José Manuel Ramia

Ambispective comparative study of two surgical strategies for liver hydatidosis

AIM To investigate the morbidity, mortality, recurrence and technical aspects of two distinct surgical strategies that were implemented in successive periods. METHODS Ninty-two patients with 113 cysts underwent surgical procedures. The study was divided into 2 periods. Data from first period (P1) were compiled retrospectively. The surgical strategy was conservative surgery. The second period (P2) included a prospective study conducted according to a protocol following the criterion that radical procedures should be performed whenever it is technically feasible. RESULTS Patients of both periods showed no statistically significant differences in age, gender, cyst location or mortality. Among the P2 group, patients exhibited more preoperative jaundice, and cyst size was smaller (P < 0.05). Changes in surgical strategy increased the rate of radical surgery, decreases morbidity and in-hospital stay (P < 0.001). A negative result in P2 was the death of two old patients (4.8%) who had undergone conservative treatments. The rate of radical surgery in P2 was around 75%. CONCLUSION Radical surgery should be the technique of choice whenever it is feasible, because it diminishes morbidity and in-hospital stay. Conservative surgery must be employed only in selected cases.

Tricks and tips in pancreatoduodenectomy

Pancreaticoduodenectomy (PD) is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum and ampulla, and represents the only hope of cure in cases of malignancy. Since its initial description in 1935 by Whipple et al, this complex surgical technique has evolved and undergone several modifications. We review three key issues in PD: (1) the initial approach to the superior mesenteric artery, known as the artery-first approach; (2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis; and (3) the extent of lymphadenectomy.

Síndrome del ducto pancreático desconectado

Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotizing pancreatitis treated medically, by percutaneous drainage, or necrosectomy. There are no clear epidemiological data on the real incidence of DPDS; approximately 10 to 30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic and surgical management have been described. We have performed a sytematic review of the literature on DPDS.

Wrapping in pancreatic surgery: a systematic review

Wrapping in pancreatic surgery involves the use of the omentum or falciform ligament (FL) to wrap the local retroperitoneal vessels, the pancreatojejunal anastomosis or the pancreatic section of distal pancreatectomy. However, there is no clear evidence that wrapping in fact provides benefits. We have performed a systematic review of the literature about this topic.

Liver metastasis of endometrial stromal sarcoma

Resection of liver metastases from gynaecological tumours is uncommon. Endometrial stromal sarcomas (ESS) are low incidence gynecological tumours which can originate in previous sites of endometriosis or following metaplasia of the pelvic peritoneal wall, and which are exceptionally associated with liver metastasis. We present a 68-year-old woman with a ESS and metachronic liver metastasis treated by liver resection. There is very little literature on clinical management about liver metastasis from ESS, but extrapolating the data obtained with liver metastasis from sarcomas and uterine tumours, we should recommend resection as this is considered a resectable extrauterine metastasis. In cases with more sites of extrauterine disease, liver resection should also be performed if the other sites are resectable.

Frank Intrabiliary Rupture in Liver Hydatidosis Located in the Hilar Plate: A Surgical Challenge

Background: Frank intrabiliary rupture (FIR) is a severe complication that occurs in around 30% of patients with liver hydatidosis. When FIR is present, the contents of the cyst may pass into the common bile duct and cause a variety of complications. If the FIR is located in the hilar confluence, surgical repair is a challenge. Currently there are no data regarding its optimum treatment. Material and Methods: Between May 2007 and December 2012, we treated 59 patients with liver hydatidosis. Four patients, all women, with a mean age of 51.7 years, had hydatid cysts located between segments IVb and V and FIR affecting the hilar plate. In 3 cases, the initial clinical condition was obstructive jaundice. The fourth patient presented recurrence after having undergone two operations as a child. Results: In each patient a major hepatectomy was performed with hilar plate reconstruction (3 left and 1 right). Morbidity included mild biliary fistula (1 patient) and abdominal collection resolved by percutaneous drainage (1 patient). There was no mortality. During follow-up (47 months), no recurrences of the disease or biliary strictures were recorded. Conclusions: FIR is a severe complication of liver hydatidosis. When it is located in the hilar confluence, liver resection may be the best surgical option for definitive resolution of the problem.

