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Graphical abstract, Introduction The COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected. Method A national descriptive study was carried out by an online voluntary specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons currently working in Spain (5203), opened from April 14th to April 24th. Results We received 337 responses from 170 centers. During the first month of the pandemic, the incidence of acute appendicitis decreased. Although conservative management increased, the surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period. Conclusion Highlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

Introduccion: La pandemia de COVID-19 ha afectado a las oportunidades de formación de los profesionales sanitarios, en parte porque se anularon muchos cursos presenciales. En este estudio se analizan los resultados de participación y satisfacción de las sesiones del Aula Virtual AEC durante su primer año. Metodología: El Aula Virtual AEC incluye un formato combinado de seminarios semanales emitidos en directo que pueden ser visionados en diferido. En este estudio se evalúan los resultados en sus primeros 12 meses, considerando el número de participantes en directo, el número de visualizaciones en diferido y el alcance global; así como los resultados de la encuesta de satisfacción realizada en cada una de las sesiones (1-10) Resultados: Desde el 16/04/2020 hasta el 15/04/2021 se realizaron 50 sesiones del Aula Virtual AEC. El alcance medio de las sesiones ha sido de 509±288 visualizaciones con un rango entre 196 y 1490. En los picos de la pandemia se observó un descenso de los participantes en directo: 275±135 vs 391±233 (p=0,032) La puntuación media sobre el formato fue 8,46± 0,31/10. Las sesiones mejor puntuadas fueron las de temática relacionada con coloproctología con una diferencia estadísticamente significativa en la puntuación media 8,79±0,42 vs 8,39±0,27 (p=0,035). Un 90,76% de usuarios consideraron las sesiones útiles. Un 97,2% consideraban que deben mantenerse tras la pandemia. Conclusion: El Aula Virtual AEC ha tenido muy buenos resultados en los primeros 12 meses de desarrollo, resultando ser una herramienta útil de docencia quirúrgica que previsiblemente sobrevivirá a la época de pandemia

Background Sarcopenia (SP) and preoperative muscle mass are independent predictive factors for short- and long-term outcome of liver transplantation. Objective To assess the influence of muscle mass index (MMI) and preoperative SP on the prognosis of patients who underwent liver transplantation in our hospital. Methods Ninety-seven patients who underwent liver transplantation in the Regional University Hospital of Malaga from September 2013 to March 2016 were analyzed. SP was determined based on the MMI, as assessed by psoas muscle area at the L4 level measured by computed tomography (CT), with adjustment for patient sex. Two cohorts were differentiated: 54 patients without SP and 42 patients with SP. Postoperative complications, graft survival, and patient survival were assessed. A 3-year follow-up was carried out. Results Recipient characteristics were similar in both cohorts, except for MMI ± SD (group without SP: 94.03 ± 15.43 cm2/m2 vs group with SP: 56.99 ± 13.59 cm2/m2; P = .001). The incidence of postoperative complications (Clavien ≥ 3) in patients with and without SP was 39.5% and 24.1%, respectively (P = .08). SP was not associated with poorer long-term graft or patient survival. Conclusions SP, determined by preoperative measurement of MMI, was identified as a predictive factor associated with a higher incidence of postoperative complications. Since MMI can be easily determined by CT, it should be assessed in all candidates for liver transplantation.

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugia-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients.

Specific training in the management of trauma patients is beneficial for surgeons. Training through specific courses in this area has a direct impact on the care of these patients. The aim of this work is to understand the participation and specific training in the care of trauma patients by Spanish surgeons. A national survey was conducted and administered to all members of the Spanish Association of Surgeons. The survey assessed their degree of participation in emergency surgery, and therefore the probability of attending trauma patients, their assessment of the initial care of trauma patients in their centre, and their specific training in this field. The survey was completed by 510 surgeons from 47 Spanish provinces, with Catalonia and Andalusia being the most represented regions. In total, 456 (89.41%) of those surveyed work in the emergency department on a routine basis. Only 171 (33.53%) refer to having a registry of trauma patients in their hospital. While 79.02% of surgeons reported that general surgeons are not involved in care of severe trauma from the outset, only 66.47% have completed the ATLS course, 40.78% the DSTC course and 18.82% the MUSEC course. Despite this, 85.69% believe that the ATLS course should be compulsory during residency and 43.33% believe that severe trauma care in their hospital is poor or very poor. Only 40% have received specific training in definitive surgical management of severe trauma. Despite this, a large percentage of surgeons work in the emergency department on a routine basis and potentially face the challenge of managing these patients.

