RESUMEN

BACKGROUND: Minimally invasive liver surgery of postero-superior segments (S4a, S7, S8) remains a challenge. The caudal view, an increased distance between trocars and the operative field, and the liver fulcrum limiting the view, contribute to the difficulty [1, 2]. We and other groups have previously reported the use of intercostal trocars to access subdiaphragmatic tumors (transdiaphragmatic approach) [3-5], only few reports on a laparoscopic total transthoracic approach, none (to our knowledge) dynamic manuscripts of a total transthoracic robotic approach, and none (to our knowledge) that use preoperative port site and anatomic modelling exist. Further, we developed a total transthoracic (thoracoscopic) approach to avoid a hostile abdomen, while bringing viewing axis and instruments close to the target [6-10]. In this context, this report details the advantages of a laparoscopic vs. robotic transthoracic approach. According to institutional protocol, reports of individual cases in print or video format do not require institutional review board approval. PATIENT: A 68-year-old male on peritoneal dialysis with left colon adenocarcinoma and a single synchronous liver metastasis in S6-7 close to the root of the right hepatic vein underwent a laparoscopic transdiaphragmatic metastasectomy. Two years later, the patient developed a recurrent 1.5 cm liver metastasis in S7, which lend itself to a robotic transthoracic approach. TECHNIQUE: Following 3-D modelling and virtual port placement planning, the first metastasectomy was performed laparoscopically using a transdiaphragmatic approach. The recurrence was managed transthoracically due to more apical, subdiaphragmatic location. For this operation, a robotic approach was optimal as robotic wrist articulation facilitates manipulation via the limited intercostal space. This was particularly helpful during the diaphragmatic reconstruction. CONCLUSIONS: Total transthoracic liver surgery is certainly an advanced procedure requiring superior MIS liver skills. Recommendations for starting with a total transthoracic approach are not unlike from starting a standard, none-transthoracic liver surgery. Early on in the experience we recommend advanced liver MIS skills, and single, small, subdiaphragmatic tumors away from major vessels. Nonetheless, when these recommendations are followed a total transthoracic approach may be safer and result in less access trauma, than traversing a hostile abdomen to reach the posterior-superior liver. Both laparoscopic and robotic transthoracic approaches can facilitate the resection of subdiaphragmatic tumors, especially in patients with hostile abdomens. While the laparoscopic approach has advantages due to a broader spectrum of available surgical tools (flexible tip camera, parenchymal dissection, and energy devices), the robotic wrist articulation facilitates manipulation via the restricted intercostal space.

Asunto(s)

Adenocarcinoma , Neoplasias del Colon , Laparoscopía , Neoplasias Hepáticas , Procedimientos Quirúrgicos Robotizados , Masculino , Humanos , Anciano , Adenocarcinoma/cirugía , Neoplasias del Colon/cirugía , Laparoscopía/métodos , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/secundario , Hepatectomía/métodos

RESUMEN

BACKGROUND: Open (OA), laparoscopic (LA), and percutaneous (PA) ablation are all ablation approaches for hepatocellular carcinoma (HCC) utilized in the United States today. However, it remains unclear today which approach is (A) most effective, (B) cost-efficient, and (C) nationally practiced. METHODS: In-hospital mortality and cost were collected from the National Inpatient Sample (NIS) database for patients undergoing liver ablation from 2011 to 2018. Secondary outcomes included length of stay, disposition, and perioperative composite complications. We used inverse probability of treatment weighting (IPTW) to adjust for differences in patient and hospital baseline characteristics. RESULTS: One thousand and one hundred and twenty-five LA, 1221 OA, and 1068 PA liver ablations were analyzed. After IPTW, in-hospital mortality risk was significantly lower in PA versus OA cohorts (0.57% vs. 2.90%, p < 0.001) and reduced among PA patients, yet not significantly different from the LA cohort (0.57% vs. 1.64%, p = 0.056). The median length of hospital stay was significantly lower in the PA and LA group compared to OA (2 days vs. 6 days, p < 0.001). The median hospitalization costs were significantly lower for PA ($44,884 vs. $90,187, p < 0.001) and LA ($61,445 vs. $90,187, p < 0.001) compared to OA. Moreover, we found significant regional differences regarding the use of each ablation approach, with the Midwest having the lowest rates of PA and LA. CONCLUSIONS: Among patients hospitalized after ablation for HCC, PA leads to the lowest hospital cost. Both PA and LA result in lower peri-operative morbidity and mortality relative to OA. Despite these reported advantages, there are significant regional differences with respect to ablation availability suggesting the need to promote the standardization of best practices.

