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To determine the efficacy of coenzyme Q10 (CoQ10) in preventing renal injury in patients with lithiasis undergoing extracorporeal shockwave lithotripsy (ESWL).Prospective, randomised, double-blind, placebo-controlled clinical trial of 100 patients with renal lithiasis who were treated with ESWL. The patients were distributed randomly into two groups receiving either placebo or CoQ10 (200 mg/day), a powerful antioxidant with vasoactive properties, orally administered during the week before ESWL and for 1 week after. Renal dysfunction markers, vasoactive hormones, oxidative stress, plasma levels of several interleukins and vascular resistance index (VRI) using Doppler ultrasound were evaluated the week before ESWL, 2 h before ESWL and at 2 h, 24 h and 7 days after ESWL.There was a significant increase in glomerular filtration (P = 0.013), as well as a decrease in the albumin/creatinine ratio and the β2 -microglobulin level (P = 0.02) after 1 week of treatment in the CoQ10 group. These changes were maintained at the follow-up after ESWL. The administration of CoQ10 was associated with improvement in vasoactive hormone parameters, VRI and interleukin levels. These improvements were maintained until the end of the follow-up period. However, the administration of CoQ10 was not associated with significant changes in the oxidative stress parameters.Our results indicate that CoQ10 administration improves renal function and vasoactive and inflammation parameter values, allowing for preconditioning before the tissue insult caused by ESWL.

The mechanism of action of the pituitary hormone PRL was studied in hepatocytes of lactating rats. PRL receptor immune complexes obtained from liver lysates have an associated tyrosine kinase activity. The tyrosine kinase has been identified in isolated hepatocytes as pp60c-src. Incubation of hepatocytes with PRL induces the association of PRL receptor with pp60c-src and the resultant stimulation of its tyrosine kinase activity. Furthermore, PRL stimulates the gene expression of c-fos, c-jun, and c-src. All of these findings support the idea that the pp60c-src tyrosine kinase participates in the early steps of the PRL intracellular signaling that promotes cell growth in liver cells., This work was supported by grants from the DGICYT (PM91-0223 and PB93-0136), CAM (C137/91and C263/91A), and the Ramón Areces Foundation.

Aim To evaluate the effectiveness of human fibrinogen-thrombin collagen patch (TachoSil®) in the reinforcement of high-risk colon anastomoses. Methods A quasi-experimental study was conducted in Wistar rats (n = 56) that all underwent high-risk anastomoses (anastomosis with only two sutures) after colectomies. The rats were divided into two randomized groups: Control group (24 rats) and treatment group (24 rats). In the treatment group, high-risk anastomosis was reinforced with TachoSil® (a piece of TachoSil® was applied over this high-risk anastomosis, covering the gap). Leak incidence, overall survival, intra-abdominal adhesions, and histologic healing of anastomoses were analyzed. Survivors were divided into two subgroups and euthanized at 15 and 30 d after intervention in order to analyze the adhesions and histologic changes. Results Overall survival was 71.4% and 57.14% in the TachoSil® group and control group, respectively (P = 0.29); four rats died from other causes and six rats in the treatment group and 10 in the control group experienced colonic leakage (P > 0.05). The intra-abdominal adhesion score was similar in both groups, with no differences between subgroups. We found non-significant differences in the healing process according to the histologic score used in both groups (P = 0.066). Conclusion In our study, the use of TachoSil® was associated with a non-statistically significant reduction in the rate of leakage in high-risk anastomoses. TachoSil® has been shown to be a safe product because it does not affect the histologic healing process or increase intra-abdominal adhesions.