Resumen El modelo Acute Care Surgery agrupa bajo una misma disciplina el trauma, la cirugia de urgencias y los cuidados intensivos posquirurgicos. Concebido y extendido durante las 2 ultimas decadas por territorio norteamericano, la magnitud e idiosincrasia clinica de la urgencia quirurgica han hecho que este modelo se haya asumido en muchos otros puntos de la geografia mundial. En nuestro pais, el reflejo ha sido la creacion e implantacion de las denominadas unidades de trauma y cirugia de urgencias, cuyos objetivos son comunes a las publicadas para el modelo original: evitar la nocturnidad en las urgencias quirurgicas, liberar a los profesionales vinculados a la cirugia electiva en horario laboral y convertirse en el eslabon y referente perfectos de la continuidad asistencial. En el presente articulo se resumen el nacimiento y la expansion del modelo original, la evidencia aportada en cuanto a resultados y la situacion actual en nuestro pais.

The aim of this study was to analyze the results of nonoperative management of patients with perforated acute diverticulitis with extraluminal air and to identify risk factors that may lead to failure and necessity of surgery. Methods included observational retrospective cohort study of patients between 2010 and 2015 with diagnosis of diverticulitis with extraluminal air and with nonoperative management initial. Patient demographics, clinical, and analytical data were collected, as were data related with computed tomography. Univariate and multivariate analyses with Wald forward stepwise logistic regression were performed to analyze results and to identify risk factors potentially responsible of failure of nonoperative management. Nonoperative management was established in 83.12% of patients diagnosed with perforated diverticulitis (64 of 77) with an overall success rate of 84.37%, a mean hospital stay of 11.98 ± 7.44 days and only one mortality (1.6%). Patients with pericolic air presented a greater chance of success (90.2%) than patients with distant air (61.5%). American Society of Anesthesiologists (ASA) grade III-IV (OR, 5.49; 95% CI, 1.04–29.07) and the distant location of air (OR, 4.81; 95% CI, 1.03–22.38) were the only two factors identified in the multivariate analysis as risk factors for a poor nonoperative treatment outcome. Overall recurrence after conservative approach was 20.4%; however, recurrence rate of patients with distant air was twice than that of patients with pericolic air (37.5 vs 17.39%). Only 14.8% of successfully treated patients required surgery after the first episode. Nonoperative management of perforated diverticulitis is safe and efficient. Special follow-up must be assumed in patients ASA III-IV and with distant air in CT.

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

Background There is still controversy about which preservation solution in pancreas transplantation could be the best. The aim of this study was to analyze our initial experience with Custodiol solution (CuS) compared with Viaspan solution (VS) and Celsior solution (CS) in pancreas transplantation. Methods A retrospective study included 94 consecutive pancreatic transplants, from 2007 until 2015. We compared 3 groups, depending on preservation solution: Viaspan (n = 41), Celsior (n = 40), or Custodiol (n = 13). The primary end point was patient and pancreas survival at 1 year after pancreas transplantation. Results The recipient and donor characteristics were similar except in cold ischemia time; it was higher with Celsior. No differences were found in postoperative complications and pancreas graft function at 3 months, 6 months, and 1 year (glucose, HbA1c, C-peptide, creatinine). The pancreas and patient survival at 1 year was comparable (pancreas survival: VS, 80%; CS, 90%; CuS, 92%; log-rank, 0.875; and patient survival: VS, 92%; CS, 97%; CuS, 100%; log-rank, 0.9). Conclusions In our institution, the Custodiol solution in pancreas transplantation presented similar outcomes in terms of postoperative complications, pancreas graft function, and 1-year survival.