Asunto(s)

Apendicitis , Carcinoma Hepatocelular , Ablación por Catéter , Laparoscopía , Neoplasias Hepáticas , Humanos , Estados Unidos/epidemiología , Carcinoma Hepatocelular/cirugía , Carcinoma Hepatocelular/complicaciones , Apendicitis/cirugía , Apendicectomía , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/complicaciones , Tiempo de Internación , Laparoscopía/métodos , Resultado del Tratamiento , Estudios Retrospectivos , Complicaciones Posoperatorias/cirugía

RESUMEN

Bcl2 family proteins play an important role in the resistance of thyroid cancer cells to apoptosis induced by chemotherapeutic drugs and targeted therapies. BH3-profiling of seven fresh primary papillary thyroid cancer (PTC) tumors showed dependence for survival on Bcl-xL (2/7), Bcl2 (2/7), and Mcl-1 (2/7), while the majority of thyroid cell lines were mainly dependent on Bcl-xL. Targeting Bcl2 family proteins with the BH3 mimetic, ABT-737, while simultaneously inhibiting ERK pathway proteins with PLX4720 and PD325901 was shown to induce significantly high apoptosis in the majority of cell lines (8505c, SW1736, HTh7, BCPAP) and moderate apoptosis in the TPC-1 cell line. In orthotopic thyroid cancer mouse models of 8505c and BCPAP, treatment with the triple drug combination reduced the size of the tumors and showed significantly higher numbers of cells undergoing apoptosis. This treatment increased the expression of pro-apoptotic protein Bim, while decreasing anti-apoptotic protein Mcl-1. Our results suggest that analyzing the results of BH3-profiling along with the mutational status of tumor can reveal an effective therapy for targeted, personalized treatment of aggressive thyroid cancer.

Asunto(s)

Apoptosis/efectos de los fármacos , Compuestos de Bifenilo/farmacología , Sistema de Señalización de MAP Quinasas/fisiología , Nitrofenoles/farmacología , Proteínas Proto-Oncogénicas c-bcl-2/antagonistas & inhibidores , Sulfonamidas/farmacología , Neoplasias de la Tiroides/tratamiento farmacológico , Animales , Benzamidas/farmacología , Línea Celular Tumoral , Difenilamina/análogos & derivados , Difenilamina/farmacología , Femenino , Humanos , Indoles/farmacología , Ratones , Proteínas Quinasas Activadas por Mitógenos/antagonistas & inhibidores , Piperazinas/farmacología , Proteínas Proto-Oncogénicas c-bcl-2/fisiología , Neoplasias de la Tiroides/patología , Proteína bcl-X/fisiología