Hepatitis C virus (HCV) clearance is an independent predictive factor for long-term survival in HIV-HCV liver transplantation patients. After 46 months of antiviral therapy it is achieved in up to 80% of cases. Little is known, however, about spontaneous viral clearance. We performed prospective study of HIV-HCV coinfected liver transplant patients.Between January 1, 2001, and December 31, 2011, we analyzed the parameters from among HIV-HCV coinfected liver transplant patients of donor and recipient ages, transplant cause, Model for End-Stage Liver Disease (MELD) score, donor and recipient serology, transplant date, viral load before and after transplantation, immunosuppressive therapy, HCV recurrence, HCV viral clearance (spontaneous and duration), retransplant cause, and viral load before and after retransplant, as well as survival.The seven transplanted HIV-HCV coinfected patients had most commonly HCV-related hepatocarcinoma (n = 5, 71.42%). Three subjects (42.85%) developed HCV recurrences. Two patients (28.57%) were retransplanted, both due to HCV recurrence with one of them developing a spontaneous clearance of HCV (14.28%). This patient showed a preoperative HIV viral load50 copies IU/mL, CD4+ count 486/μL, HCV-RNA 2564 IU copies/mL, Anti-HBc+, and MELD 30. The donor was an 81-year-old female who was Anti-HBc+. Immunosuppressive therapy consisted of cyclosporine, mycophenolate, and prednisone. One month after transplantation, the patient developed an acute cellular rejection episode with progression of liver disease secondary to the HCV recurrence (56.5 × 105 copies IU/mL). He started antiviral treatment (α-interferon and ribavirin), but due to side effects and interactions with the antiretrovirals, they were stopped after four doses. The viral load decreased spontaneously and progressively until it became negative at 146 days after transplantation; he was retransplanted and HCV-RNA has continued to be negative after 772 days.Spontaneous clearance of HCV among HIV-HCV coinfected liver transplant patients is possible. Despite no treatment, one patient still has no detectable HCV viral load after retransplantation.

Hepatic artery complications after orthotopic liver transplantation are associated with a high rate of graft loss and mortality (23% to 35%) because they can lead to liver ischemia. The reported incidence of hepatic artery thrombosis (HAT) after adult liver transplantation is 2.5% to 6.8%. Typically, these patients are treated with urgent surgical revascularization or emergent liver retransplantation. Since January 2007, we have recorded the postanastomotic hepatic artery flow after revascularization. The aim of this study was to assess the relationship between hepatic blood flow on revascularization and early HAT. Retrospectively, we reviewed perioperative variables from 110 consecutive liver transplantation performed at the Virgen del Rocio University Hospital (Seville, Spain) between January 2007 and October 2010. We evaluated the following preoperative (donor and recipient) and intraoperative variables: donor and recipient age, cytomegalovirus serology, ABO-compatibility, anatomical variations of the donor hepatic artery, number of arterial anastomoses, portal and hepatic artery flow before closure, cold ischemia time, and blood transfusion. These variables were included in a univariate analysis. Of the 110 patients included in the study, 85 (77.7%) were male. The median age was 52 years. ABO blood groups were identical between donor and recipient in all the patients. The prevalence of early HAT was 6.36% (7 of 110). Crude mortality with/without HAT was 22% versus 2% (P = .001), respectively. Crude graft loss rate with/without HAT was 27% versus 4% (P = .003), respectively. Early HAT was shown to be primarily associated with intraoperative hepatic artery blood flow (93.3 mL/min recipients with HAT versus 187.7 mL/min recipients without HAT, P < .0001). No retransplantation showed early HAT. In our experience, intraoperative hepatic artery blood flow predicts early HAT after liver transplantation.

Objective The objective of this study was to analyze survival, and mortality, rates as well as its causes during the month following liver transplantation with respect to the model for end-stage liver disease (MELD) model. Material and Methods We reviewed the mortality at 24 and 48 hours as well as 1 and 4 weeks of 380 transplanted patients over the past 7 years with regard to the MELD score. Results The mean patient age was 55 years. Among subjects with MELD score ≤ 15 (n = 142; 37.36%), there were 34 deaths (23.94%), including 7 (4.92%) who died during the first month. The mean cause of death during this period was hemorrhage (n = 3; 8.8%). Among those with MELD scores between 16 and 18 (n = 76; 20%), the mortality rate increased to 23.68% (n = 18), including 3 who died during the first month (3.94%) with 1 case due to hemorrhage. Among the cohort with MELD scores between 19 and 21 (n = 78; 20.52%), 25 (32.05%) died, including 9 during the first month (11.53%). The most frequent cause of death was septic shock (n = 5; 20%). The mortality rate among patients with a MELD score between 22 and 24 was 22% (n = 11), of which 8% (n = 4) died in the month. The mean cause of death during this period was multiple organ dysfunction (n = 2; 18.1%). The patient group with a MELD score >24 had a 32.3% mortality rate (n = 11); 4 patients died during the first month following transplantation (11.76%). The most frequent cause of death was hemorrhage (n = 2; 18.1%). Conclusions Survival during the first month did not seem to be related to the MELD score at the time of transplantation, nor did we observe a direct correlation between the MELD score and the overall risk of mortality.

