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Antecedentes: Diseño de un modelo de simulación para formación en cirugía laparoscópica. Métodos: Dentro del Máster Anatomía Aplicada a la Clínica se implementaron tres etapas de formación progresiva en médicos residentes. La etapa 1 se realizó en simulador con material no biológico: manejo de objetos, disección con pinza y tijera, y sutura laparoscópica. La etapa 2 utilizó material biológico (tubo digestivo en fresco) en simulador, para la práctica de sección intestinal y anastomosis intracorpórea. En la etapa 3 se realizaron técnicas laparoscópicas en cadáver en fresco (apendicectomía, colecistectomía, apertura de la transcavidad epiploica, hemicolectomías derecha e izquierda). Se añadió una encuesta de satisfacción a los participantes de la actividad. Resultados: El programa se impartió a 6 residentes de Cirugía General. Todos completaron los ejercicios de las etapas 1 y 2. En la etapa 3 se pudo realizar el neumoperitoneo sin dificultad y los tejidos presentaron una textura adecuada. Los residentes de primer año completaron la apendicectomía y la colecistectomía, pero procedimientos más complejos requirieron residentes con más experiencia. Los participantes encuestados reflejaron que el programa es adecuado y útil para el entrenamiento en laparoscopia. Conclusiones: El modelo propuesto es reproducible y adecuado en adquisición de competencias básicas en cirugía laparoscópica. Background: Design of a simulation model training in laparoscopic surgery for surgical residents. Methods: Three stages of progressive training were programmed within a Postgraduate Degree in Clinical Anatomy. Stage 1 was performed in a box-trainer with synthetic materials: managing small objects, dissection with clamp and scissors, and laparoscopic intracorporeal suture. Stage 2 used biological material (fresh digestive tract from a human corpse) in box-trainer, practicing section and intracorporeal anastomosis. In stage 3, laparoscopy was performed on a fresh corpse (appendectomy, cholecystectomy, lesser sac opening, right and left colectomy). A satisfaction survey was carried out to the participants. Results: Some six General and Digestive Surgery residents took the program. All of them completed the stage 1 and 2 exercises. In stage 3, the pneumoperitoneum could be performed without any complications, and tissues presented an adequate texture. First-year residents completed appendectomy and cholecystectomy, but more complex procedures required more experienced residents. The participants reflected that the program is adequate and useful to gain basic skills in laparoscopy. Conclusions: The proposed model is reproducible and adequate in acquisition of basic skills in laparoscopic surgery.

Aim To determine predictive factors of axillary lymph node dissection (ALND) results in breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), and subsequent staging using Targeted Axillary Dissection (TAD). Material and method Case-control study between January 2016 and August 2019. Patients with BC, cN1 staging, marked with a metallic clip prior to NACT, and subsequently staged with TAD and ALND were included. They were divided into 2 groups: ALND patients with or without metastatic involvement (group 1 and group 2, respectively). We carried out a univariate analysis comparing clinical, radiological, surgical and pathological variables, and a logistic regression, (dependent variable: positive result of ALND; independent variables: number of suspicious lymph nodes in diagnostic ultrasound, positive hormone receptors, HER2 positive, complete clinical-radiological response to NACT, positive TAD, and biopsy of ≤2 nodes in TAD). A score for prediction of a metastatic ALND was proposed, with an internal validation study. Results 60 patients were included: Group 1: 33 (55.0%); Group 2: 27 (45.0%). Tumor size (Odds Ratio (OR) = 1.67; 95%CI 1.02–2.74), number of suspected nodes in ultrasound (OR = 2.20; 95%CI 1.01–4, 77), HER2 positive (OR 0.04; 95%CI 0.003–0.54), clinical-radiological response to NACT (OR = 0.07; 95%CI 0.01–0.75), and positive TAD (OR 15.48; 95%CI 1.68–142.78) were independent predictors of a positive result in ALND. We developed a “positive ALND predictive score”, with good calibration (Hosmer-Lemeshow test: p = 0.65), and discrimination (AUC = 0.93; 95% CI 0, 87–0.99), with highest Youden index (0.7) at cut-off point of 17% risk of positive ALND (sensitivity = 100%; specificity = 70%). Conclusion Tumor size, number of suspected nodes, positive HER2, response to NACT, and metastatic TAD are independent predictors of ALND. The predictive score for positive ALND would be a good indicator to safely omit ALND.

Procalcitonin (PCT) and C-Reactive Protein (CRP) are acute-phase reactants that indicate the presence and severity of an infection. The aim of this study was to verify the utility of CRP and PCT as tools for early diagnosis of anastomotic leakage (AL) in patients undergoing elective colorectal surgery. A prospective observational study including 95 patients undergoing elective colorectal surgery with anastomosis, where patients were divided into two groups according to whether or not AL happened. Different variables were compared using a uni- and multivariate analyses to identify the risk factors for AL. Receiver Operating Characteristic (ROC) curves were added to establish a cut-off point for CRP and PCT. The inflammatory marker levels were analysed in other complications different from AL. AL was detected in 11 patients (14%), 7 required an emergency reoperation. The overall morbidity rate was 42.1% and the mortality was 3.2%. In the univariate study, increased CRP on days 3 and 5, male sex and intraoperative complications were significantly associated with AL. In the multivariate study, CRP on day 5 was the only factor related to AL. AUC at ROC curves showed that CRP results ≥ 15.3 mg/dL on day 3 and 9.1 mg/dL on day 5 were predictors of AL. Normal CRP and PCT values had a high negative predictive value. CRP on postoperative day 5 is a reliable marker for early detection of anastomotic leakage in colorectal surgery. Both CRP and PCT on days 3 and 5 have a high negative predictive value. Trial registration: The study has been registered at ClinicalTrials.gov. Code: NCT04632446.