RESUMEN

The interaction of programmed cell death-1 and its ligand is widely studied in cancer. Monoclonal antibodies blocking these molecules have had great success but little is known about them in thyroid cancer. We investigated the role of PD-L1 in thyroid cancer with respect to BRAF mutation and MAP kinase pathway activity and the effect of anti PD-L1 antibody therapy on tumor regression and intra-tumoral immune response alone or in combination with BRAF inhibitor (BRAFi). BRAFV600E cells showed significantly higher baseline expression of PD-L1 at mRNA and protein levels compared to BRAFWT cells. MEK inhibitor treatment resulted in a decrease of PD-L1 expression across all cell lines. BRAFi treatment decreased PD-L1 expression in BRAFV600E cells, but paradoxically increased its expression in BRAFWT cells. BRAFV600E mutated patients samples had a higher level of PD-L1 mRNA compared to BRAFWT (p=0.015). Immunocompetent mice (B6129SF1/J) implanted with syngeneic 3747 BRAFV600E/WT P53-/- murine tumor cells were randomized to control, PLX4720, anti PD-L1 antibody and their combination. In this model of aggressive thyroid cancer, control tumor volume reached 782.3±174.6mm3 at two weeks. The combination dramatically reduced tumor volume to 147.3±60.8, compared to PLX4720 (439.3±188.4 mm3, P=0.023) or PD-L1 antibody (716.7±62.1, P<0.001) alone. Immunohistochemistry analysis revealed intense CD8+ CTL infiltration and cytotoxicity and favorable CD8+:Treg ratio compared to each individual treatment. Our results show anti PD-L1 treatment potentiates the effect of BRAFi on tumor regression and intensifies anti tumor immune response in an immunocompetent model of ATC. Clinical trials of this therapeutic combination may be of benefit in patients with ATC.

Asunto(s)

Protocolos de Quimioterapia Combinada Antineoplásica/farmacología , Antígeno B7-H1/antagonistas & inhibidores , Indoles/farmacología , Proteínas Proto-Oncogénicas B-raf/antagonistas & inhibidores , Sulfonamidas/farmacología , Carcinoma Anaplásico de Tiroides/tratamiento farmacológico , Neoplasias de la Tiroides/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Animales , Anticuerpos Monoclonales/farmacología , Proliferación Celular/efectos de los fármacos , Femenino , Humanos , Masculino , Ratones , Persona de Mediana Edad , Inhibidores de Proteínas Quinasas/farmacología , Proteínas Proto-Oncogénicas B-raf/genética , Carcinoma Anaplásico de Tiroides/inmunología , Carcinoma Anaplásico de Tiroides/patología , Neoplasias de la Tiroides/inmunología , Neoplasias de la Tiroides/patología

RESUMEN

BACKGROUND: Investigating BRAF((V600E)) inhibitors (BRAFi) as a strategy to treat patients with aggressive thyroid tumors harboring the BRAF((V600E)) mutant currently is in progress, and drug resistance is expected to pose a challenge. MicroRNAs (miRNAs) are involved in development of resistance to a variety of drugs in different malignancies. METHODS: miRNA expression profiles in the human anaplastic thyroid cancer cell line (8505c) were compared with its PLX4720-resistant counterpart (8505c-R) by the use of Illumina deep sequencing. We conducted a functional annotation and pathway analysis of the putative and experimentally validated target genes of the significantly altered miRNAs. RESULTS: We identified 61 known and 2 novel miRNAs whose expression was altered greatly in 8505c-R. Quantitative reverse-transcription polymerase chain reaction validated altered expression of 7 selected miRNAs in 8505c-R and BCPAP-R (PLX4720-resistant papillary thyroid cancer cell line). We found 14 and 25 miRNAs whose expression levels changed substantially in 8505c and 8505c-R, respectively, after treatment with BRAFi. The mitogen-activated protein kinase and phosphatidylinositol 3-kinase-AKT pathways were among the prominent targets of many of the deregulated miRNAs. CONCLUSION: We have identified a number of miRNAs that could be used as biomarkers of resistance to BRAFi in patients with thyroid cancer. In addition, these miRNAs can be explored as potential therapeutic targets in combination with BRAFi to overcome resistance.