The age of 50 has been considered as a cut-off to discriminate older subjects within HIV-infected people according to the Centers for Disease Control and Prevention (CDC). However, the International AIDS Society (IAS) mentions 60 years of age and the Department of Health and Human Services (DHHS) makes no consideration. We aimed to establish an age cut-off that could differentiate response to highly active antiretroviral therapy (HAART) and, therefore, help to define advanced age in HIV-infected patients. CoRIS is an open, prospective, multicenter cohort of HIV adults naive to HAART at entry (January 2004 to October 2009). Survival, immunological response (IR) (CD4 increase of more than 100 cell/ml), and virological response (VR) (HIV RNA less than 50 copies/ml) were compared among 5-year age intervals at start of HAART using Cox proportional hazards models, stratified by hospital and adjusted for potential confounders. Among 5514 patients, 2726 began HAART. During follow-up, 2164 (79.4%) patients experienced an IR, 1686 (61.8%) a VR, and 54 (1.9%) died. Compared with patients aged

Mesenchymal neoplasms of the gallbladder are rare and in particular leiomyomas of the gallbladder have been rarely reported, all of them in patients with immune system disorders. This is the first report in Spanish of a 23-year-old female patient with a gallbladder leiomyoma without associated immunodeficiency. The patient lacks a previous history of uterine leiomyoma or any other form of neoplasm. She refers several episodes of epygastralgia. A hydatic cyst led to an initial diagnosis and the gallbladder was removed by means of simple cholecystectomy. The abnormal macroscopic aspect of the sample prompted intraoperative biopsy which revealed a benign gallbladder angiomyoma. Subsequent immunohistochemical analysis of the resected sample yielded the diagnosis of intramural endocavitary leiomyoma negative for EBV and C-kit / CD-117. The patient has good general condition and remains asymptomatic 15 months after surgery.

Introduction and indications. Robotic surgery has numerous advantages in rectal cancer surgery. Studies have reported the advantages associated with single-port approaches, such as eliminating the need for additional incisions, as well as the difficulties inherent in this technique. The authors present a hybrid technique that they performed using a robotic total mesorectal excision with the aid of a single port-device. Materials and methods. The authors performed the technique on 2 patients using a single-port device through an umbilical incision and 3 accessory ports for the robotic arms. There was no need to place ports for the assistant’s equipment or for an assistant incision. Results and complications. The operation time was 177.5 minutes, and there were no intraoperative or postoperative complications. Both patients were discharged 7 days after the operation. Conclusions. This technical variation is an additional step forward for oncological surgery with minimal damage to the abdominal wall.

A 49-year-old man presented at the emergency department for severe epigastric pain and a 48-hour episode of vomiting with a greatly affected general state. This is a patient diagnosed with Behcet’s disease and ankylosing spondylitis, operated for a hiatal hernia two months before his admission, where a laparoscopic Nissen fundoplication and pillars closure were performed. During the immediate postoperative period, he manifested a picture of vomiting and dysphagia after waking up from the anesthetic procedure. Both disappeared with corticosteroid administration. At the admission to the hospital, the patient showed clear signs of difficulty breathing, paleness, sweating, tachypnea, and tachycardia. On examination, we found no breath sounds in the right hemithorax, and the abdominal exploration revealed signs of rigidity of abdominal wall. Chest X-ray (Fig. 1). Our differential diagnosis stated hiatal hernia recurrence vs. secondary acute esophageal perforation for abdominal overpressure due to persistent nausea (Boerhaave syndrome). A thoraco-abdominal CT scan was requested (Fig. 2). An urgent surgery was performed, where we found a complete transhiatal migration from stomach to chest and an associated organoaxial volvulus, as well as a partially disrupted fundoplication. Once the herniated viscera were reintroduced in the abdominal cavity, a proper vascularisation was showed. The fundoplication was rebuilt and the pillars were approached. An abdominal drainage was inserted and removed 4 days after the postoperative period.