The possibility of avoiding axillary lymphadenectomy (AL) in patients with breast cancer (BC) after positive sentinel lymph node biopsy (SLNB) and low metastatic burden (ó = 2 positive lymph nodes) has put into question the role of axillary ultrasound due to the risk of overtreatment after positive axillary lymph node biopsy with low metastatic burden. Our aim was to identify clinical and ultrasound features to detect low and high metastatic burden.A retrospective study of 405 BC patients with primary surgical treatment with axillary ultrasound examination and subsequent AL after positive fine needle aspiration (FNA) or SLNB. The low and high tumor burdens after AL were correlated with clinical and ultrasound variables: lymph node morphology (UN1 to UN5), number of suspicious lymph nodes, and Berg level.Positive FNA, lymph node morphology UN4 (focal thickening with displacement of the fatty hilum) or UN5 (complete replacement of the fatty hilum) and2 suspicious lymph nodes were significantly associated with "high metastatic burden". Lymph node morphology UN2 and UN3, even after FNA+, lymph node morphology UN4 after FNA-, and suspicious lymph nodes at Berg level I were low metastatic burden criteria. Lymph node morphology UN5, lymph node morphology UN4 after FNA+, two nodes or more with UN4/UN5 morphology, and suspicious lymph nodes at Berg levels II and III with FNA+ were associated with high metastatic burden.Axillary lymph node ultrasound data for patients with early BC allows predicting the axillary metastatic burden, guiding the optimal clinical management of the axilla.

Background There could be important failures in clinical data and plan records that potentially influence the surgical care process. Objective To complete a quality of care improvement cycle on the surgical care process in the General Surgery ward rounds. Structured quality criteria were measured, in order to identify major deficiencies, to implement improvement measures and to reassess the quality of surgical care process. Furthermore, we'll value the viability the implementation of a structured registration system and nutritional assessment method. Method Comparative quality study (n = 60) before-after the setting of several improvement measures derived from the analysis of the surgical care process. Evaluated criteria were the information received by the patient, adequate recording of the clinical course and plan of care established by the surgeon in the Electronic Health Record, recording of patient's weight and size and nutritional assessment. Informative sessions, subjective, objective, assessment, plan notes on the electronic clinical record and a nutritional assessment test were implemented. Results There was a significant improvement in all measured criteria (information, data records and nutritional assessment). Conclusion Simple organizational measures allow a significant improvement in the information process, clinical records and malnutrition risk detection in a surgical ward.

To analyse factors that may predict the appearance of rib fracture complications during the first days of evolution and determine whether the number of fractures is related to these complications. Retrospective case–control study of patients admitted with a diagnosis of rib fractures between 2010 and 2014. Two groups were established depending on the appearance or not of pleuropulmonary complications in the first 72 h, and the following were compared: age, sex, Charlson comorbidity index (CCI), number and uni- or bilateral involvement, mechanism of trauma, days of hospital stay, haemoglobin on discharge minus haemoglobin on admission, pleuropulmonary complications during admission (pneumothorax, haemothorax or pulmonary contusion) and placement of pleural drainage. One hundred and forty-one cases of rib fractures were admitted in the period mentioned. There were no differences in the patients’ baseline characteristics (age, sex and Charlson Comorbidity Index) between the two groups. Differences were found in the number of fractures (2.98 ± 1.19 in the group without complications vs 3.55 ± 1.33 in the group with complications, p = 0.05) and in the drop in the level of haemoglobin (0.52 ± 0.91 mg/dl vs 1.22 ± 1.29 mg/dl, p = 0.01). The length of hospital stay varied considerably in each group (5.35 ± 4.05 days vs 7.86 ± 6.96 days), but without statistical significance (p = 0.11). The number of fractured ribs that best predicted the appearance of complications (delayed pleuropulmonary complications and greater bleeding) was 3 or more.

In previous studies, there seems to be a relationship between different genetic polymorphisms and postoperative nausea and vomiting (PONV). We perform a systematic review of the current literature about the relationship between genetic polymorphisms and the presence of PONV. Two bibliographic searches were carried out in three databases (PubMed, Web of Science, and Scopus) of studies, preferably prospective, about PONV following abdominal surgery. It was completed with a backward citation searching. A total of 73 articles were found of which 6 were selected after their critical lecture using CASPe network criteria. Relative frequency and relative risk were taken in each study according to the polymorphism. Studies about 5-HT3B gene receptor polymorphisms, ABCB1 transporter, and dopamine D2 receptor showed a significant association with the presence of PONV (p = 0.02, 0.01, and 0.034 respectively). In relation to cytochrome P-450 2D6 (CYP2D6) polymorphisms, two of the three analysed articles showed a significant association with postoperative vomiting (p = 0.007). Genetic polymorphisms could play an important role in PONV. The AAG deletion in both alleles of the 5-HT3B receptor gene, the Taq IA polymorphism of the dopamine D2 receptor, and the presence of three or more functional alleles of CYP2D6 seem to be related with a higher incidence of PONV, especially in the first 24 h after surgery. The 2677TT and 3435TT genotypes of the ABCB1 transporter could reduce the PONV due to their association with a greater effectiveness of ondansetron. However, new quality studies are needed to consider this relationship.

Aim to study the feasibility and value of “Targeted Axillary Dissection” (TAD) in cN1 breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), in order to avoid unnecessary axillary lymph node dissection (ALND). Materials and methods Design: Prospective observational study. Inclusion criteria: Patients with histologically confirmed cN1 staging BC and treated with NACT between January 2016 and August 2019 who accomplished clinical response. Method: Fine-Needle Aspiration (FNA) positive axillary nodes were marked with a metallic clip prior to neoadjuvant treatment. All patients were summited to TAD and ALND. Analysis of data: We performed [1]: a feasibility analysis of clinical, radiological and pathological variables, as well as difficulties and complications of the TAD [2]; a diagnostic test study of the sentinel lymph node biopsy (SLNB), clipped lymph node biopsy (BCLIP) and their combination (TAD), using ALND as the Gold Standard. Results 60 patients were included. 43 patients (71.7%) had a complete clinical lymph node response to NACT. Neither limitations nor complications in clip placement were found. Intraoperative location of the clipped node was problematic in 7 cases (11.7%). The pathological complete response rate (pCR) was 30.5% (18 patients) and ypN0 staging rate was 38.3% (23 patients). Sensitivity values of each technique were: SLNB: 80.9% (95%CI: 61.8–100); BCLIP: 80.8% (95%CI: 63.7–97.8); TAD: 92.6% (95%CI: 80.9–100) with negative predictive values of: SLNB: 84.6% (95%CI: 68.8–100); BCLIP: 81.0% (95%CI: 63.7–97.8); TAD: 91.3% (95%CI: 77.6–100). Conclusion TAD is feasible and valid to rule out axillary metastatic involvement in cN1 breast cancer patients who respond to NACT.