Asunto(s)

Resistencia a Antineoplásicos/genética , Indoles/farmacología , MicroARNs/genética , Proteínas Proto-Oncogénicas B-raf/antagonistas & inhibidores , Sulfonamidas/farmacología , Neoplasias de la Tiroides/genética , Biomarcadores de Tumor/genética , Línea Celular Tumoral , Estudio de Asociación del Genoma Completo , Humanos , MicroARNs/metabolismo , Neoplasias de la Tiroides/patología

RESUMEN

INTRODUCTION: In pediatric care, the role of focused abdominal sonography in trauma (FAST) remains ill defined. The objective of this study was to assess the sensitivity and specificity of FAST for detecting free peritoneal fluid in children. METHODS: The trauma registry of a single level I pediatric trauma center was queried for the results of FAST examination of consecutive pediatric (<18 years) blunt trauma patients over a period of 36 months, from January 2010 to December 2012. Demographics, type of injuries, FAST results, computerized tomography (CT) results, and operative findings were reviewed. RESULTS: During the study period, 543 injured pediatric patients (mean age 8.2 ± 5 years) underwent FAST examinations. In 95 (17.5 %) FAST was positive for free peritoneal fluid. CT examination was performed in 219 (40.3 %) children. Positive FAST examination was confirmed by CT scan in 61/73 (83.6 %). CT detected intra-peritoneal fluid in 62/448 (13.8 %) of the patients with negative FAST results. These findings correspond to a sensitivity of 50 %, specificity of 88 %, positive predictive value (PPV) of 84 %, and a negative predictive value (NPV) of 58 %. In patients who had negative FAST results and no CT examination (302), no missed abdominal injury was detected on clinical ground. FAST examination in the young age group (<2 years) yielded lower sensitivity and specificity (36 and 78 % respectively) with a PPV of only 50 %. CONCLUSIONS: This study shows that although a positive FAST evaluation does not necessarily correlate with an IAI, a negative one strongly suggests the absence of an IAI, with a high NPV. These findings are emphasized in the analysis of the subgroup of children less than 2 years of age. FAST examination tempered with sound clinical judgment seems to be an effective tool to discriminate injured children in need of further imaging evaluation.

RESUMEN

BACKGROUND: The recently introduced Afirma gene expression classifier (AGEC) provides binary results (benign or suspicious) to guide management of cytologically indeterminate thyroid nodules. The AGEC is intended to reduce unnecessary surgeries for benign nodules, and management algorithms favor surgery for suspicious results. Limited data are available on the performance of this test for Hürthle cell nodules (HCNs). This study hypothesized that a predominance of Hürthle cells leads to an increased rate of suspicious AGEC results with a potential for overtreatment, despite a relatively low risk of malignancy. METHODS: The pathology databases from three tertiary care facilities were queried from 2010 to 2014 for fine-needle aspirates (FNAs) diagnosed as suspicious for Hürthle cell neoplasm (SHCN) or atypia of undetermined significance/follicular lesion of undetermined significance concerning for Hürthle cell neoplasm (AFHCN). Cytology diagnoses were rendered internally prior to AGEC testing. The patient demographics, FNA diagnosis, AGEC result, surgical procedure, and pathologic outcomes were recorded. RESULTS: The cohort consisted of 134 patients with HCNs. Prior to AGEC availability, 62 patients underwent surgery: 81% (50/62) of patients had surgery, and 34% (17/50) of the resected index nodules were malignant. After introduction of the AGEC, 72 patients underwent AGEC testing: 65% (47/72) of patients had surgery, and 13% (6/46) of the resected nodules were malignant. Thirty-two percent (23/72) of patients had a benign AGEC result and did not undergo surgery, and 4% (3/72) had surgery despite a benign AGEC result with benign final pathology, whereas 63% (45/72) of patients had suspicious AGEC results, with 96% of these patients (43/45) undergoing surgery, and 14% (6/43) of these index nodules were malignant. CONCLUSIONS: While 32% of tested patients declined surgery based on a benign AGEC, 86% of patients with suspicious AGEC findings had unnecessary surgery, reflecting a substantially lower rate of malignancy from what was previously reported for all indeterminate nodules. Given the approximate pretest malignancy risk of 25-35% for an FNA diagnosis of SHCN or AFHCN, a suspicious AGEC diagnosis does not increase the probability of malignancy in an HCN, and patients should be counseled accordingly.

