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INTRODUCTION: Laparoscopic surgery has been increasingly used for treatment of gastric cancer. However, standardization of this minimally invasive approach has not been reached yet because of its technical difficulties and the concern about oncological safety. The aim of the study was to analyze the outcomes of our learning curve in this complex surgical technique. MATERIAL AND METHODS: The first consecutive 100 cases of laparoscopic gastrectomy performed at our Hospital from November 2008 to February 2018 were enrolled. Patients were divided into 2 groups on the basis of the period during which they were operated upon. The training phase was considered between 2008 and 2014 (46 cases) and the more developed phase (MDP) between 2015 and 2018 (54 cases). Conversion, lymphadenectomy and retrieved lymph nodes, hospital length of stay, mean operative time, complications, reintervention, and mortality rates were compared between the 2 phases of learning curve. RESULTS: The number of retrieved lymph nodes was higher in the MDP (17±8.6 vs. 23.3±10.4; P=0.004). Furthermore, we have also found less complications (47.8% vs. 27.8%; P=0.038), a decreased reintervention rate (15.2% vs. 1.85%; P=0.023), and overall mortality (8.7% vs. 0%; P=0.003) in the MDP. There were no significant differences in conversion rate, mean operative time, and hospital length of stay between phases. CONCLUSIONS: Although we consider that our learning curve is not yet completed, as the average of monitored parameters have not reached a steady state, the improvement on surgical parameters and postoperative course in the last 2 years have showed that our results are close to the best results published in the literature.

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INTRODUCTION: Leiomyomas are the most common benign tumors of the esophagus. Although classically surgical enucleation through thoracotomy or laparotomy has been widely accepted as treatment of choice, development of endoscopic and minimally invasive procedures has completely changed the surgical management of these tumors. MATERIAL AND METHODS: We performed a retrospective review of all esophageal leiomyoma operated at Hospital Universitario Ramón y Cajal (Madrid, Spain) between January 1986 and December 2014, analyzing patients' demographic data, symptomatology, tumor size and location, diagnostic tests, surgical data, complications and postoperative stay. RESULTS: Thirteen patients were found within that period, 8 men and 5 women, with a mean age of 53.62 years (range 35-70 years). Surgical enucleation was achieved in all patients. In 8 cases (61.54%) a thoracic approach was performed (4 thoracotomies and 4 thoracoscopies), and in 5 cases (38.56%) an abdominal approach was performed (3 laparotomies and 2 laparoscopies); enucleation was carried out through a minimally invasive approach in 6 patients (46.15%). There were no cases of endoscopic resection alone. Surgery mean length was 174.38 minutes (range 70-270 minutes) and median postoperative stay was 6.5 days (range 2-27 days). There was neither mortality nor cases of intraoperative complications were described. No postoperative major complications were reported; however one patient presented important pain in his right hemithorax that required management and long term follow-up by the Pain Management Unit. With a mean follow-up of 165.57 months (median 170; range 29-336 months) no recurrences were reported. CONCLUSION: Enucleation is the treatment of choice for the majority of esophageal leiomyomas. In our experience, duration of the surgical procedure through minimally invasive approach was longer than surgery through open approach; however, postoperative stay was shorter in the first group. Paradoxically, incision pain after surgery (thoracic neuralgia) was found to be higher in the minimally invasive approach group. Nevertheless, none of the results obtained in the study reached statistical significance, probably due to the small simple size.

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INTRODUCTION: Duodenal stump fistula (DSF) after gastrectomy has a low incidence but a high morbidity and mortality, and is therefore one of the most aggressive and feared complications of this procedure. MATERIAL AND METHODS: We retrospectively evaluated all DSF occurred at our hospital after carrying out a gastrectomy for gastric cancer, between January 1997 and December 2014. We analyzed demographic, oncologic, and surgical variables, and the evolution in terms of morbidity, mortality and hospital stay. RESULTS: In the period covered in this study, we performed 666 gastrectomies and observed DSF in 13 patients (1.95%). In 8 of the 13 patients (61.5%) surgery was the treatment of choice and in 5 cases (38.5%) conservative treatment was carried out. Postoperative mortality associated with DSF was 46.2% (6 cases). In the surgical group, 3 patients developed severe sepsis with multiple organ failure, 2 patients presented a major hematemesis which required endoscopic haemostasis, 1 patient had an evisceration and another presented a subphrenic abscess requiring percutaneous drainage. Six patients (75%) died despite surgery, with 3 deaths in the first 24 hours of postoperative care. The 2 patients who survived after the second surgical procedure had a hospital stay of 45 and 84 days respectively. In the conservative treatment group the cure rate was 100% with no significant complications and an average postoperative hospital stay of 39.5 days (range, 26-65 days). CONCLUSION: FMD is an unusual complication but it is associated with a high morbidity and mortality. In our experience, conservative management has shown better results compared with surgical treatment.