Background There is no unified system for reporting surgical complications after bariatric surgery. One increasingly used system for notifying postoperative complications is the Clavien-Dindo classification, which focuses on their therapeutic implications. Objective The aim of this study is to validate and apply the Clavien-Dindo scale to a series of cases of bariatric surgery and systematically review its use worldwide. Setting University hospital. Methods A cohort of 321 patients with morbid obesity (Mean BMI: 45.4±5.5 kg/m2) underwent surgery by the same team of surgeons, fundamentally using a laparoscopic gastric bypass. Initially, the Clavien-Dindo scale was translated and validated for its acceptability and reproducibility using the Kappa index. The scale was then applied to the whole of the bariatric series. A systematic review was also conducted in the literature regarding the use of the Clavien-Dindo classification after bariatric surgery. Lastly, a comparison was made with our results. Results The classification was validated without any difficulty. Most of the postoperative complications are grades I (8.4%) and III (7.8%). We found it used in 15 series (including our own), which accounts for 10,347 patients. The overall results are analogous to our series. Conclusions The Clavien-Dindo scale has been validated and translated into Spanish. Application is quick and simple and enables comparisons to be made between centers and series. Our results are similar to those reported by other authors.

Resumen Introduccion Describir las principales caracteristicas clinicas, anatomopatologicas, terapeuticas y evolutivas de una serie amplia de tumores estromales gastrointestinales (GIST). Metodos Estudio observacional de una serie de 66 casos de GIST tratados en nuestro hospital de 2002 a 2015. Seleccionamos variables relacionadas con los antecedentes personales, las manifestaciones clinicas, el tratamiento medico y quirurgico, la anatomia patologica y la morbimortalidad. Anadimos una revision de la literatura para correlacionarla con nuestros resultados. Resultados La localizacion mas frecuente fue el estomago (65,2%), en el que destaco como region predominante el fondo. La manifestacion clinica mas habitual fue la hemorragia digestiva (45,5%), seguida del hallazgo casual tras la realizacion de alguna prueba de imagen o procedimiento invasivo (33,3%). Recibieron cirugia 58 pacientes (90,6%), el 15,5% de caracter urgente. El 69% de los GIST tenian un tamano entre 2 y 10 cm. La mortalidad al ano debida al tumor fue de un 7,9% (5 casos), todos ellos relacionados con extension local o a distancia, o complicacion quirurgica. Conclusiones La variabilidad clinica de los GIST es muy amplia. El tratamiento de primera eleccion es la cirugia, que es factible en la mayoria de los casos y debe ser lo mas conservadora posible. El pronostico es variable, dependiendo del tamano y del indice de proliferacion, por lo que debe realizarse un seguimiento estrecho. No existe un marcador tumoral claramente asociado a un peor pronostico, por lo que se necesitan nuevos estudios de biologia molecular con el objetivo de encontrar dianas terapeuticas.

Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence.

We present the case of a patient with an inflammatory bowel disease to whom a pelvic desmoid tumor is discovered during an infertility study.

Resumen El ileo paralitico es una de las principales complicaciones del postoperatorio. Con la introduccion de los protocolos fast-track para acelerar la recuperacion, han aparecido nuevas medidas, como la toma temprana de cafe, mascar chicle y el gastrografin. Para conocer mejor estas actuaciones, se ha realizado un resumen de la evidencia actual, utilizando las bases de datos de MEDLINE, Cochrane Database of Systematic Reviews, Web of Science y SCOPUS. Los terminos empleados fueron «postoperative ileus» AND («definition» OR «epidemiology» OR «risk factors» OR «management»). Se han seleccionado 44 articulos, de los cuales 9 son revisiones sistematicas, 11 revisiones narrativas, 13 ensayos clinicos aleatorizados, 6 estudios observacionales y los 5 restantes cartas cientificas, hipotesis, etc. Se ha visto que existe poca literatura acerca del tema, que los estudios son heterogeneos (con disparidad en los resultados) y se centran en cirugia colorrectal y ginecologica. Se necesitan nuevos estudios, preferentemente ensayos clinicos aleatorizados, que esclarezcan la utilidad de estas medidas.

Postoperative ileus is one of the main complications in the postoperative period. New measures appeared with the introduction of «fast-track surgery» to accelerate recovery: coffee, chewing gum and gastrograffin. We performed a summary of current evidence, reviewing articles from MEDLINE, Cochrane Database of Systematic Reviews, ISI Web of Science, and SCOPUS databases. Employed search terms were «postoperative ileus» AND («definition» OR «epidemiology» OR «risk factors» OR «Management»). We selected 44 articles: 9 systematic reviews 11 narrative reviews, 13 randomized clinical trials, 6 observational studies, and the remaining 5 scientific letters, assumptions, etc. There is little literature about this topic, studies are heterogeneous, with disparity in the results. In addition, they only focus on colorectal and gynecological surgery. New high-quality studies are needed, preferably randomized clinical trials, in order to clarify the usefulness of these measures.

