Joaquín Marchena-Gómez

Identification of Risk Factors for Perioperative Mortality in Acute Mesenteric Ischemia

IntroductionAcute intestinal ischemia is in most cases a lethal condition with a low survival rate. Risk factors of perioperative mortality are poorly defined. The aim of this study was to define risk factors that predict an adverse outcome of acute mesenteric ischemia (AMI).MethodsA total of 132 consecutive patients (73 men, 59 women), mean ± SD age 71.96 ± 13.64 years, who underwent surgery because of AMI in a university tertiary care center were evaluated over a period of 10 years. Clinical features, laboratory findings, etiologic factors, and surgical procedures were recorded and assessed as possible risk factors for perioperative mortality.ResultsOf 132 patients, 86 (65.2%) died during the perioperative period as a direct result of AMI. Significant univariate predictors of perioperative mortality were age (P = 0.01), cardiopathy (P = 0.002), digoxin intake (P = 0.015), shock (P = 0.01), urea plasma level (P < 0.001), creatinine (P < 0.001), potassium (P = 0.042), low pH (P = 0.015) and bicarbonate (P = 0.035); hemoglobin ≥ 2.48 mmol/L (P = 0.035); time delay to surgery (P = 0.023); colonic involvement (P < 0.001); small and large bowel involvement (P < 0.001); arterial versus venous ischemia (P = 0.007); and intestinal resection (P < 0.001). In the multivariate analysis, the variables previous cardiac illness (P = 0.045), urea plasma levels (P < 0.001), and small and large bowel involvement were identified as independent risk factors of perioperative mortality. Intestinal resection (P < 0.001) was a favorable predictor.ConclusionsAge, time delay to surgery, shock, and acidosis significantly increase the risk of mortality due to AMI, whereas intestinal resection has a protective effect. However, only previous cardiac illness, acute renal failure, and large bowel ischemia have a negative effect as independent risk factors of mortality of AMI.

Can Early Diagnosis of Symptomatic Colorectal Cancer Improve the Prognosis

Patients with colorectal cancer continue to present with relatively advanced tumors. Delay in diagnosis is often believed to have been a contributing factor, and the validity of this hypothesis has seldom been questioned. The aim of this study was to establish whether a delay in diagnosis is related to long-term survival and if the most frequent symptoms were related to the stage or time at which the carcinoma was diagnosed. Data from 660 patients surgically treated for uncomplicated colorectal carcinoma in our institution between 1985 and 2000 were analyzed retrospectively. Age, sex, initial symptoms, duration of symptoms, neoplasm location, curative surgery, TNM stage, and survival time were the variables recorded. Patients were classified into two groups according to symptom duration: < 3 months versus ≥ 3 months. Comparative statistical analysis was performed for the two groups as well as the initial symptom, TNM stage, and survival time. Also, the initial symptoms most frequently reported were compared with the TNM stage. The two groups were found to be equal with regard to distribution of age, gender, location of the neoplasm, type of surgery performed, and TNM stage. We found that symptom duration was shortened in the presence of abdominal pain (p = 0.002) [odds ratio (OR) 0.53; 95% confidence interval (CI) 0.35–0.80] and was delayed in the presence of an anemic syndrome (p = 0.006) (OR 2.4; 95% CI 1.27–4.56). Also, the stage of the neoplasm was related to rectal bleeding (p < 0.001) and abdominal pain (p = 0.008). The log-rank test indicated that duration of symptoms was not related to long-term survival (p = 0.90). We concluded that the duration of colorectal cancer symptoms is not related to the stage or prognosis of tumors.

Pyogenic liver abscesses: mortality-related factors.