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Introducción: el leiomioma es el tumor benigno más frecuente del esófago. Aunque clásicamente, el tratamiento de este tipo de tumores ha consistido en la enucleación por medio de una laparotomía o toracotomía, el auge de las técnicas endoscópicas y mínimamente invasivas ha revolucionado totalmente el manejo terapéutico de este tipo de tumores. Material y métodos: realizamos un estudio retrospectivo de todos los leiomiomas esofágicos intervenidos en el Hospital Universitario Ramón y Cajal entre el 1 de enero de 1986 y el 31 de diciembre de 2014, analizando características demográficas de los pacientes, sintomatología, localización tumoral, pruebas diagnósticas, datos quirúrgicos, complicaciones y estancia hospitalaria. Resultados: encontramos un total de 13 pacientes, siendo 8 varones y 5 mujeres, con una edad media de 53,62 años (rango 35-70 años). El tratamiento quirúrgico fue en todos los casos una enucleación. En 8 casos (61,54%) se realizó un abordaje torácico (4 toracotomías y 4 toracoscopias) y en 5 casos (38,56%) el abordaje fue abdominal (3 laparotomías y 2 laparoscopias). La enucleación se llevó a cabo a través de un abordaje mínimamente invasivo en 6 pacientes (46,15%). No hubo ningún caso de resección puramente endoscópica. La media de duración de la cirugía fue de 174,38 minutos (rango 70-270 minutos) y la mediana de estancia hospitalaria de 6,5 días (rango 2-27 días). No se describió ningún caso de mortalidad ni complicación intraoperatoria, aunque un paciente presentó importante dolor en hemitórax derecho que requirió manejo y seguimiento por la unidad del dolor. Con un seguimiento medio de 165,57 meses (mediana 170; rango 29-336 meses), no se han observado recidivas. Conclusiones: la enucleación constituye el tratamiento de elección en la mayor parte de los leiomiomas esofágicos. En nuestra experiencia, la duración de la cirugía es mayor tras cirugía mínimamente invasiva (CMI) que tras cirugía abierta (CA), sin embargo, la estancia media hospitalaria es menor. Paradójicamente, en valores absolutos, las complicaciones relacionadas con el dolor de la herida quirúrgica (neuralgia torácica) son mayores en el grupo de CMI. Sin embargo, ninguno de los resultados obtenidos en el trabajo es estadísticamente significativo, seguramente debidos al escaso tamaño muestral (AU)

Introduction: Leiomyomas are the most common benign tumors of the esophagus. Although classically surgical enucleation through thoracotomy or laparotomy has been widely accepted as treatment of choice, development of endoscopic and minimally invasive procedures has completely changed the surgical management of these tumors. Material and methods: We performed a retrospective review of all esophageal leiomyoma operated at Hospital Universitario Ramón y Cajal (Madrid, Spain) between January 1986 and December 2014, analyzing patients’ demographic data, symptomatology, tumor size and location, diagnostic tests, surgical data, complications and postoperative stay. Results: Thirteen patients were found within that period, 8 men and 5 women, with a mean age of 53.62 years (range 35-70 years). Surgical enucleation was achieved in all patients. In 8 cases (61.54%) a thoracic approach was performed (4 thoracotomies and 4 thoracoscopies), and in 5 cases (38.56%) an abdominal approach was performed (3 laparotomies and 2 laparoscopies); enucleation was carried out through a minimally invasive approach in 6 patients (46.15%). There were no cases of endoscopic resection alone. Surgery mean length was 174.38 minutes (range 70-270 minutes) and median postoperative stay was 6.5 days (range 2-27 days). There was neither mortality nor cases of intraoperative complications were described. No postoperative major complications were reported; however one patient presented important pain in his right hemithorax that required management and long term follow-up by the Pain Management Unit. With a mean follow-up of 165.57 months (median 170; range 29-336 months) no recurrences were reported. Conclusion: Enucleation is the treatment of choice for the majority of esophageal leiomyomas. In our experience, duration of the surgical procedure through minimally invasive approach was longer than surgery through open approach; however, postoperative stay was shorter in the first group. Paradoxically, incision pain after surgery (thoracic neuralgia) was found to be higher in the minimally invasive approach group. Nevertheless, none of the results obtained in the study reached statistical significance, probably due to the small simple size (AU)