Background and objective Thyroid cancer may be clinically evident as a tumor mass in the neck or as a histopathological incidental finding after thyroid surgery for an apparent benign condition. Our objective was to assess the differences in clinical signs, surgical management, and course between incidental and clinically diagnosed thyroid tumors. Methods A retrospective study was conducted on patients operated on for benign or malignant thyroid disease from January 2000 to March 2014. Among the 1415 patients who underwent any thyroid surgery, 264 neoplasms were found, of which 170 were incidental. A comparison was made of incidental versus non-incidental carcinomas. Among incidental carcinomas, cases whose indication for surgery was Graves’ disease were compared to those with multinodular goiter. Results Incidental carcinomas were in earlier stages and required less aggressive surgery. There were no differences in surgical complications between incidental and clinical tumors, but mortality and relapses were markedly higher in non-incidental cancers (4.4% vs 0% and 13.2% vs 4.8% respectively). Carcinomas developing on Graves’ disease showed no differences from all other incidental tumors in terms of complications, mortality, or relapse after surgery. Conclusions Early stage thyroid cancer has better survival and prognosis after surgical treatment.

Population-based screening programmes for colorectal cancer (CRC) allow an early diagnosis, even before the onset of symptoms, but there are few studies and none in Spain on the influence they have on patient survival. The aim of the present study is to show that patients receiving surgery for CRC following diagnosis via a screening programme have a higher survival and disease-free survival rate than those diagnosed in the symptomatic stage.Prospective study of all the patients undergoing programmed surgery for CRC at the JM Morales Meseguer Hospital in Murcia (Spain) between 2004 and 2010. The patients were divided into two groups: (a) those diagnosed through screening (125 cases); and (b) those diagnosed in the symptomatic stage (565 cases). Survival and disease-free survival were analysed and compared for both groups using the Mantel method.The screen-detected CRC patients show a higher rate of survival (86.3% versus 72.1% at 5 years, p0.05) and a lower rate of tumour recurrence (73.4% versus 88.3% at 5 years, p0.05).Population-based screening for CRC is an effective strategic measure for reducing mortality specific to this neoplasia.

ResumenAntecedentesLa úlcera de Marjolin se define como la aparición de una neoplasia en el seno de una herida crónica. La histología más frecuente es epidermoide. Presentamos 2 casos tratados en nuestro hospital.Caso clínicosCaso 1. Varón de 71 años que consultó por supuración y enrojecimiento de las heridas que presentaba en el pie derecho, tras una descarga eléctrica 40 años antes. En la radiología se apreciaba afectación del 4° y 5° metatarsianos y del tarso. Se realizó amputación supracondílea, con resultado de carcinoma epidermoide bien diferenciado infiltrante. Caso 2. Varón de 56 años, parapléjico desde hacía 20 años. Es tratado por úlcera en talón derecho sobreinfectada, con mejoría parcial pero con persistencia de la lesión ulcerosa. Se realizó biopsia, de la que se informó como carcinoma epidermoide. Se realizó amputación infracondílea. El diagnóstico fue de carcinoma escamoso bien diferenciado que infiltraba la dermis.ConclusionesLa prevalencia de la úlcera de Marjolin es de 1.3-2.2% de todas las úlceras. El diagnóstico es difícil, por lo que se recomienda biopsia de toda lesión sospechosa o de cualquier úlcera, que después de 1 mes de tratamiento conservador (aunque este límite es impreciso) no presenta mejoría. El tratamiento es quirúrgico; la escisión local con margen de un centímetro es suficiente; si la lesión es extensa es necesaria la amputación.La supervivencia se estima entre el 66-80% a los 2 años, con tasas de recurrencia del 23%. Los factores desfavorables son la pobre diferenciación y las metástasis, que aparecen en el 20% de los casos.AbstractBackgroundMarjolin's ulcer is defined as the appearance of a neoplasm within a chronic wound. The most common histological type is squamous. A total of 2 cases treated in our hospital are presented.Clinical caseCase 1. A 71 year old man who presented with redness and suppuration from the wounds he had in his right foot after an electric shock 40 years earlier. The radiology showed involvement of the 4° and 5° metatarsal. Supracondylar amputation was performed, showing a well-differentiated invasive squamous cell carcinoma. Case 2. A 56 year old male, paraplegic for 20 years. He was treated due to an infected right heel ulcer, with partial improvement, but the ulcers persisted. Biopsy was performed, reporting as epidermoid carcinoma. Infracondylar amputation was performed. The diagnosis was a well-differentiated squamous cell carcinoma infiltrating the dermis.ConclusionThe prevalence of Marjolin's ulcer is 1.3-2.2% of all ulcers. Diagnosis is difficult, so biopsy is recommended on any suspicious lesion or ulcer that has received conservative treatment for one month without improvement, although this time limit is not clear. The treatment is the surgery. Local excision with a margin of an inch is enough. If the ulcer is extensive, amputation is required. Survival is estimated between 66 and 80% at 2 years, with recurrence rates of 23%. Unfavourable factors are poor tumour differentiation and metástasis, appearing in 20% of cases.

Background Marjolin's ulcer is defined as the appearance of a neoplasm within a chronic wound. The most common histological type is squamous. A total of 2 cases treated in our hospital are presented. Clinical cases Case 1 . A 71 year old man who presented with redness and suppuration from the wounds he had in his right foot after an electric shock 40 years earlier. The radiology showed involvement of the 4° and 5° metatarsal. Supracondylar amputation was performed, showing a well-differentiated invasive squamous cell carcinoma. Case 2. A 56 year old male, paraplegic for 20 years. He was treated due to an infected right heel ulcer, with partial improvement, but the ulcers persisted. Biopsy was performed, reporting as epidermoid carcinoma. Infracondylar amputation was performed. The diagnosis was a well-differentiated squamous cell carcinoma infiltrating the dermis. Conclusion The prevalence of Marjolin's ulcer is 1.3–2.2% of all ulcers. Diagnosis is difficult, so biopsy is recommended on any suspicious lesion or ulcer that has received conservative treatment for one month without improvement, although this time limit is not clear. The treatment is the surgery. Local excision with a margin of an inch is enough. If the ulcer is extensive, amputation is required. Survival is estimated between 66 and 80% at 2 years, with recurrence rates of 23%. Unfavourable factors are poor tumour differentiation and metastasis, appearing in 20% of cases.