Goal To analyse the characteristics and mortality-related factors in a series of patients hospitalized for pyogenic liver abscess (PLA). Background Pyogenic liver abscesses are infrequent but potentially life threatening. Factors related to mortality have been less studied. Study The medical records of 84 patients, 56 men and 28 women, mean age of 64.4 years (SD: 14) who were hospitalized between 1992 and 2005 owing to a PLA were reviewed. The past medical history, clinical signs and symptoms, laboratory values, imaging studies, microbiological features, treatment, complications and mortality were recorded. Factors related to complications and mortality were analysed. Results One or more bacteria were isolated in 65 patients (77.4%), being Streptococcus spp. (40.5%), Escherichia coli (27.4%), Klebsiella spp. (14.3%) and anaerobics (17.9%) the most frequent isolates. Complications developed in 60.7% of the cases, the most common one being a right pleural effusion (34.5%). Mortality rate was 19% (95% confidence interval: 10–28%). Mortality was associated with age (P=0.005), a previous history of coronary heart disease (P=0.016), absence of fever (P=0.001), development of sepsis and/or septic shock (P<0.001), raise of bilirubin levels (P=0.004), a biliary (P=0.035), or cryptogenetic origin (P=0.039), infection owing to E. coli (P=0.01) or to Candida (P=0.009) and development of pneumonia (P<0.001). Logistic regression revealed sepsis and/or septic shock as an independent risk factor for mortality. Conclusions Mortality associated with PLA is high. The main risk factor for mortality is the development of sepsis and/or septic shock.

Five-year survival and prognostic factors in a cohort of hospitalized nonagenarians

BACKGROUND The number of hospitalized nonagenarians is increasing. Only a few studies have evaluated long-term predictors of survival in these patients. The aim of this study was to determine the 5-year outcome of a cohort of hospitalized nonagenarians, and to identify predictors of long-term survival. METHODS In 124 consecutive medical hospitalized patients older than 89 years, and followed up during 5 years, the following variables were prospectively recorded: sociodemographic characteristics, main diagnoses, Charlson comorbidity index, Barthel index, Lawton-Brody test, Mini-Mental State Examination, Short Portable Mental Status Questionnaire of Pfeiffer, Mini Nutritional Assessment, albumin levels, and the 5-year survival. RESULTS Out of the 124 patients, 109 died (87.9%) during the follow-up. The probability of being alive at 1, 3 and 5 years was 45%, 22% and 12%, respectively. A worse 5-year survival was significantly related to the diagnoses of pneumonia (p=0.037), heart failure (p=0.045), higher Charlson index (p=0.026), poorer functional status measured by the Barthel index (p=0.003), and the Lawton-Brody test (p=0.007), cognitive impairment measured by the Pfeiffer test (p=0.011), and lower levels of albumin (p=0.028). In the multivariate analysis, the Charlson index (p<0.001), and the Barthel index (p=0.003) were independently related to 5-year survival. These two variables were also 5-year survival prognostic factors in the subgroup of discharged patients. A prognostic index using these two variables was created: PI=(0.2 × Charlson index + 0.6 × Barthel index) × 0.92. CONCLUSIONS In hospitalized nonagenarian patients, poor scores in the Barthel Index and a higher comorbidity evaluated by the Charlson index are independently related to 5-year survival.

The Age-Adjusted Charlson Comorbidity Index as an Outcome Predictor of Patients with Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a catastrophic surgical condition, especially in older patients with multiple comorbidities. The aim of this study was to evaluate the impact of comorbidity on perioperative mortality and overall survival in patients surgically treated for AMI. A series of 186 consecutive patients (106 men and 80 women) who underwent surgery because of AMI in a university tertiary care center between 1990 and 2006 were retrospectively studied. The Charlson Comorbidity Index (CCI) score, unadjusted and adjusted by age, was preoperatively calculated in each patient. Perioperative mortality and overall survival were also recorded. The association between unadjusted and adjusted by age CCI and perioperative mortality and overall survival were analyzed. The mean age of the studied population was 72.1 years (SE +/-13.7 years). Hospital mortality was 64.5%. One-year, 3-year, and 5-year overall estimated survival by the Kaplan-Meier method after surgery for AMI was 26%, 23% and 21%, respectively. Perioperative mortality was not related to the unadjusted preoperative CCI (p = 0.093). Nevertheless, a statistically significant association was found between mortality and preoperative adjusted CCI (p = 0.007). Likewise, CCI unadjusted was almost related to overall survival (p = 0.055), but the values of the categorized CCI adjusted by age showed a statistically significant difference in overall survival (p = 0.012). In multivariate analysis, CCI adjusted by age remained independent prognostic factor of mortality. Comorbidity adjusted by age may play a role as a predictive factor for perioperative mortality and long-term survival in patients operated on for AMI.