Garengeot’s hernia: two case reports with CT diagnosis and literature review

Abstract Garengeot’s hernia (GH) is defined as the presence of the appendix inside a femoral hernia. It occurs in 0.9% of femoral hernias and is usually an incidental finding during surgery. Its treatment is controversial and the aim of this article is to review the diagnostic methods and surgical considerations. We report two cases diagnosed preoperatively by contrast-enhanced computed tomography (CT) and discuss the treatment options based on a review of the literature published in PubMed updated on 1 December, 2015. Fifty articles reporting 64 patients (50 women, mean age 70 years) with GH were included in the analysis. Diagnosis was performed by preoperative CT in only 24 cases, including our two. The treatment of GH is emergency surgery. Several options are available laparoscopic or open approach: insertion of a mesh or simple herniorrhaphy, with or without appendectomy. Conslusion The preoperative diagnosis with CT can guide the choice of treatment. Appendectomy and hernioplasty should be performed via inguinotomy, if there is no perforation or abscess formation.

Estudio multicéntrico sobre adenomas hepáticos

INTRODUCTION Hepatic adenomas (HA) are benign tumours which can present serious complications, and as such, in the past all were resected. It has now been shown that those smaller than 3 cm not expressing β-catenin only result in complications in exceptional cases and therefore the therapeutic strategy has been changed. MATERIAL AND METHOD Retrospective study in 14 HPB units. INCLUSION CRITERIA patients with resected and histologically confirmed HA. STUDY PERIOD 1995-2011. RESULTS 81 patients underwent surgery. Age: 39.5 years (range: 14-75). Sex: female (75%). Consumption of oestrogen in women: 33%. Size: 8.8 cm (range, 1-20 cm). Only 6 HA (7.4%) were smaller than 3 cm. The HA median was 1 (range: 1-12). Nine patients had adenomatosis (>10HA). A total of 51% of patients displayed symptoms, the most frequent (77%) being abdominal pain. Eight patients (10%) began with acute abdomen due to rupture and/or haemorrhage. A total of 67% of the preoperative diagnoses were correct. Surgery was scheduled for 90% of patients. The techniques employed were: major hepatectomy (22%), minor hepatectomy (77%) and one liver transplantation. A total of 20% were performed laparoscopically. The morbidity rate was 28%. There were no cases of mortality. Three patients had malignisation (3.7%). The follow-up period was 43 months (range 1-192). Two recurrences were detected and resected. DISCUSSION Patients with resected HA are normally women with large lesions and oestrogen consumption was lower than expected. Its correct preoperative diagnosis is acceptable (70%). The major hepatectomy rate is 25% and the laparoscopy rate is 20%. There was a low morbidity rate and no mortality.