Asunto(s)

Adenocarcinoma Folicular/genética , Carcinoma Neuroendocrino/genética , Carcinoma/genética , Regulación Neoplásica de la Expresión Génica , Células Oxífilas/metabolismo , Neoplasias de la Tiroides/genética , Nódulo Tiroideo/genética , Adenocarcinoma Folicular/diagnóstico , Adenoma Oxifílico , Adulto , Anciano , Biopsia con Aguja Fina , Carcinoma/diagnóstico , Carcinoma Neuroendocrino/diagnóstico , Carcinoma Papilar , Estudios de Cohortes , Diagnóstico Diferencial , Femenino , Perfilación de la Expresión Génica , Humanos , Masculino , Persona de Mediana Edad , Células Oxífilas/patología , Estudios Retrospectivos , Cáncer Papilar Tiroideo , Neoplasias de la Tiroides/diagnóstico , Nódulo Tiroideo/diagnóstico

RESUMEN

Percutaneous gastrostomy is well established root for long term feeding of patients who cannot be fed orally. The risks of percutanous gastrostomy insertion are low. Tube related complications often resolved by placing a Foley catheter or other balloon gastrostomy tube as a temporary solution. Gastrostomy tube related gastric, duodenal and billiary obstruction were reported. Gastrostomy tube related pancreatitis is scarcely described. We described a patient who suffered a pancreatitis related to Foley catheter gastrostomy dislodgment. Reviewing all reported cases of gastrostomy related pancreatitis revealed higher incidence in patient with Foley catheter used as gastrostomy and revealed questionable trends in conducting tube replacement. We suggest a proper manner for tube replacement and concluded that should a Foley catheter used as a temporary solution a replacement should be schedule in a timely manner to avoid life threatening complications.

RESUMEN

BACKGROUND: Colon cancer is common, affecting mostly older people. Since age is a risk factor, young patients might not be given the same attention as older ones regarding symptoms that could imply the presence of colon cancer. OBJECTIVES: To investigate whether young patients, i.e., under age 50, complain of symptoms for longer than older patients until the diagnosis of colon cancer is established. METHODS: In this retrospective cohort study, patients were divided into two groups: < 50 years old (group 1) and > or = 50 (group 2). All had undergone surgery for left or right-colon cancer during the 10 year period of the study from January 2000 through December 2009 at one medical center. Rectal and sigmoid cancers were excluded. Data collected included age, geander, quantity and quality of complaints, duration of complaints, in-hospital versus community diagnosis, pathological staging, the side of colon involved, and overall mortality. The primary outcome was the quality and duration of complaints. Secondary outcomes were the pathological stage at presentation and the mortality rate. RESULTS: The study group comprised 236 patients: 31 (13.1%) were < 50 years old and 205 (86.9%) were > or = 50. No significant difference was found in the quantity and quality of complaints between the two groups. Patients in group 1 (< 50 years) complained for a longer period, 5.3 vs.2.4 months (P= 0.002). More younger patients were diagnosed with stage IV disease (38.7% vs. 21.5%, P= 0.035) and fewer had stage I disease (3.2% vs. 15.6%, P= 0.06); the mortality rates were similar (41.9% vs. 39%). Applying a stepwise logistic regression model, the duration of complaints was found to be a predictor of mortality (P= 0.03, OR 1.6, 95% CI 1-3.6), independently of age (P= 0.003) and stage (P< 0.001). CONCLUSIONS: Younger patients are more often diagnosed with colon cancer later, at a more advanced stage. Alertness to patients' complaints, together with evaluation regardless of age but according to symptoms and clinical presentation are crucial. Large-scale population-based studies are needed to confirm this trend.