Predictive factors of years of potential life lost by colorectal cancer

Objective To evaluate the impact of colorectal cancer (CRC) by estimating the years of potential life lost (YPLL) by this neoplasm in a cohort of patients, as well as to define the predictive factors of YPLL. Methods A descriptive cross-sectional study of 980 consecutive patients diagnosed and treated because of CRC in our institution between 1985 and 2002 was carried out. Demographic, clinical, pathological, surgical, hospital stay, complications, and mortality variables were recorded. The primary endpoint of this study was to calculate individual YPLL. Univariate analysis was performed to compare each independent variable with the variable YPLL. All clinically relevant variables significantly associated with YPLL were included in an ordinal regression model to identify independent factors prognostic of YPLL. Results The final study sample was 794 patients, 413 (52%) men and 381 (48%) women, mean age 65.3 years [confidence interval (CI) 95%: 64.4–66.2 years; SD: 12.8]. The mean global YPLL for the 351 patients who died of CRC was 15.2 years (SD: 10.7; CI 95%: 14.1–16.3). Lower age [odds ratio (OR)=0.98; CI 95%: 0.97–0.98], male sex (OR=1.19; CI 95%: 1.00–1.43), lower tumor, nodes, metastasis (TNM) stage (OR=0.29; CI 95%: 0.24–0.35), and rectum localization of the tumor (OR=1.37; CI 95%: 1.14–1.64) were independent prognostic factors for YPLL. Conclusion In our community, the mean number of YPLL by CRC exceeds 15 years. Lower age, male sex, higher TNM stage, and rectum localization are negative predictors of YPLL.

Metachronic malignant transformation of small bowel and rectal endometriosis in the same patient

BackgroundMalignant transformation of intestinal endometriosis is a rare event with an unknown rate of incidence. Metachronous progression of endometriosis to adenocarcinoma from two distant intestinal foci happening in the same patient has not been previously reported.Case presentationWe describe a case of metachronic transformation of ileal and rectal endometriosis into an adenocarcinoma occurring in a 45-year-old female without macroscopic pelvic involvement of her endometriosis. First, a right colectomy was performed due to intestinal obstruction by an ileal mass. Pathological examination revealed an ileal endometrioid adenocarcinoma and contiguous microscopic endometriotic foci. Twenty months later, a rectal mass was discovered. An endoscopic biopsy revealed an adenocarcinoma. En bloc anterior rectum resection, hysterectomy and bilateral salpingectomy were performed. A second endometrioid adenocarcinoma arising from a focus of endometriosis within the wall of the rectum was diagnosed.ConclusionIntestinal endometriosis should be considered a premalignant condition in premenopausal women.