«Ancient» schwannoma localizado en el músculo psoas

Schwannomas are benign peripheral nerve sheath tumours whose intramuscular localisation is exceptional. Approximately 15 cases of schwannomas in the psoas muscle have been published in the international literature. We present a new case and review the limited literature about this type of lesions and the ‘‘ancient schwannoma’’ variety that our patient presented. The patient is a 62-year-old woman with no medical history of interest except having undergone surgery on three different occasions for a right inguinal hernia. She currently reported having severe post-hernioplasty pain in the entire inguinal region that did not radiate to the right leg. Abdominal-pelvic MRI revealed a well-defined, oval, cystic mass located in the outer portion of the right psoas muscle that measured 2.6 cm 2.5 cm 3.5 cm. The mass was hypointense in T1 and hyperintense in T2, with a solid pole at the lower margin and internal septa that were enhanced with injected contrast material (Fig. 1). Lab work-up and tumour marker studies (CEA, CA19-9) were normal. We proceeded with surgical exeresis through an abdominal approach with the suspected diagnosis of a malignant nerve tumour (Fig. 2). We performed a Cattell manoeuvre to access the retroperitoneum and locate the ureter, right renal vein and kidney, and inferior vena cava. A 3 cm lesion was observed in the psoas at the cited location, which was resected with free margins (R0). The postoperative period transpired without incident. The histology study showed an encapsulated lesion with expansive edges comprised of cells with elongated nuclei, without atypia and with eosinophil cytoplasm presenting areas of Antoni A with Verocay bodies and other Antoni B areas. Occasionally, pleomorphic nuclei were seen with myxoid and cystic changes, as in evolved forms (‘‘ancient schwannomas’’). The immunohistochemistry study was positive for S-100, vimentin and neuron-specific enolase, and negative for smooth muscle actin (SMA) and CD117. The free surgical margins were comprised of muscle tissue. At later follow-up visits, (6 months) the patient presented no functional loss; the pain in the inguinal region continued, but the patient refused triple neurectomy. There have been no signs of recurrence. Schwannomas are tumours formed by the Schwann cells of peripheral nerve sheaths. They are usually benign, although on rare occasions they may undergo malignant transformation; nonetheless, there are no available data about their rate of malignisation or related clinical characteristics. Associations have been described with neurofibromatosis. Schwannomas are solid, encapsulated, slow-growing lesions most frequently located in the head, neck and trunk. Histologically, they present two alternating areas: one with dense cellularity, known as Antoni A; and, other areas of myxoid matrix, known as Antoni B. Immunohistochemically, schwannomas are positive for S-100, vimentin and neuron-specific enolase, and negative for SMA and CD117. There is a variety of schwannoma with solid-cystic characteristics and degenerative histological changes that is known in the English literature as ‘‘ancient schwannoma’’, which was first described by Ackerman and Taylor in 1951. The typical histological characteristics of this variety are attributed to the progressive growth and age of the lesion. The existence of nuclear atypia and hyperchromatosis in this variety can cause an erroneous diagnosis of malignancy. The prognosis and rate of malignant transformation are identical to those of typical schwannomas. The case that we present in this report would be of the ‘‘ancient’’ variety. Schwannomas are usually asymptomatic. When they cause symptoms, they are due to compression or infiltration of neighbouring organs, with no specificity. Diagnoses are habitually incidental, as in our case. We believe that the pain experienced by our patient was related to the hernioplasty and not with the mass in the psoas. Abdominal MRI and CT scan show no pathognomonic characteristics that would be able to confirm the diagnosis of schwannoma preoperatively. Therefore, the definitive diagnosis is obtained in many patients during the histology study after surgical resection. Imaging tests usually show c i r e s p . 2 0 1 6 ; 9 4 ( 2 ) : e 3 7 – e 3 9

Biological markers of severity in acute pancreatitis

AbstractNone of the definitions of severity used in acute pancreatitis (AP) is ideal. Many of the scoring systems used to predict and measure its severity are complex, cumbersome and inaccurate.Aimto evaluate the usefulness of the most commonly used early markers for predicting severity, necrosis and mortality in patients with AP, and the need for surgery or Intensive Care Unit (ICU) admission.Material&methodsProspective study was performed from March 2009 to August 2010 based on patients diagnosed with AP seen consecutively at a secondary hospital. The early prognostic markers used were Apache II score ≥8 and Ranson’s score ≥3, RCP>120mg/l and Ht>44% in the first 24 hours.Results131 patients were prospectively enrolled. Median age was 63 years, 60% were men. The most frequent etiology of AP was biliary (68%). Fifteen patients were admitted to the ICU (11.6%) and five (3.9%) required surgery. Twelve patients (9.2%) had necrosis on CT. Four patients (3%) died, all of them in the Severe AP group. Only hematocrit>44 was predictor of mortality in univariate analysis.Conclusionhematocrit ≥ 44% was a significant predictor of mortality. The other indicators present limitations for predicting severity, necrosis and mortality, especially in the first 24 hours.