Varon de 29 anos que sufre traumatismo dorsolumbar cerrado de alta energia por desprendimiento de una roca. Ante la estabilidad hemodinamica, se realiza TC urgente que no aprecia lesion diafragmatica (fig. 1). Se coloca tubo de torax y fijacion pelvica. Al tercer dia aparece velamiento del hemitorax derecho en la radiografia de control y se realiza nueva TC que objetiva rotura diafragmatica derecha (fig. 2). Se realiza laparotomia subcostal derecha (fig. 3), reduccion del contenido y cierre primario del desgarro mediante sutura continua de PDS loop reforzada posteriormente mediante protesis Proceed fijada con sutura de polipropileno y adhesivo de fibrina. c i r e s p . 2 0 1 5 ; 9 3 ( 9 ) : e 1 0 1

Resumen Presentamos el caso clinico de una mujer de 33 anos diagnosticada de carcinoma suprarrenocortical en estadio avanzado. Describimos la forma de presentacion clinica, los metodos diagnosticos empleados y el tratamiento, especialmente en su aspecto quirurgico, que puede precisar en determinadas ocasiones conocimientos y habilidades en cirugia hepatica y vascular para intentar conseguir la reseccion completa del tumor y mejorar la supervivencia en estos pacientes, generalmente muy jovenes; asimismo, realizamos una actualizacion bibliografica diagnosticoterapeutica de esta neoplasia, rara en su frecuencia pero agresiva en su evolucion

Acute renal failure is a relevant complication in obstructive jaundice (OJ). The extracellular water volume (ECW) depletion and myocardial dysfunction affects haemodynamic and renal disturbance in patients with OJ.A prospective open randomised study was conducted to evaluate the effect of peridrainage saline infusion associated with dopamine administration on hormonal and renal function derangements in 102 patients with malignant OJ. Patients were randomly distributed according to whether (n=64) or not (n=38) received dopamine with saline solution before endoscopic biliary drainage. Furthermore, patients receiving dopamine were randomly distributed whether (n=31) or not (n=33) received additional dopamine administration during the postdrainage phase. Different parameters such as ECW, serum levels of aldosterone, renin, atrial natriuretic peptide (ANP), antidiuretic hormone (ADH), endothelin-1 (ET-1), urine PGE2 and creatinine clearance (CrCl) were analyzed.Fluid administration was accompanied by an increase in the ECW (p=0.01) and an improvement in the CrCl (p=0.01). Dopamine increased CrCl by 11% (p=0.04) and reduced urinary PGE2 concentration (p=0.02). After drainage, a transient worsening of CrCl was seen in patients on i.v. fluid infusion alone but not in dopamine groups (p=0.001). Improvement of CrCl after dopamine administration was found in patients with serum bilirubin16 mg/dl and sodium urine excretion145 mEq/l.The administration of dopamine associated with appropriate i.v. fluid infusion in the peridrainage period has an impact on renal function only in selected patients with malignant biliary obstruction. This effect is more relevant in patients with higher marked cholestasis.

Rifampicin has been used for the treatment of patients with jaundice and pruritus. This study evaluated the effect of rifampicin on the expression of different detoxification systems and bile acid transporters during in-vivo and in-vitro experimental models of cholestasis.Rifampicin was administered to glycochenodeoxycholic acid (GCDCA)-treated human hepatocytes and bile duct-obstructed rats. Different parameters related to cell death, and the expression of phase I and II drug metabolizing enzymes (DME) and bile acid transporters were determined.The induction of hepatocellular injury induced by cholestasis was associated with a reduction in cytochrome P4503A4 (CYP3A4), CYP7A1, and UDP-glucuronosyltransferase 2B4 (UGT2B4) expression, as well as an increase in import (Na(+)-taurocholate co-transporting polypeptide, NTCP) system expression. The beneficial properties of rifampicin were associated with an increase in DME and export bile acid systems (multidrug resistance-associated protein 4, MRP4, and bile acid export pump to bile duct, BSEP) expression, as well as a reduction in NTCP expression.The beneficial effect of rifampicin in cholestasis is associated with an increase in DME expression involved in toxic, bile acid and cholesterol metabolism, as well as a reduction in the bile acid importing system in hepatocytes.

Ascaris lumbricoides infection in Spain is anecdotal and is usually associated with travel to areas with high endemicity such as India and South America. Biliopancreatic disease caused by this parasite is both rare and one of the most feared complications. There are few publications in the literature about pancreatic involvement in ascariasis. We describe a case of pancreatic ascariasis diagnosed after a pancreaticoduodenectomy was performed for a suspected pancreatic adenocarcinoma.A 58-year-old man consulted for longstanding abdominal pain and diarrhea. Computed tomography and magnetic resonance scans, endoscopy, and endoscopic ultrasound-guided fine-needle cytology were performed. The pathological diagnosis was moderately differentiated adenocarcinoma of the pancreatic head.Cephalic pancreaticoduodenectomy was performed. The postoperative course was favorable. A pancreatic fistula type B (ISGPF classification) developed and was resolved with conservative treatment. Analysis of the surgical specimen revealed the presence of a pancreatic pseudotumor due to Ascaris lumbricoides. After these findings, treatment was completed with oral albendazole.Pancreatic ascariasis in our environment is unusual, but should be included in the differential diagnosis of tumors and inflammatory processes of the pancreas.