Resumen Objetivo Analizar el incremento del apoyo radiologico solicitado para el diagnostico de la apendicitis aguda (AA), su justificacion a partir de su repercusion clinica asi como los parametros de rentabilidad diagnostica de ECO y TAC para esta enfermedad. Material y metodo Estudio observacional analitico de cohortes, con pacientes intervenidos por sospecha de AA en un hospital de tercer nivel, excluyendo menores de 14 anos y gestantes. Grupo de estudio: enero de 2010-diciembre de 2011 (n1 = 419). Grupo control: muestra de pacientes entre 18 y 65 anos intervenidos entre octubre de 2001 y septiembre de 2003 (n2 = 237). Variables de estudio en ambas muestras: 1) porcentaje de exploraciones realizadas como apoyo radiologico al diagnostico de la apendicitis; 2) sensibilidad y valor predictivo positivo (VPP) de ECO y TAC; 3) tasa de cirugias en blanco y con diagnosticos diferentes de AA. Analisis estadistico: software SPSS, con test de la χ2, aceptando como significativos niveles de p Resultados Ambas muestras fueron homogeneas en cuanto a edad, genero o porcentaje de localizaciones atipicas y formas evolucionadas. El numero de exploraciones solicitadas durante el periodo de estudio fue significativamente mayor que en el control (78,8 vs. 30,4%; p Conclusion El incremento de solicitudes de apoyo radiologico al diagnostico de AA conlleva un significativo aumento de intervenciones con diagnostico certero.

The aim of this study is to analyze the increasing need of radiological support in the diagnosis of acute appendicitis (AA), the clinical repercussions associated, and the parameters of diagnostic accuracy of ultrasound and computed tomography (CT) scan for AA.Observational and analytical study. Cohort, patients operated on for suspected AA at a tertiary referral hospital. Pregnancy and14 years were exclusion criteria.January 2010-December 2011 (n1=419).set of patients aged 18 to 65 years old operated between October 2001-September 2003 (n2=237). Variables analyzed in both groups: 1) percentage of radiological support for diagnosis of acute appendicitis; 2) sensitivity and positive predictive value (PPV) of ultrasound and CT scan; 3) rate of surgical explorations with negative result or with diagnosis other than acute appendicitis.SPSS software, χ(2) test, statistical significance accepted with P.05, 95% confidence interval (95% CI) for the odds ratio (OR).Age, gender, percentage of atypical locations and gangrenous/perforated episodes were similar in both groups. The number of radiological examinations needed for diagnosis was significantly higher in the study group (78.8% vs. 30.4%, P.0,000). Sensitivity was significantly superior for CT than for ultrasound scan (97% vs. 86%), but PPV was similar in both tests (92% vs. 94%). Surgical exploration percent values with diagnosis of acute appendicitis was significantly higher in the study group (94.5% vs. 88.6%; P.006, OR 2.2; CI 95% 1.25-4).CT and ultrasound scan are excellent diagnostic tools for acute appendicitis, and have contributed to a significant increase in surgical explorations with correct diagnosis.

Introduction: Total hepatectomy with temporary porto caval shunt involves an anhepatic phase until liver transplantation. The severity of the patient's state is conditioned by the physiopathologic alterations occurred during the anhepatic phase and the availability or not of organs in the short term. Methods: We report the case of a male patient undergoing liver transplantation for liver failure caused by the hepatitis C virus (HCV). Until liver transplantation, the patient experienced an anhepatic phase of 22 hours secondary to acute vascular failure during surgery. The patient is alive at five follow-up years. Conclusions: Total hepatectomy with temporary portocaval anastomosis in combination with appropriate management of physiopathologic alterations at the Intensive Care Unit improve survival in severely-ill patients awaiting transplantation.