Aim. To study the feasibility and validity of ultrasound-guided pre-chemotherapy marking of metastatic axillary lymph nodes followed by targeted axillary dissection (TAD), in breast cancer patients undergoing neoadjuvant chemotherapy (NACT). Material and method Prospective diagnostic test study conducted between January 2016 and March 2018. Patients with breast cancer and indication for NACT, cN1 or cN2 axillary staging, were included. A clip was placed in the affected lymph node prior to NACT. A sentinel lymph-node biopsy (SLNB) and a clipped lymph-node biopsy (BCLIP) were conducted, followed by axillary lymph node dissection (ALND). Location rate (LR) and negative predictive value (NPV) were evaluated, taking SLNB, BCLIP and their combination (TAD) as evaluated tests and metastatic involvement in the ALND specimen as the gold standard. Results Twenty-three patients were included in the study. Sentinel lymph node could only be detected in 19 cases (LR = 80.61%), whereas BCLIP was successful in 22 (LR = 95.65%). The sentinel lymph node coincided with the marked lymph node in 14 patients (60.9%). We found a NPV for the SLNB of 0.85 (95%CI: 0.61–1.0), whereas for TAD it was 1.00 (95%CI: 0.74–1.0). Conclusion TAD is a feasible test for axillary restaging after NACT, with a higher success rate than SLNB.

espanolIntroduccion: la endometriosis es una patologia relativamente frecuente en mujeres en edad fertil y poco prevalerte en mujeres prepuberes o postmenopausicas. Caso clinico: presentamos el caso clinico de una mujer de 57 anos, con antecedentes de histerectomia y doble anexectomia por endometriosis ovarica, diagnosticada de neoplasia de recto T3N1. Se realizo neoadyuvancia preoperatoria y reseccion anterior baja, sin complicaciones. La anatomia patologica describia infiltracion de la pared rectal por adenocarcinoma pobremente diferenciado de origen ginecologico. Discusion: la endometriosis tiene una prevalencia estimada del 10-20% y su lugar de aparicion puede ser variado, tanto gonadal como extragonadal. La frecuencia de endometriosis extragonadal de localizacion intestinal se estima en un 3-37% de mujeres con endometriosis pelvica, y de estas la mayoria se localizan en colon sigmoide y recto. La transformacion maligna de un foco de endometriosis se estima entre el 0,3 y el 1%. El gold estandar para el diagnostico es la reseccion y estudio histologico. La radioterapia y quimioterapia adyuvante todavia no ha demostrado su clara utilidad. EnglishBackground: Endometriosis is a relatively common disease among women with child-bearing potential, and rare before puberty or following menopause. It consists of the presence of hormoneresponsive endometrium outside the endometrial cavity. Case report: We report the case of a patient with a rectal lesion, initially approached as a primary rectal malignancy, where histopathology eventually revealed an adenocarcinoma arising from endometrial tissue in the colonic wall. Discussion: Endometriosis has an estimated rated of 10-20%. Sites may be split up into two larger categories - gonadal and extragonadal. The frequency of extragonadal endometriosis in the bowel is estimated to involve 3%-37% of women with pelvic endometriosis, and most lesions are found in the sigmoid colon and rectum. The malignant transformation of endometriotic lesions is estimated between 0.3% and 1% of cases. The gold standard in the diagnosis of intestinal endometriosis is exploratory laparotomy and the pathological study of specimens. Adjuvant radiotherapy and chemotherapy, although used for some patients, have not proven effective

Resumen Objetivos La hemorragia digestiva alta (HDA) es una potencial complicacion tras la cirugia bariatrica, con una incidencia entre el 2 y el 4%. El objetivo de este estudio es presentar nuestra incidencia de HDA tras cirugia bariatrica, su forma de presentacion y su manejo mediante un algoritmo terapeutico. Pacientes y metodo Estudio observacional prospectivo de una serie de 300 cirugias bariatricas por laparoscopia de manera consecutiva, desde enero del 2004 hasta diciembre del 2012. Se recogen datos demograficos, forma de presentacion, diagnostico y tratamiento de la HDA. En 280 pacientes se practico bypass gastrico segun la tecnica de Wittgrove modificada, con anastomosis circular en 265 y anastomosis longitudinal en 15. En 20 pacientes se practico gastrectomia vertical. Resultados Aparecieron 27 casos (9%) de HDA tratados con: cirugia en un caso por inestabilidad hemodinamica; con gastroscopia diagnostica-terapeutica en 13 casos (en 2 casos, 2 veces); en 10 de ellos, aparecio de forma precoz (1-6 dias) cuyo origen fue la linea de sutura de la anastomosis gastroyeyunal (GY) y en 3 de forma tardia, a los 15-20 dias, siendo su origen una ulcera en la boca anastomotica. En el resto (13 pacientes), el manejo fue de forma conservadora. Conclusiones Aunque el manejo conservador de la HDA resuelve la mayoria de los casos, la clinica y la forma de presentacion deben alertarnos, por lo que, en casos graves de sangrado, se requerira de una endoscopia urgente. Es importante un equipo multidisciplinar y una comunicacion estrecha entre cirujanos y endoscopistas para el manejo de esta seria complicacion.

Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm.From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy.Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively.Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.