The syntheses of eight conformationally restricted analogues of N -acetylmuramyl- l -alanyl d -isoglutamine (MDP) based on the d -glucopyrano[2,3- d ]oxazolidine ring system are described.

The electron impact mass spectra of 29 oxazolidines derived from sugars were examined. Four general pathways of fragmentation were encountered, the importance of which depends on the nature of the different substitutents.

Aims To present our case series of fully covered self-expandable metallic stents (FCSESs) placed to treat biliary stenosis after liver transplantation and leakage after failure of plastic stenting. Materials and methods We retrospectively reviewed the courses of patients who had undergone liver transplantation with a biliary complication that was treated by an FCSES installed by endoscopic retrograde cholangiopancreatography. We evaluated the following variables: gender, age, indication for transplantation, time between transplant and diagnosis of the complication, number of plastic stents placed before the FCSES, and procedure-related complications. Results From April 2008 to March 2010, 11 patients who had undergone a duct-to-duct anastomosis suffered posttransplant biliary stenosis or leakage with failure of endoscopic treatment using a plastic biliary stent: Namely, eight cases of stenosis and three of biliary leaks. Three patients underwent a papillotomy to place the FCSES, with no significant morbidity. No severe complications were observed after the endoscopic treatments; two patients developed mild pancreatitis; two, hyperamylasemia; and one, mild biliary sepsis. We removed the FCSES after a mean of 280 (range = 173–310) days. Five patients lost the FCSES spontaneously. One patient underwent a choledocojejunostomy and two are waiting biliary surgery. Conclusion We avoided cholangiojejunostomy in 6/9 cases (not including the two deaths). Papillotomy did not engender a greater morbidity. The spontaneous loss of the stent is a problem that need to be resolved.

Backgrounds Patients with liver cirrhosis suffer various degrees of cardiac dysfunction which may be crucial in determining the outcome of surgery. The aim of this study was to determine the role of natriuretic peptides on the assessment of cardiac dysfunction in patients with liver cirrhosis. Methods Prospective longitudinal study of 30 patients with hepatic cirrhosis. Severity of disease was assessed according to the Child-Turcotte-Pugh and Model for End Stage Liver Disease (MELD) scores. Cardiac function was assessed using endocrine markers [atrial natriuretic peptide-brain natriuretic peptide (BNP)] and isotopic ventriculography at baseline and after stimulation with dobutamine. Results The ejection fraction was higher in patients with Child A+B and MELD less than 18 than in patients with advanced liver disease. A significant correlation between BNP plasma levels and MELD values was observed. Dobutamine induced a marked improvement in myocardial performance associated to a decrease in BNP levels. Multivariate analysis showed that BNP has prognostic value as a marker of cardiac ejection fraction. Patients whose baseline BNP concentrations were more than 70 pg/ml had an ejection fraction of around 45%. Conclusion This study has shown that increased baseline BNP concentrations may be regarded together with high Child and MELD scores, as the critical cardiac dysfunction threshold in cirrhotic patients.

Whether peritoneal dialysis is a risk factor for the development of intra-abdominal infection after simultaneous pancreas-kidney (SPK) transplantation is controversial.We investigated the incidence of intra-abdominal infection and graft survival rates in 100 patients who underwent SPK transplantation. Prior to transplantation, 25 patients received peritoneal dialysis (PD) and 75 received hemodialysis (HD); mean duration of dialysis was 25 +/- 35 months and 17 +/- 10 months, respectively.The two groups displayed similar gender distribution, cold ischemia time, dialysis duration, diabetes duration, and method of exocrine drainage. Intra-abdominal infections developed in 23 patients in the HD group (30%) and in 6 (24%) patients in the PD group (P = 0.41). In the HD group, 61% of patients with intra-abdominal infections had grades 3 and 4 complications requiring surgery, compared with only 33% in the PD group. The 1-year pancreas graft survival rate was 88% for HD and 94% for PD (P = 0.67) (mean follow-up = 55 +/- 38 months). There were no significant intergroup differences in acute rejection episodes, kidney graft survival rates, or length of hospital stay.In our experience, PD prior to SPK transplantation is not associated with increased incidence of intra-abdominal infection compared to HD.