Resumen Se estudian las complicaciones arteriales (CA) ocurridas en 400 trasplantes realizados entre 1997 y 2006. Se dividen en 2 grupos segun el tipo de tratamiento realizado: grupo i : tratamiento invasivo (tratamiento sobre la arteria o retrasplante), y grupo ii : tratamiento conservador o sintomatico. Se analizan el impacto del tratamiento sobre la supervivencia y las complicaciones biliares (CB). Resultados Se han presentado 18 CA (4,5%), 10 complicaciones precoces (7 trombosis y 3 estenosis) y 8 complicaciones tardias (5 trombosis y 3 estenosis). El 90% de las complicaciones precoces se trato de forma invasiva (4 trombectomias urgentes, un retrasplante, 3 angioplastias y una ligadura de arteria hepatica), y el 25% de las complicaciones tardias se trato con retrasplante (3); el 75% restante recibio tratamiento sintomatico. La supervivencia a 12 y 60 meses fue inferior en el grupo ii (el 57 y el 42%) que en el grupo i (el 90 y el 68%), aunque sin alcanzar significacion estadistica. La tasa global de CB de enfermos con trombosis arterial fue del 50%. En el grupo i del %, significativamente menor que el grupo ii con el 71% (p Conclusiones El tratamiento invasivo de las CA en el trasplante hepatico se asocia a una mayor supervivencia a corto plazo y reduce de forma significativa la aparicion de CB. En nuestra experiencia, los pacientes se benefician de un diagnostico precoz y un tratamiento intensivo en este tipo de complicaciones.

Background Induction therapy for simultaneous pancreas-kidney (SPK) transplantation. Both thymoglobulin (ATG) and basiliximab are the most-used types of induction antibodies therapies in clinical practice. The aim of our report was to analyze our experience comparing 2 induction therapies, for SPK transplantation in terms of pancreas and patient survival, as well as rejection rate. Methods We reviewed retrospectively a total of 97 SPK transplantations in our institution. The cases were divided according to induction therapy in 2 groups, basiliximab (n = 38) and ATG (n = 59). Rejection, patient and graft survival, and postoperative complications were analyzed. Results Survival in the ATG group was better without statistical difference at 1-, 3-, and 5-year follow-up (97%, 95%, and 95% versus 92%, 90%, and 87%, respectively). No difference was detected in pancreas graft survival after 1-, 3-, and 5-year follow-up (basiliximab 85%, 80%, and 77% versus ATG 84%, 84%, and 81%, respectively; log-rank, 0.847). Overall cellular rejection and early rejection were more common in the basiliximab group (30 versus 14%, and 21% versus 6%). In the multivariate analysis considering human leukocyte antigen (HLA) mismatches, the ATG group was a protective factor for cellular rejection. Major complications (Grade III-IV) and median length of the hospital stay were higher in the basiliximab group (55% versus 34%, P = .057, and 21 versus 16 days, P = .056). Conclusions The pancreas graft survival was not affected by induction therapy. ATG induction therapy compared with basiliximab is associated with lower overall and early rejection rate. Over time this difference disappears.

Resumen Introduccion El hepatocarcinoma es una complicacion frecuente de la cirrosis. El trasplante hepatico es una opcion terapeutica valida para esta enfermedad siempre que se cumplan unos criterios morfologicos de seleccion (criterios de Milan). Objetivo Valorar la eficacia de las pruebas de imagen en la deteccion y caracterizacion preoperatoria de lesiones neoplasicas en pacientes cirroticos candidatos a trasplante hepatico. Pacientes y metodo Estudio retrospectivo de 250 pacientes cirroticos trasplantados, en el que se compara el diagnostico radiologico preoperatorio con el anatomopatologico definitivo, lo que permite conocer la sensibilidad diagnostica de las diferentes pruebas, asi como identificar el grado de concordancia entre la estadificacion tumoral preoperatoria y la postoperatoria. Resultados El estudio de las 250 piezas de hepatectomia total permitio identificar a 58 pacientes con tumor hepatico, con un total de 136 nodulos tumorales. En 53 casos se trataba de hepatocarcinomas, 9 de los cuales fueron incidentales. Hubo 6 casos falsos positivos radiologicos. Los pacientes con hepatocarcinoma presentaban lesiones multiples en el 62% de los casos. La resonancia magnetica fue la tecnica mas sensible para el diagnostico de lesiones menores de 1 cm. Solo hubo concordancia entre la estadificacion preoperatoria y la postoperatoria en el 63,6% de los casos, y ello condiciono que hubiera un 43% de pacientes que fueron trasplantados superando los criterios de Milan (el 20% en estadio T3 y el 23% en estadio T4a). Conclusiones Las tecnicas de imagen presentan un importante porcentaje de incorrecta estadificacion en cuanto al diagnostico del tamano y el numero de lesiones tumorales.