Diagnosis of colorectal cancer (CRC) based on clinical symptoms is usually established in its advanced stages. One strategy for reducing mortality is the early detection and removal of preneoplastic and initial neoplastic lesions, even before the first symptoms appear, by means of population-based screening campaigns. The aim of the present study is to determine whether CRC diagnosed via a screening campaign has more favourable histopathological prognostic factors than when diagnosed in the symptomatic phase.The prospective study of all the patients undergoing programmed CRC surgery at the JM Morales Meseguer Hospital (Spain) is between 2004 and 2010. The patients were divided into two groups: one diagnosed from clinical symptoms and one through a screening campaign. The following factors were compared: tumour size; degree of tumour invasion of the wall; lymph node, perineural and lymphovascular involvement; tumour stage; and grade of differentiation.Compared to the symptomatic group, the screen-detected patients had smaller-sized tumours (lesions of less than 5 cm in 84 vs 69.55%, p0.001), a lower degree of colorectal wall invasion (T0-1 in 36 vs 9.02%, p0.001), less lymph node involvement (N0 in 72 vs 58.76%, p0.05), less vascular invasion (7.20 vs 15.22%, p = 0.79) and less perineural invasion (6.4 vs 20.70%, p0.001). The TNM staging in the screening group was lower than in the symptomatic group (stage 0-1 in 50.40 vs 18.58%, p0.001).CRC diagnosed through a population-based screening programme presents more favourable histopathological characteristics than that diagnosed from the appearance of symptoms.

Resumen Introduccion La estenosis de la anastomosis gastroyeyunal (GY) representa la complicacion mas frecuente en la cirugia de derivacion gastrica por laparoscopia, llegando en algunas series a alcanzar el 15%. Presentamos nuestra incidencia de estenosis de la anastomosis GY en el bypass gastrico laparoscopico, su forma de presentacion y su manejo a largo plazo. Material y metodo Desde enero del 2004 hasta diciembre del 2012 se han realizado 280 bypass gastricos por la laparoscopia, segun la tecnica de Wittgrove modificada. La anastomosis GY circular se practico con material de autosutura tipo CEAA n.° 21 en 265 casos, en los restantes se realizo con una anastomosis longitudinal con grapadora lineal de 45 mm. A todos los pacientes con intolerancia persistente a la alimentacion se les realizo transito baritado o gastroscopia. Cuando se evidencio estenosis GY (diametro Resultados En 20 casos (7,1%) se desarrollo una estenosis GY, en 4 de ellos el diagnostico inicial fue con transito baritado. Todos los casos fueron confirmados por gastroscopia. De ellos, 5 pacientes tenian antecedentes de hemorragia digestiva alta que precisaron esclerosis endoscopica de la linea de sutura de la anastomosis GY. Todos los casos se han resuelto mediante dilatacion endoscopica, precisando en un caso 2 sesiones de dilatacion, en otro caso 3 sesiones y el resto, una. No se han detectado reestenosis. Uno de los pacientes sufrio una perforacion de ulcera postanastomotica. Conclusiones La estenosis de la anastomosis GY es una complicacion frecuente tras el bypass gastrico en Y de Roux. Favorecida por anastomosis de pequeno calibre. La endoscopia es la piedra angular para el diagnostico y tratamiento, pues resuelve la mayoria de casos, siendo rara la revision quirurgica.

Objective Gastrojejunal stricture (GYS), is not only a common complication after laparoscopic gastric bypass, but its frequency is also about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass. Patients and method From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis, which was performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance barium transit and/or gastroscopy were performed. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation. Results Twenty cases (7.1%) developed a gastrojejunal stricture; in 4 of these cases the initial diagnosis was made by barium transit and all cases were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up re-stricture has not been detected. Conclusion Stricture at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.

Background Body contouring surgery is in high demand following the increase in bariatric surgery. But these types of procedures are associated with high complication rates that cause long hospital stays and have a negative effect on patient satisfaction. The purpose of this study is to identify predictors of complications in order to optimize outcomes in these patients and find a relationship between complication rate and satisfaction. Materials and methods Out of a group of 175 post-bariatric patients, 72 patients underwent body contouring surgery following massive weight loss from 2003 to 2008. They were reviewed retrospectively for demographic data, pre- and postoperative weight status, co-morbidities and complications and reoperation rate. Patient satisfaction was evaluated. Results (a) Complications: The overall complication rate was 45.8%. The most frequent were seromas (23.6%); infection (13.9%), bleeding (11.1%), hematoma (6.9%) (needing transfusions [6.9%]), skin necrosis (6.9%) and umbilical necrosis (4.2%). A total of 8 patients required reoperation (11.1%). (b) Satisfaction rating: (1) very satisfied: 51.4%, (2) satisfied: 31.9%, (3) dissatisfied: 8.3%, (4) very dissatisfied: 8.3%. (c) The presence of complications was significantly associated with patients’ satisfaction, reoperation rate and longer hospital stays ( P 001). Conclusions Post operative complications were frequent. No predictors could be found to prevent these complications and optimize patient selection and appropriate timing of surgery. Patients with complications had a significantly higher reoperation rate, longer hospital stay and more dissatisfaction. The patients’ satisfaction was negatively influenced by complication occurrence and not by the esthetic results.

Resumen Introduccion Las abdominoplastias se han convertido en un proceso quirurgico frecuente en pacientes con perdida masiva de peso tras cirugia bariatrica. Este tipo de procedimientos no estan exentos de complicaciones que afectan a la calidad de vida y satisfaccion del paciente. El objetivo de este estudio es encontrar los factores de riesgo para desarrollar dichas complicaciones y evaluar la satisfaccion de nuestros pacientes. Material y metodos A un total de 72 pacientes, de los 175 intervenidos de cirugia bariatrica, se les realizo una abdominoplastia entre 2003 y 2008. Fueron revisados, retrospectivamente: datos demograficos, estado pre- y poscirugia, comorbilidades, tasa de complicaciones y reintervencion. El nivel de satisfaccion fue medido mediante una encuesta expresada en una escala tipo Likert. Se realizo un analisis comparativo de las distintas variables entre pacientes con y sin complicaciones. Resultados a) Complicaciones: tasa global del 45,5%. La mas frecuente fue el seroma (23,6%); infeccion (13,9%), sangrado (11,1%), hematoma (6,9%) (requiriendo transfusion [6,9%]), necrosis de piel (6,9%) y necrosis umbilical (4,2%). Se reintervino a 8 pacientes (11,1%). b) Satisfaccion: 1) muy satisfecho: 51,4%; 2) satisfecho: 31,9%; 3) insatisfecho: 8,3%; 4) muy insatisfecho: 8,3%. c) Se encuentra una relacion estadisticamente significativa entre complicaciones, reintervencion, estancia media y satisfaccion (p Conclusion Las complicaciones son relativamente frecuentes en este tipo de pacientes, alargando la estancia media y posteriores controles ambulatorios. No hemos identificado factores de riesgo que ayuden a prevenir este tipo de complicaciones. El grado de insatisfaccion esta en relacion con las complicaciones postoperatorias del procedimiento quirurgico y no con el resultado estetico.