Disfagia tras artrodesis cervical por migración del material protésico

La fijación de la columna cervical mediante abordaje anterior es habitual en el tratamiento de lesiones traumáticas o degenerativas a este nivel. Presentamos el caso de una infrecuente complicación esofágica tardı́a tras cirugı́a de artrodesis cervical anterior. Mujer de 43 años, diabética e hipertensa, que tras sufrir accidente de tráfico con lesión cervical y afectación medular con tretraparesia, fue intervenida quirú rgicamente practicándose discectomı́a C5-C6 y artrodesis con placa. La paciente recuperó la movilidad con escasas secuelas. Al año comenzó con disfagia progresiva a sólidos y lı́quidos, regurgitación no ácida, sensación de ocupación a nivel farı́ngeo, ruidos hidroaéreos con la deglución y pérdida de 10 kg de peso en 6 meses. La tomografı́a computarizada (TC) y la resonancia magnética nuclear (RMN) cervical (fig. 1A) evidenciaron pérdida de fijación y migración de la placa de artrodesis, contactando esta con la pared posterior del esófago. El esofagograma con bario (EGD) reveló protrusión de la placa metálica sobre una formación sacular faringoesofágica de 3-4 cm (fig. 1B). Se completó el estudio con una endoscopia digestiva alta (EDA) donde apareció totalmente incluida dicha pieza de osteosı́ntesis en la pared posterior de un gran divertı́culo faringoesofágico. Ante estos hallazgos, se decidió tratamiento quirú rgico mediante cervicotomı́a izquierda, objetivando un divertı́culo faringoesofágico, de base amplia, en cuya pared posterior se encontraba totalmente incluida la placa metálica de artrodesis. Se realizó sección del mismo, miotomı́a del cricofarı́ngeo y sutura de refuerzo, procediéndose a la extirpación completa del divertı́culo y placa, tras retirada de los tornillos de fijación (figs. 2A y B). Por ú ltimo, se comprobó radiológicamente la estabilidad ósea. El estudio de la pieza quirú rgica mostró una formación sacular de 3,5 2,5 cm con mucosa congestiva e histologı́a compatible con divertı́culo de Zenker. La paciente evolucionó satisfactoriamente, siendo dada de alta al 10.8 dı́a postoperatorio tras comprobación radiológica de buen paso de contraste y ausencia de signos de fuga. La incidencia de disfagia tras cirugı́a espinal con abordaje cervical anterior es cercana al 12%, aunque probablemente infravalorada, y de etiologı́a muy variada. En el periodo postoperatorio inmediato, normalmente leve y transitoria, suele relacionarse con la compresión esofágica por edema secundario a la manipulación intraoperatoria de los tejidos. Aunque puede deberse a causas más infrecuentes y graves, como la perforación esofágica. La lesión del esófago, tras este tipo de cirugı́a, puede ocurrir entre el 0 y el 1,6%. Habitualmente se asocia a procedimientos de instrumentación anterior, entre los niveles C5-C7, pero también a intubación orotraqueal o colocación de sonda nasogástrica. Se presenta con dolor cervical, odinofagia, disfagia, disfonı́a, crepitación, absceso cervical y fiebre, pudiendo desembocar en complicaciones potencialmente mortales como mediastinitis y/o sepsis. Las perforaciones esofágicas de aparición tardı́a, como la de nuestra paciente, suelen presentarse de forma insidiosa, con fiebre, disfagia, signos inflamatorios locales y, ocasionalmente, absceso cervical con fistulización cutánea. Su incidencia oscila entre el 0,2 y el 1,5% y, normalmente, son complicaciones derivadas de la migración, rotura o malposición de los dispositivos de fijación espinal. Otro mecanismo podrı́a ser la isquemia crónica por la presión ejercida al migrar la placa. Incluso hay casos de extrusión, sobre todo de tornillos, a través de la pared esofágica con regurgitación o paso al tracto gastrointestinal de forma asintomática. El EGD, la TAC y la RMN son ú tiles para el diagnóstico. La EDA permite la visualización directa de la región faringoesofágica y la protrusión del material protésico. El tratamiento de esta complicación aú n no está totalmente definido. Cuando se diagnostica la perforación esofágica durante la operación, la sutura simple es el tratamiento de elección. Sin embargo, durante el periodo postoperatorio van a influir factores como el momento del diagnóstico, tamaño de la perforación o sintomatologı́a. Aunque hay registros de c i r e s p . 2 0 1 5 ; 9 3 ( 8 ) : 5 3 7 – 5 4 5

Upper intestinal obstruction due to inverted intraduodenal diverticulum.

Inverted intraduodenal diverticulum is a rare congenital abnormality usually arising near the ampulla of Vater. We describe a case of an inverted duodenal diverticulum in a patient that presented with an upper recurrent intestinal obstruction that required surgery. Recognition of the entity and its anatomic relationships to the ampulla of Vater is essential to the prevention of iatrogenic complications. The inverted intraduodenal diverticulum must be considered in the management of upper intestinal obstruction of unclear origin.