Resumen Introduccion El trasplante de pancreas supone, hoy dia, la unica alternativa terapeutica capaz de restablecer una absoluta normalidad en las cifras de glucemia en el paciente diabetico; ademas, va a frenar e incluso revertir las complicaciones derivadas de la diabetes. El objetivo de nuestro estudio es presentar la experiencia y los resultados de los 4 primeros anos del programa de trasplante pancreatico en nuestro centro. Material y metodo Desde febrero de 2000 hasta junio de 2004 se han realizado en el Hospital Regional Carlos Haya de Malaga 43 trasplantes de pancreas en 42 receptores. En todos los pacientes se ha utilizado la tecnica de drenaje enterico de la secrecion exocrine y la derivacion venosa sistemica (a cava inferior) para la endocrina. Resultados Treinta y siete (88,1%) casos fueron trasplantes simultaneos pancreas-rinon (SPR), 4 (9,5%) en pacientes con rinon previamente trasplantado (PDR) y en 1 (2,4%) caso se trato de un retrasplante. En todos los casos se consiguio la normalizacion de la hemoglobina glucosilada y del peptido C. La supervivencia del paciente y del injerto pancreatico han sido del 91 y del 84%, respectivamente, con una mediana de seguimiento de 19 meses. La tasa de reintervenciones ha sido del 31%, con un 16% del global de perdida del injerto. Conclusiones Nuestros resultados obtenidos son equiparables a lo publicado por las grandes series.

Endometriosis, defined as the presence of endometrial tissue outside the uterine cavity, is most frequently located in the pelvic organs. Hepatic endometriosis is extremely rare, and only 12 cases have previously been reported. A wide variety of symptoms have been described, from asymptomatic masses (incidental findings) to acute abdomen. The diagnostic method of choice is abdominal CT, which should always be used in the differential diagnosis of cystic liver masses. Because of the high percentage of malignant transformation, the first-line treatment is surgical resection with adequate safety margins. We report a case of in situ adenocarcinoma arising in a hepatic endometrioma, which was treated with right hepatectomy.

Background Pancreas transplantation offers excellent outcomes today in patients who have type-1 diabetes mellitus (DM) with difficult control in terms of increasing patient and pancreatic graft survival. Different factors in donors, recipients, and the perioperative period have been associated with long-term graft survival. The aim of this study was to compare pancreatic graft survival in simultaneous pancreas-kidney transplantation (SPK) and the other two modalities, pancreas-alone and pancreas-after-kidney transplantation (non-SPK), at our institution. Methods This retrospective cohort study included 63 pancreas transplantation patients from January 2007 to May 2012 at our institution. The patients were divided into two groups: SPK and non-SPK transplantations. We excluded those patients who had transplants with vascular graft loss. The primary endpoint was 1-year and overall graft survival with consideration of multiple relevant variables. Non-parametric tests were calculated with the statistical package SPSS 20 (SPSS INC, Chicago, IL). Results The 1-year and overall graft survival in this period was 87.3% and 82.5%, respectively. The median follow-up was 963 days. The causes of graft loss were vascular (64%) and immunologic (34%). Finally, we included 56 pancreas transplantations, 46 (82%) were SPK and 10 (18%) non-SPK. The donor and recipient characteristics were similar in both groups, except for the duration of DM (SPK 22 years vs. non-SPK 29 years) and recipient body mass index (SPK 23 vs. non-SPK 28); P = .042 and P = .003, respectively. The cold ischemia time was 563 minutes (standard deviation, 145). Bivariate analysis showed that long-term graft loss was only influenced by matching for gender ( P = .023). Using the Kaplan-Meier method, the pancreas graft survival was better in SPK than in non-SPK transplants (log rank .038). Conclusions Patients who receive pancreas-alone or pancreas-after-kidney grafts have shorter long-term graft survival. Multiple strategies should be applied to improve immunologic surveillance and obtain an early diagnosis of graft rejection.