Asunto(s)

Adenocarcinoma , Colectomía , Colon , Neoplasias del Colon , Evaluación de Síntomas , Tiempo de Tratamiento/estadística & datos numéricos , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adenocarcinoma/fisiopatología , Adenocarcinoma/cirugía , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Colectomía/métodos , Colectomía/estadística & datos numéricos , Colon/patología , Colon/fisiopatología , Colon/cirugía , Neoplasias del Colon/mortalidad , Neoplasias del Colon/patología , Neoplasias del Colon/fisiopatología , Neoplasias del Colon/cirugía , Femenino , Humanos , Israel/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Mortalidad , Estadificación de Neoplasias , Evaluación de Resultado en la Atención de Salud , Estudios Retrospectivos , Factores de Riesgo , Evaluación de Síntomas/métodos , Evaluación de Síntomas/estadística & datos numéricos

RESUMEN

AIM: To elucidate the relationship between clinical presentation and outcome. METHODS: A single institution retrospective chart review of patients admitted with the diagnosis of colon cancer. We used univariate and a multivariate analysis to identify symptoms association with mortality. An odds ratio based clinical score was created to evaluate the contribution of the quality of symptoms to outcome. Primary measure of outcome was survival. RESULTS: During the study period, 236 patients met the inclusion criteria. Overall survival was 60.6%, mean follow-up 3.0 years. A bivariate analysis showed that increasing number of symptoms is not associated with mortality. However, a symptom-specific analysis performed using a logistic regression model controlling for age, stage and the duration of complaints revealed that the presence of melena was independently associated with mortality [P = 0.04, odds ratio (OR) 7.4], while rectal bleeding was associated with survival (P = 0.004, OR 3.9). Applying the proposed clinical score to an receiver operating characteristic curve showed that score > 1 had a strong association with mortality. The same logistic regression model was applied. The results showed that a score > 1 was an independent predictor of mortality (P < 0.001) and associated with node-positive disease (P = 0.008). CONCLUSION: The quality of symptoms rather than quantity is correlated with outcome among patients with colon cancer. The proposed clinical scoring system may correctly predict the patient's outcome.

Asunto(s)

Antígeno CA-19-9/sangre , Quistes/sangre , Enfermedades del Bazo/sangre , Adulto , Quistes/diagnóstico , Quistes/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Laparotomía , Esplenectomía , Enfermedades del Bazo/diagnóstico , Enfermedades del Bazo/cirugía , Tomografía Computarizada por Rayos X

Asunto(s)

Ampolla Hepatopancreática/patología , Tumores del Estroma Gastrointestinal/patología , Anciano de 80 o más Años , Ampolla Hepatopancreática/cirugía , Diagnóstico Diferencial , Femenino , Tumores del Estroma Gastrointestinal/diagnóstico , Tumores del Estroma Gastrointestinal/cirugía , Humanos , Tomografía Computarizada por Rayos X

RESUMEN

Autoimmune pancreatitis can mimic pancreatic cancer in its clinical presentation, imaging features and laboratory parameters. Differentiating between those two entities requires implementation of clinical judgment and experience along with objective parameters that may suggest either condition. Few strategies have been proposed for the surgeon to implement when facing borderline cases. The following case is an example of a clinical scenario compatible with an accepted algorithm for diagnosis of pancreatic cancer, which eventually proved wrong. We present a 75-year-old patient who was admitted for obstructive jaundice. Imaging features were highly suggestive for pancreatic cancer as was the carbohydrate antigen 19-9 (CA 19-9) level, leading to a decision for surgery. Pathological examination revealed autoimmune pancreatitis. Though no frank carcinoma was found, premalignant ductal changes of pancreatic intraepithelial neoplasia (PanIN) I and PanIN II were discovered throughout the pancreatic duct. Caution is advised when relying on the combination of highly suggestive radiology features and elevated levels of CA 19-9 in the diagnosis of pancreatic cancer. When the tissue diagnosis is not conclusive, obtaining IgG4 and antinuclear Ab levels is advised, to rule out the rare possibility of autoimmune pancreatitis. Patients with autoimmune pancreatitis should be followed carefully as precancerous lesions may accompany the benign disease and the correlation of these two entities has not been ruled out.