Primer tratamiento PIPAC en un hospital público español. Una novedosa técnica para el tratamiento de la carcinomatosis

Peritoneal carcinomatosis is a metastatic state consisting of tumor dissemination affecting the peritoneal serosa and neighboring structures. The origin is usually gastrointestinal or gynecological tumors, and less frequently sarcomas, stromal and peritoneal tumors. Considered a terminal situation, it was not until Sugarbaker developed the cytoreduction surgical technique associated with hyperthermic intraperitoneal chemotherapy (HIPEC) that its treatment with curative intent became possible. This procedure demonstrated reproducible results that far outperformed those obtained with classic management, consisting of systemic chemotherapy and palliative measures. However, many patients present with advanced peritoneal carcinomatosis, which impedes curative surgery and is relegated to palliative management. During the remainder of their lives, these patients experience progressive clinical deterioration (pain, distension, dyspnea, ascites and intestinal obstruction), resulting in declining quality of life. Recently, a new surgical technique has been developed for the palliative treatment of these patients. It involves the use of aerosolized chemotherapy at an elevated intra-abdominal pressure, which causes the destruction of, or at least a decrease in, tumor implants in the abdominal cavity, achieving significant improvement in patient quality of life. Known as pressurized intraperitoneal aerosol chemotherapy (PIPAC), it consists of 3 key elements: relative safety, minimum duration and proven patient benefits. It was developed in 2011 by Professor Reymond for palliative use in patients with unresectable carcinomatosis. Since then, several articles have appeared, first about the application in animals and later regarding clinical practice in humans. To date, the published studies are based on 3 types of tumors, mainly ovarian, gastric and colorectal. Despite its palliative intent, it has been shown that up to 5% of patients have tumor remission, which allows for reevaluation for curative surgery. The procedure is performed laparoscopically with 2 balloon trocars, 10 and 5 mm, through which a nebulizer (Capnopen) and a 5 mm optical system are inserted. PIPAC is minimally invasive, and recovery is fast (in some European hospitals, it is conducted as day surgery), so treatment with systemic chemotherapy can be resumed. Therefore, it is a coadjuvant procedure to systemic chemotherapy, which does not lose its fundamental role. The technique involves administering aerosol chemotherapy in the abdominal cavity at a high pressure (12 mmHg), which achieves greater penetration of the cytostatic agent and a more homogeneous distribution using lower doses than usual in HIPEC, causing minor side effects. This fact should not be confused with the overall result of cytoreductive surgery associated with HIPEC, since PIPAC is administered on unresected tumor tissue and HIPEC on the tumor bed or, in the worst case scenario, on few residual tumors. In fact, any surgical procedure associated with PIPAC is contraindicated due to the weakness that its application causes to healthy tissue when greater tissue depth is reached, resulting in a risk of complications. The results of this treatment are evident from the beginning (even though the average number of procedures performed was 3), with improved quality of life due to a decrease in pain, ascites, abdominal distension and gastrointestinal symptoms. In addition, in all procedures, peritoneal biopsies were taken to analyze the histological response of the tumor to successive treatments, which demonstrated significant tumor regression. Despite the relative innocuity of the procedure, Alyami et al., in their multicenter study on the implementation of a PIPAC treatment program, point out that the highest rates of morbidity and mortality occurred during the treatment of the first 20 patients, highlighting the importance of a correct learning curve in the selection of patients, even at hospitals with extensive experience in the management of peritoneal carcinomatosis. On May 8, the Carcinomatosis Unit of the General and Digestive Surgery Service at the Hospital Universitario de Gran Canaria Dr. Negrı́n conducted the first PIPAC at a public hospital in Spain. Following the established protocol, doxorubicin and cisplatin were administered at doses of 1.5 and 7.5 mg/m, respectively, instilled by a high-pressure pump at a maximum of 20 bar, with a flow of 30 mL/m for 30 min, at a constant intra-abdominal pressure of 12 mmHg. The treatment was applied to a 63-year-old patient with ovarian carcinomatosis previously considered by our group as unresectable due to massive involvement of the small intestine and a peritoneal cancer index (PCI) of 29. At the time of the intervention, the patient had a PCI of 31. During the procedure, 450 cc of ascitic liquid were extracted and peritoneal biopsies were taken to