Background Vascular graft thrombosis (VGT) is still the achuilles heel in pancreas transplantation (PT); it is the main cause of nonimmunologic graft loss. Early diagnosis is essential to avoid transplantectomy. The aim of our study was to analyze the peak amylase during the first 3 days after PT as risk factor for VGT. Methods This retrospective study included 58 pancreas transplants in 55 patients from January 2007 to November 2011. They underwent an anticoagulation protocol based on unfractionated heparin and low-molecular-weight heparin. The technique consisted of enteric drainage and systemic venous drainage. The primary endpoint was VGT with consideration of multiple relevant variables. The maximum amylase level was determined during the first 3 days after transplantation. A receiver operating characteristic analysis was performed to establish a cutoff point as (mean plus one standard deviation; 745 mg/dL), calculating the sensitivity, specificity, and predictive values. Results Recipient characteristics were 71% males with an overall mean age of 39 years (range, 23–55) and body mass index 24 (range, 19–36). The donor sex was similar. Mean donor age was 32 years with occurrences of hypotension in 9%, cerebrovascular brain death in 46%. Mean ischemia time was 10 hours and 45 minutes. Mean blood amylase peak was 395 mg/dL. Seven VGT cases were diagnosed during the postoperative period including six with complete thrombosis requring transplantectomy. Bivariate analysis showed the group of subjects with amylase levels above 745 mg/dL to display on eight-fold greater risk for VGT (odds ratio = 8.6; P = .032). The area under the curve of blood amylase peak during the first 3 days to detect VGT was 0.630 (95% confidence interval 0.41–0.84). Conclusions A blood amylase peak above 745 mg/dL in the first 3 days after transplantation was associated with risk for VGT.

Background: Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial. We studied the results of initial conservative treatment (antibiotics and percutaneous drainage if necessary, with or without interval ap pendectomy) compared with immediate surgery. Methods: We undertook an observational, retrospective co hort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon, treated in our hospital between January 1997 and March 2009. Patients youn ger than 14, with severe sepsis or with diffuse peritonitis were ex cluded. A study group of 15 patients with acute appendicitis com plicated with an abscess or phlegmon underwent conservative treatment. A control group was composed of the other patients, who all underwent urgent appendectomy, matched for age and la ter randomized 1:1. The infectious risk stratification was establis hed with the National Nosocomial Infections Surveillance System (NNIS) index. Dependent variables were hospital stay and surgical site infection. Analysis was with SPSS, with p < 0.05 considered significant. Results: Interval appendectomy was performed in 7 study group patients. Surgical site infection episodes were more fre quent in the control group (6 vs. 0, p < 0.001). A greater percen tage of high risk patients (NNIS ≥ 2) was identified in the control group (80 vs. 28.7%, p < 0.03), mostly related with contaminated or dirty procedures in this group (p < 0.001). No significant diffe rence between groups was found in hospital stay. Conclusion: Initial conservative treatment should be conside red the best therapeutic choice for acute appendicitis with abscess or phlegmon.

The double piggyback technique has been proposed for domino liver transplantation. To make this possible, it is necessary to reconstruct the venous outflow of the domino liver graft on the back table. We describe an alternative method of reconstruction of hepatic venous outflow, in which a neocaval segment is obtained using both common iliac veins from the cadaveric donor.

as we previously reported. 4 Due to this, in our appendiceal mass treatment protocol, we systematically include this surgery as the last step of the treatment, which is offered to be carried out between weeks 6 and 8 from the start of the clinical condition (having first carried out a colonoscopy when patients are over 45 years of age). Although the morbidity published with the interval appendectomy in these circumstances ranges from 12 to 23 %, 3 in our experience, far from it being an aggressive form of surgery, it is in fact a safe procedure. A significant reduction in complications (7 vs. 33 %, p=0.01) and, more specifically, the rate of surgical site infection (0 vs. 29 %, p=0.00) was obtained when comparing our series of 27 cases of inflammatory masses treated with this protocol from January 1997 to February 2013 with a control group of patients operated on directly from our historic series (1:1 matching and subsequent random allocation). Furthermore, no greater resection was necessary, with the advantage that, when carrying out the interval appendectomy, we avoided leaving an inadvertent tumor in the inflamed appendix. And all by means of a procedure that we were able to perform by laparoscopy in 74 % of the cases, compared with 22 % in the control group (p