Asunto(s)

Gastrectomía/métodos , Vólvulo Intestinal/congénito , Intestino Delgado , Laparoscopía/métodos , Complicaciones Posoperatorias/etiología , Pérdida de Peso , Dolor Abdominal/etiología , Adulto , Gastroplastia/métodos , Humanos , Masculino , Obesidad Mórbida/cirugía

RESUMEN

Aberrant right subclavian artery (ARSA) is asymptomatic in most cases. This variant anatomy can cause dysphagia in elderly patients. Impaction of foreign body in the esophagus is rarely the presenting symptom of ARSA. We present an eighty four years old patient who first presented with esophageal foreign body impaction and was diagnosed with an aberrant right subclavian artery compressing the esophagus just below the site of impaction.We assume that the exact place of impaction was not incidental and that a relative narrowing of the esophagus caused by the vascular anomaly is responsible for this specific presentation.

RESUMEN

BACKGROUND: Anastomotic leaks, stenosis, and bleeding from the gastrojejunal anastomosis (GJA) after gastric bypass may carry high morbidity and mortality. To date, the standard operation with the circular stapler (CS) used the 25 mm with a staple height of 4.8 mm. We present herein our experience with the 3.5-mm staple height. METHODS: A total of 1,074 morbidly obese patients who underwent fully stapled laparoscopic Roux-en-Y Gastric Bypass over a period of 18 months were included in the study. Mean body mass index was 41.9 (range 28.6-70.7). Mean age was 40.9 years (range 15-74 years). Mean operating time was 73 min (range 43-210 min) and the mean length of stay was 4.2 days (range 1-25 days). The 30-day complication rate associated with GJA was prospectively analyzed. RESULTS: Twenty patients (1.86%) developed postoperative bleeding. Four developed GJA bleeding (0.37%). One leak was recorded from the vertical staple line of the gastric pouch, but no leaks from the GJA were seen. Conversion to open approach was required in two patients (0.18%). Reoperation and readmission rates were 1.7% and 1.8%, respectively. Perioperative complications were observed in 34 patients (3.1%). One case of clinical GJA stenosis was detected in a mean follow-up of 10.5 months (range 5-20 months). There was no mortality in our series. CONCLUSION: Compared to our previous experience with 4.8 mm CS, creating the GJA using a smaller staple height significantly reduced the bleeding rate and seems to be a safe technique that potentially reduces other complications related to the GJA as reported in the literature.

Asunto(s)

Gastrostomía/métodos , Yeyunostomía/métodos , Laparoscopía , Obesidad Mórbida/cirugía , Grapado Quirúrgico/métodos , Adolescente , Adulto , Anciano , Femenino , Derivación Gástrica , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Tiempo , Adulto Joven

Asunto(s)

Mucosa Intestinal/diagnóstico por imagen , Neoplasias Intestinales/diagnóstico por imagen , Neoplasias Intestinales/secundario , Intestino Delgado/diagnóstico por imagen , Leiomiosarcoma/patología , Neoplasias Uterinas/patología , Medios de Contraste , Diagnóstico Diferencial , Femenino , Fluorodesoxiglucosa F18 , Humanos , Neoplasias Intestinales/complicaciones , Leiomiosarcoma/complicaciones , Persona de Mediana Edad , Obesidad Mórbida/complicaciones , Tomografía de Emisión de Positrones/métodos , Intensificación de Imagen Radiográfica/métodos , Neoplasias Uterinas/complicaciones

RESUMEN

The outbreak of the H1N1 influenza pandemic resulted in unprecedented, overwhelming exposure in the medical and lay media, with the obvious focus of healthcare providers being on patients in internal medicine or intensive care settings.Recently, we treated 3 patients with various surgical emergencies who were also diagnosed with active H1N1 influenza. The purpose of this report is to bring the issue of H1N1 flu in association with surgical emergencies to the forefront of the literature, and suggest that surgical diseases might be significantly accentuated in patients with H1N1 influenza.