Resumen La adquisicion y jerarquizacion de la evidencia, asi como la posterior formulacion de recomendaciones, constituyen la base del desarrollo de las guias de practica clinica. Sistemas de graduacion de la calidad de la evidencia y de la fuerza de las recomendaciones han existido muchos y actualmente se va imponiendo el modelo Grading of Recommendations, Assessment, Development and Evaluation (GRADE). En el sistema GRADE la calidad de la evidencia se clasifica, inicialmente, en alta o baja, segun provenga de estudios experimentales u observacionales; posteriormente, segun una serie de consideraciones, la evidencia queda en alta, moderada, baja y muy baja. La fuerza de las recomendaciones se apoya no solo en la calidad de la evidencia, sino en una serie de factores como son el balance entre riesgos y beneficios, los valores y preferencias de pacientes y profesionales, y el consumo de recursos o costes.

The acquisition and classification of scientific evidence, and subsequent formulation of recommendations constitute the basis for the development of clinical practice guidelines. There are several systems for the classification of evidence and strength of recommendations; the most commonly used nowadays is the Grading of Recommendations, Assessment, Development and Evaluation system (GRADE). The GRADE system initially classifies the evidence into high or low, coming from experimental or observational studies; subsequently and following a series of considerations, the evidence is classified into high, moderate, low or very low. The strength of recommendations is based not only on the quality of the evidence, but also on a series of factors such as the risk/benefit balance, values and preferences of the patients and professionals, and the use of resources or costs.

Chyle leak following axillary lymph node clearance is a rare yet important complication. The treatment of postoperative chyle fistula still remains unclear. Conservative management is the first line of treatment. It includes axillary drains on continuous suction, pressure dressings, bed rest, and nutritional modifications. The use of somatostatin analogue is well documented as a treatment for chylous fistulas after neck surgery. We present a case of chylous fistula after axillary surgery resolved with the use of octreotide.

Introduction This study was aimed to assess the main clinical, pathological and therapeutic characteristics of a cohort of gastrointestinal stromal tumors (GIST). Methods Observational study including 66 patients diagnosed with GIST admitted to our hospital between 2002 and 2015. Parameters related to medical history, clinical manifestations, medical and surgical treatment, histopathology, and morbi-mortality were studied. A review of the literature was included to correlate with the results. Results The most frequent location of GIST in our patients was the stomach (65.2%), in which the gastric fondo was the predominant region. The most common clinical manifestation was gastrointestinal hemorrhage (45.5%), followed by incidental finding after imaging or invasive procedures (33.3%). 58 patients underwent surgery (90.6%), 15.5% were urgent. A total of 69% of the GISTs had a size between 2 and 10 cm. The one-year mortality was 7.9%, all cases related to local or remote extension, or surgical complications. Conclusion There is a large clinical variability among GIST cases. The first choice of treatment is surgery, which is feasible in most cases and should be as conservative as possible. The prognosis varies depending on the size and proliferation index, thus close follow-up should be performed. No tumor marker is clearly associated with a poor prognosis. New molecular biology studies are needed in order to find therapeutic targets.

The obesity surgery mortality risk score (OS-MRS) was developed to determine the risk of postoperative mortality in patients undergoing bariatric surgery. The aim of the present study is to assess the utility of this score for preventing the risk of postoperative complications from bariatric surgery. Prospective study of 321 patients undergoing bariatric surgery to whom the OS-MRS was applied. Postoperative complications were classified according to the Clavien-Dindo system. The relation between the OS-MRS and the appearance of complications and mortality was analyzed. A Medline/Embase search was conducted using bariatric surgery, mortality, and complications as key words. Studies using the OS-MRS to predict morbidity and mortality were included. Of the 321 patients, 303 (94.3%) underwent gastric bypass and the remaining 18 (5.6%) a sleeve gastrectomy. The OS-MRS classified 178 patients as class A (55.5%), 129 as class B (40.2%), and 14 as class C (4.4%). According to the Clavien-Dindo system, 10.4% of the complications were ≥III. There was one death (class B). No significant association was found between the OS-MRS and the rate of complications. In our study, the OS-MRS is not correlated with the appearance of early complications or mortality. Future studies must focus on systems for predicting the appearance and severity of postoperative complications classified according to the Clavien-Dindo system, and not only on mortality.

This study was performed to determine if defect size after laparoscopic incisional hernia repair is predictive of recurrence during the long-term follow-up evaluation.We performed a prospective clinical study on 310 patients who underwent laparoscopic incisional hernia repair to identify predictable risk factors for hernia recurrence. Univariate and multivariate Cox regression analysis were used. The defect size was analyzed with curve receiver operating characteristic curve.The overall recurrence rate was 6% after an average follow-up period of 60 months. On univariate analysis of the defect size (categories:10 cm, 10-12 cm, and15 cm), obesity, previous repairs, hernia location, surgical time, hospital stay, morbidity, and recurrences were significantly different (P.001). By multivariate analysis, only obesity and defect size were independent prognostic factors (P.001).The predictive value of defect size is shown. Patients with large defects have a higher risk of recurrence. Our study recommends reserving the laparoscopic technique for hernias not exceeding 10 cm in size, where it can be put to better use.

