IV rectal cancer provides high rates of pathologic regression in the rectal tumor and may allow surgery without CRM involvement.

Fox Fordyce disease as a secondary effect of laser hair removal

Abstract Fox Fordyce disease (FFD) has been recently described as an adverse effect of laser hair removal. It is an apocrine gland disorder characterized by pruritus and a folliculocentric papular eruption in apocrine sweat gland areas. Different etiologies have been proposed to be the cause of this entity. It has been suggested that a fisical factor could contribute to FFD phatogenesis. We report a new case of FFD after laser hair removal.

Experimental model of non–heart-beating donors: oxidative stress metabolism in kidney after cardiac arrest (30 minutes of warm ischemia) and reimplantation 24 hours later

THE procurement of organs from non–heart-beating donors (NHBD) is a new way to increase the number of the grafts available for transplantation. Because of increasing organ demand, it is important to establish a protocol to select optimal donors. Postischemic renal failure is an important problem, especially if the kidney has been harvested from a NHBD, presumably because of the combined injury from warm and cold ischemia. The organs obtained from NHBDs go through potential periods of injury for ischemia reperfusion: warm ischemia (NHBD with cardiopulmonary resuscitation; hyperoxygenated reperfusion (cardiopulmonary resuscitation); cold ischemia (preservation and storage); and reperfusion (graft revasculation). Free radicals generated from oxygen by activated xanthine oxidase at reperfusion have been shown to be a major mediator of renal injury following either warm or cold ischemia. The process in human has not been reproduced in animals totally. The goals of the present study are to develop a NHBD process that reproduces the human one in animals; to study ischemia–reperfusion lesion repercution, determining ATP, reduced glutathione (GSH), malondialdehyde (MDA), and myeloperoxidase (MPO); to evaluate warm ischemia as an indicator of graft viability with 30 minutes of renal ischemia; and to determine the quality and quantity of damage in each phase. MATERIALS AND METHODS

Asociación entre la inestabilidad de microsatélites y las características clínicas y anatomopatológicas en pacientes con cáncer de colon esporádico

Universidad de Navarra. Pamplona. Navarra. Espana. Fundamento y objetivo: La inestabilidad de microsatelites derivada del fallo en la reparacion de los falsos emparejamientos del ADN es la alteracion caracteristica de los tumores de la via mutadora o inestables (MSI). Tales casos parecen presentar diferencias desde el punto de vista clinicopatologico con los tumores de la via supresora o estables (MSS). Los tumores con alto grado de inestabilidad (MSI-H) parecen constituir una nueva entidad de tumores con diferencias en determinadas caracteristicas anatomopatologicas y clinicas con respecto a los tumores estables (MSS) e inestables de bajo grado (MSI-L). En el presente estudio se valora la posible asociacion entre el alto grado de inestabilidad de microsatelites con la localizacion, contenido mucinoso, grado de diferenciacion, estadio, asi como el intervalo libre de enfermedad y supervivencia. Pacientes y metodo: Se clasifica a 117 pacientes con cancer de colon esporadico en las poblaciones MSS/MSI-L y MSI-H (siguiendo las recomendaciones del National Cancer Institute) mediante reaccion en cadena de la polimerasa y electroforesis de 7 microsatelites. Resultados: Los tumores MSI-H tendieron a localizarse en el colon derecho (p = 0,022) y a presentar contenido mucinoso (p = 0,04). El conjunto de pacientes MSI-H de estadios II y III no presento intervalos libres de enfermedad ni periodos de supervivencia mas prolongados (p = 0,54, p = 0,37, respectivamente). Los tumores MSI-H de estadio II presentaron periodos de supervivencia mas prolongados que los tumores MSS/MSI-L (p = 0,027). No observamos diferencias en la respuesta a quimioterapia con 5-fluorouracilo y leucovorin entre los grupos MSS/MSI-L y MSI-H (p = 0,38). Conclusiones: El alto grado de inestabilidad de microsatelites se asocia con determinadas caracteristicas patologicas, asi como con periodos de supervivencia mas prolongados para los tumores de estadios II.

Partial unilateral lentiginosis treated with alexandrite Q-switched laser: Case report and review of the literature

Abstract Partial unilateral lentiginosis (PUL) is a rare pigmentary disorder characterized by multiple lentigines grouped within an area of normal skin, often in a segmental pattern and appearing at birth or in childhood. There is no established standard treatment for this condition. We present two cases of PUL succesfully treated with alexandrite Q-switched laser. In our cases, this laser proved to be a safe and effective treatment for cosmetically disfiguring lentigines. Special precautions are needed when treating dark-skinned patients because side effects are more likely. We propose that this modality be considered in the treatment of this rare disorder.

Metabolic and immunohistochemical asessment of endocrine pancreatic function after orthotopic multivisceral transplantation

IT is well known that pancreatic allografts normalize hyperglycemia a few hours after reperfusion. Endocrine function has been intensively studied in pancreas allografts from a biochemical point of view. Outstanding among functional studies is intravenous (IV) glucagon test, which has rarely been used in pancreas transplantation. However, there is little information on early histochemical aspects of pancreas transplantation and endocrine function has not been properly studied in multivisceral transplantation with the pancreas allograft draining into the portal vein of the liver graft. We studied the endocrine function of the orthotopically transplanted pancreas after multiorgan procurement in a multivisceral transplantation model in a previously reported model.

Pancreatic preservation in a multiorgan procurement procedure and transplantation.

U M LTIORGAN harvesting for individual organ transplantation is well defined according to the principles of Starzl. However, some pancreatic transplant surgeons believe the pancreas should not suffer hyperperfusion as occurs in multiorgan harvesting. This is in conflict with the need of all donor organs for transplantation and specially when multivisceral transplantation is planned. We believe that the pancreas is not so sensitive to high-volume flushing: most pancreata are harvested from multiorgan donors with good functional results. Even when flushing to the pan-creas in the adult donor is only 2 L, severe allograft pancreatitis has been reported in multivisceral transplantation. There must be some other etiologic factors of pancreatic preservation injury, namely warm ischemia and preservation time. We studied the quality of pancreas preservation in a multiorgan conventional preservation and orthotopic multivisceral transplantation technique.