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Introducción: la fístula del muñón duodenal (FMD) es una de las complicaciones más agresivas tras una gastrectomía. Aunque la incidencia reportada en la literatura es baja, su asociación con una elevada morbimortalidad hace que sea una de las complicaciones más temidas por los cirujanos. Material y métodos: evaluamos de forma retrospectiva todas las FMD acaecidas en nuestro centro tras realizar una gastrectomía programada por neoplasia gástrica, en el periodo comprendido entre enero de 1997 y diciembre de 2014. Analizamos variables demográficas, oncológicas y quirúrgicas, así como la evolución posterior en términos de morbimortalidad y estancia hospitalaria. Resultados: en el periodo que comprende el estudio se realizaron 666 gastrectomías y observamos una FMD en 13 pacientes, lo que supone una incidencia del 1,95%. En 8 casos (61,5%) se efectuó un tratamiento quirúrgico, y en 5 casos (38,5%), un tratamiento conservador. La mortalidad postoperatoria asociada a una FMD fue del 46,2% (6 casos). En el grupo quirúrgico, 3 pacientes presentaron una sepsis grave con fracaso multiorgánico, 2 una hematemesis importante que requirió la realización de hemostasia endoscópica, una evisceración, y un absceso subfrénico que requirió drenaje percutáneo. Seis de los pacientes (75%) fallecieron a pesar del tratamiento quirúrgico, siendo 3 de las muertes en las primeras 24 horas tras la reintervención. Los 2 pacientes que consiguieron sobrevivir tras la reintervención presentaron una estancia de 45 y 84 días respectivamente. En el grupo de tratamiento conservador, la tasa de curación fue del 100%, no observándose complicaciones significativas y siendo la estancia media postoperatoria de 39,5 días (rango, 26-65 días). Conclusión: la FMD constituye una complicación poco frecuente pero asociada a una elevada morbimortalidad. En nuestra experiencia, el manejo conservador ha demostrado mejores resultados en cuanto a morbimortalidad en comparación con el tratamiento quirúrgico (AU)

Introduction: Duodenal stump fistula (DSF) after gastrectomy has a low incidence but a high morbidity and mortality, and is therefore one of the most aggressive and feared complications of this procedure. Material and methods: We retrospectively evaluated all DSF occurred at our hospital after carrying out a gastrectomy for gastric cancer, between January 1997 and December 2014. We analyzed demographic, oncologic, and surgical variables, and the evolution in terms of morbidity, mortality and hospital stay. Results: In the period covered in this study, we performed 666 gastrectomies and observed DSF in 13 patients (1.95%). In 8 of the 13 patients (61.5%) surgery was the treatment of choice and in 5 cases (38.5%) conservative treatment was carried out. Postoperative mortality associated with DSF was 46.2% (6 cases). In the surgical group, 3 patients developed severe sepsis with multiple organ failure, 2 patients presented a major hematemesis which required endoscopic haemostasis, 1 patient had an evisceration and another presented a subphrenic abscess requiring percutaneous drainage. Six patients (75%) died despite surgery, with 3 deaths in the first 24 hours of postoperative care. The 2 patients who survived after the second surgical procedure had a hospital stay of 45 and 84 days respectively. In the conservative treatment group the cure rate was 100% with no significant complications and an average postoperative hospital stay of 39.5 days (range, 26-65 days). Conclusion: FMD is an unusual complication but it is associated with a high morbidity and mortality. In our experience, conservative management has shown better results compared with surgical treatment (AU)

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Accessory spleens are usually asymptomatic, although they may cause hematological disorders associated with hypersplenism, usually after splenectomy. Moreover, cases of hypersplenism occurring secondary to enlargement of an accessory spleen with an unaltered normal spleen have been reported. An accessory spleen can also mimic an intra-abdominal neoplasm. We report a case of hypersplenism that occurred secondary to an increase in the size of the accessory spleen, which was located in the mesentery close to the cecum, mimicking recurrence of previously resected renal carcinoma.

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