Introduccion La incontinencia fecal (IF) es un trastorno de elevada prevalencia, que afecta gravemente a la calidad de vida relacionada con la salud (CVRS), de los pacientes que la padecen. La neuromodulacion es un tratamiento minimamente invasivo que ha demostrado su eficacia en el tratamiento de los sintomas de IF durante los ultimos 10 anos. El objetivo de nuestro trabajo es comprobar si existe una mejora en la calidad de vida, utilizando el EuroQuol 5D (EQ-5D) en los pacientes con incontinencia fecal tratados con neuromodulacion de raices sacras. Metodologia Estudio observacional con recogida prospectiva de datos de calidad de vida, antes y despues, utilizando el EQ-5D sobre una serie de pacientes con diagnostico de IF moderada o intensa con esfinter integro o reparado a los que se ha implantado de forma definitiva el neuroestimulador MEDTRONIC Interstim® 3023 tras una fase de estimulacion subcronica con buena respuesta. Resultados El numero medio de escapes inicial es de 3,1±1 y el final 0,5±0,6. El numero medio de escapes por semana se reduce en 2,6 escapes (IC 95%: 2,1-3,1) tras el implante definitivo del estimulador de raices sacras (p

Faecal incontinence (FI) is a highly prevalent disorder that severely affects the health related quality of life (HRQOL) of the patients who suffer from it. Neuromodulation is a minimally invasive treatment that has demonstrated its efficacy in the treatment of FI symptoms over the past 10 years. The aim of this study is to check whether there is an improvement in the quality of life, using EuroQuol (EQ-5D), in patients with faecal incontinence treated with sacral root neuromodulation.An observational study with prospective recording of quality of life data, before and after, using the EQ-5D on a series of patients diagnosed with moderate to severe FI with a complete or repaired sphincter who had a definitive MEDTRONIC Interstim(®) 3023 implant after a subchronic stimulation phase with a good response.The initial mean number of leaks was 3.1±1, and the final was 0.5±0.6. The mean number of escapes per week decreased to 2.6 escapes (CI 95%: 2.1-3.1) after the definitive implant of the sacral root stimulator (P.001). The mean baseline health status score was 55.9±13, and after neuromodulation it was 63.1±13. Thus, the visual analogue scale score increased by 7.1 points (CI 95%: 0.37-14) after the definitive implant of the sacral root stimulator (P.05). In the HRQOL variables studied with the EQ-5D questionnaire, we found an improvement with neuromodulation in the mobility and the presence of anxiety and/or depression variables. On the other hand we found an improvement with the neurostimulator implant, which was not significant, in personal care, performing daily activities and the presence of pain and/or discomfort. The current health was better in 11 patients (57.9%), the same in 7 (36.8%) and worse in 1 (5.3%).Neuromodulation is a therapy that has demonstrated a significant improvement in HRQOL measured with the EQ-5D.

Introduccion El analisis molecular intraoperatorio del ganglio centinela con el metodo one-step nucleic acid amplification (OSNA) es una tecnica ya validada para la deteccion de metastasis ganglionares en el cancer de mama. Los autores comparan el coste economico de este nuevo metodo frente al estudio histopatologico convencional diferido. Metodologia Estudio retrospectivo de analisis coste-beneficio que incluyo a pacientes con cancer de mama operable y axila clinica y ecograficamente negativa que fueron intervenidas desde el 15 de octubre de 2008 hasta el 15 de diciembre de 2009. El analisis del ganglio centinela se realizo en el Grupo 1 (45 pacientes) mediante estudio histopatologico convencional diferido, mientras que en el Grupo 2 (35 pacientes) se realizo segun el metodo OSNA. Se analizaron las siguientes variables: edad, tamano tumoral, tipo histologico, numero de ganglios centinela, resultado de la biopsia, tiempo quirurgico, dias de hospitalizacion, complicaciones postoperatorias, ganglios positivos en caso de linfadenectomia axilar, coste por paciente, coste por hospitalizacion y coste por intervencion. Resultados El tiempo quirurgico de la primera intervencion en el Grupo 1 fue significativamente menor, pero el tiempo total fue mayor en el Grupo 1. La estancia media fue mayor en el Grupo 1 (p

Background context Surgery for disc herniation is one of the most common traumas and neurosurgical procedures. Although discectomy has low morbidity, serious intra-abdominal complications can affect retroperitoneal structures, such as the large vessels, small intestine, and ureters. Case report A 36-year-old woman in uncontrollable pain presented with left sciatic neuralgia in the L5 region. Magnetic resonance imaging revealed an extruded left paracentral hernia at L5–S1. With the patient in the decubitus prone position, trauma surgeons specializing in spine surgery performed an L5–S1 flavectomy and a simple discectomy. Intraoperative complications were not observed. About 4 hours after surgery, the patient reported sharp abdominal pain and had persistent hypotension. Emergency abdominal computed tomography showed hemoperitoneum in the pouch of Douglas and left parietocolic space. Laparoscopic exploration confirmed hemoperitoneum without visible cause, a seton perforation of the small intestine, and a few adhesions in the right iliac fossa that were consequences of previous appendectomy. A laparotomy was then performed. A lesion was discovered in the mesentery of the rectosigmoid junction coinciding with the S5–L1 space. A segmental bowel resection and mechanical side-to-side anastomosis, with drainage, were done. The patient recovered satisfactorily despite a surgical wound infection. Discussion Although bowel perforation after discectomy rarely occurs, spine surgeons must try to prevent them by being more cautious during surgery. General surgeons must be highly suspicious of the presence of an intra-abdominal complication when there are signs and symptoms of a postoperative acute abdomen.

Resumen Las nauseas y vomitos postoperatorios no han recibido el suficiente interes hasta la fecha. Se han considerado molestias inherentes e inevitables tras muchas intervenciones quirurgicas. Sin embargo, esta desagradable complicacion tiene un manejo que puede resultar eficaz. Para ello hay que valorar adecuadamente el riesgo y actuar en consecuencia. Existe una amplia variedad de opciones profilacticas disponibles relacionadas con la tecnica anestesica, ademas del oportuno tratamiento antiemetico. En este articulo se revisan los factores de riesgo y se efectuan una serie de recomendaciones operatorias y postoperatorias.