Necrosis of pancreatic parenchyma or extrapancreatic tissues is present in 10%-20% of patients with acute pancreatitis, defining the necrotizing presentation frequently associated with high morbidity and mortality rates. During the initial phase of acute necrotizing pancreatitis the most important pillars of medical treatment are fluid resuscitation, early enteral nutrition, endoscopic retrograde colangiopancreatography if associated cholangitis and intensive care unit support. When infection of pancreatic or extrapancreatic necrosis occurs, surgical approach constitutes the most accepted therapeutic option. In this context, we have recently assited to changes in time for surgery (delaying the indication if possible to around 4 wk to deal with “walled-off” necrosis) and type of access for necrosectomy: from a classical open approach (with closure over large-bore drains for continued postoperative lavage or semiopen techniques with scheduled relaparotomies), trends have changed to a “step-up” philosophy with initial percutaneous drainage and posterior minimally invasive or endoscopic access to the retroperitoneal cavity for necrosectomy if no improvement has been previously achieved. These approaches are progressively gaining popularity and morbidity and mortality rates have decreased significantly. Therefore, a staged, multidisciplinary, step-up approach with minimally invasive or endoscopic access for necrosectomy is widely accepted nowadays for management of pancreatic necrosis.

To analyze our results after the introduction of a fast-track (FT) program after laparoscopic liver surgery in our Hepatobiliarypancreatic Unit.All patients (43) undergoing laparoscopic liver surgery between March 2004 and March 2010 were included and divided into two consecutive groups: Control group (CG) from March 2004 until December 2006 with traditional perioperative cares (17 patients) and fast-track group (FTG) from January 2007 until March 2010 with FT program cares (26 patients). Primary endpoint was the influence of the program on the postoperative stay, the amount of re-admissions, morbidity and mortality. Secondarily we considered duration of surgery, use of drains, conversion to open surgery, intensive cares needs and transfusion.Both groups were homogeneous in age and sex. No differences in technique, time of surgery or conversion to open surgery were found, but more malignant diseases were operated in the FTG, and then transfusions were higher in FTG. Readmissions and morbidity were similar in both groups, without mortality. Postoperative stay was similar, with a median of 3 for CG vs 2.5 for FTG. However, the 80.8% of patients from FTG left the hospital within the first 3 d after surgery (58.8% for CG).The introduction of a FT program after laparoscopic liver surgery improves the recovery of patients without increasing complications or re-admissions, which leads to a reduction of the stay and costs.

Presacral tumors are rare, but can comprise a great variety of histological types. Congenital tumors are the most common. Once the diagnosis is established, surgical resection is essential because of the potential for malignancy or infection. Previous biopsy is not necessary or may be even harmful. To decide the best surgical approach (abdominal, sacral or combined) an individual and multidisciplinary analysis must be carried out. We report three cases of cystic presacral masses in which a posterior approach (Kraske procedure) enabled complete resection, the only way to decrease local recurrence. All patients had a satisfactory recovery. A brief overview of retrorectal tumors is presented, focusing on classification, clinical presentation, diagnosis and surgical management.

A study was made of the arterial complications documented in 400 transplants performed between 1997 and 2006. The patients were divided into two groups according to the type of treatment provided. Group I: invasive management (arterial treatment or re-transplant), and Group II: conservative or symptomatic management. The impact of management on survival and biliary complications was analysed. Results There were 18 arterial complications (4.5%): 10 early (7 thromboses and 3 stenoses) and 8 late (5 thromboses and 3 stenoses). Ninety percent of the early complications were subjected to invasive management (4 emergency thrombectomies, one re-transplant and 3 angioplasties), while 25% of the late complications were treated with re-transplant and the remaining 75% were subjected to symptomatic treatment. Survival after 12 and 60 months was lower in Group II (57% and 42%) than in Group I (90% and 68%), although without reaching statistical significance. The overall biliary complications rate among the patients with arterial thrombosis was 50%. The rate was significantly lower in Group I than in Group II (10% versus 71%) (P Conclusions Invasive management of the arterial complications of liver transplantation is associated with longer short-term survival and significantly fewer biliary complications. In our experience, patients benefit from an early diagnosis and aggressive management of complications of this kind.