Background: Several models have recently been developed to predict mismatch repair (MMR) gene mutations. Their comparative performance with clinical criteria or universal molecular screening in a population based colorectal cancer (CRC) cohort has not been assessed. Methods: All 1222 CRC from the EPICOLON cohort underwent tumour MMR testing with immunohistochemistry and microsatellite instability, and those with MMR deficiency (n= 91) underwent MLH1/ MSH2 germline testing. Sensitivity, specificity and positive predictive value (PPV) of the PREMM1,2 and the Barnetson models for identification of MLH1/ MSH2 mutation carriers were evaluated and compared with the revised Bethesda guidelines (RBG), Amsterdam II criteria, and tumour analysis for MMR deficiency. Overall discriminative ability was quantified by the area under the ROC curve (AUC), and calibration was assessed by comparing the average predictions versus the observed prevalence. Results: Both models had similar AUC (0.93 and 0.92, respectively). Sensitivity of the RBG and a PREMM1,2 score > 5% was 100% (95% CI 71% to 100%); a Barnetson score.0.5% missed one mutation carrier (sensitivity 87%, 95% CI 51% to 99%). PPVs of all three strategies were 2 - 3%. Presence of MMR deficiency increased specificity and PPV of predictive scores ( 97% and 21% for PREMM1,2 score > 5%, and 98% and 21% for Barnetson > 0.5%, respectively). Conclusions: The PREMM1,2 and the Barnetson models offer a quantitative systematic approach to select CRC patients for identification of MLH1/MSH2 mutation carriers with a similar performance to the RBG.

In patients with type 1 diabetes mellitus and end-stage renal disease, simultaneous pancreas-kidney transplantation is associated with increased survival when compared with solitary deceased kidney transplant or dialysis. We consider that the analysis of our long-term program (based in a single center) of simultaneous pancreas-kidney transplantation would provide valuable information for this therapeutic approach regarding patient and organ survival.The outcome of 57 consecutive pancreas-kidney transplants patients was analyzed. The analysis included characteristics of the donor and recipient and survival rates of patients and both grafts. We also analyzed age and modality of renal replacement treatment as possible mortality risk factors.Ten-year patient, kidney and pancreas graft survival rates were 75.8%, 57.2% and 42.7%, respectively. Censoring for patient death, the results for 10-year kidney and pancreas survival were 78.5% and 58%, respectively.Our results add evidence to support the notion that the double and simultaneous pancreas-kidney transplantation is in fact the treatment of choice in selected patients with end-stage renal failure due to type 1 diabetes mellitus.

Gastrointestinal stromal tumors (GIST) are an infrequent cause (1%) of severe gastrointestinal hemorrhage. Treatment is mainly surgical through complete tumoral resection. We report the case of a 29-year-old woman who presented to the emergency room with severe gastrointestinal bleeding manifested by melena. On physical examination the patient had a painless, palpable mass in the left abdomen. Esophagogastroduodenoscopy, computed tomography, angiography and urgent surgical intervention led to diagnosis of a jejunal GIST.

IN OUR SECTIONS, diabetic nephropathy as a result of diabetes mellitus type I is the etiology of terminal renal insufficiency in 6% of patients on a dialysis program and in 8.7% of kidney transplant patients. This group of patients can benefit from a combined pancreas-kidney transplant (PKT), rather than an isolated kidney transplant (KT). This type of transplant eliminates the need for dialysis and therapy with insulin, as well as stabilizes retinopathy, neuropathy, and diabetic nephropathy. The aim of this article is to compare the results of PKT with those of isolated KT in patients with terminal renal insufficiency secondary to mellitus diabetes type I, assessing the number of rejections, kidney graft function, kidney and pancreas graft survival and patient survival during the first 2 posttransplant years.

A 52-year-old woman with a prior history of haemodialysis and a failed renal transplant was studied for hyperparathyroidism. A SPECT (single-photon emission computed tomography)-CT scan was performed that revealed intense-tracer uptake in the right superior thyroid lobe (Fig. 1), and several extra-thyroid locations, in the sternum, right acromium, proximal third of both humerus bones, and in the middle-third of the 6th and 7th right ribs (Fig. 2), compatible with osteitis fibrosa cystica (brown tumours), although bone metastasis could not be ruled out. Biopsy confirmed brown tumours. A parathyroidectomy was performed and PTH and calcium levels returned to normal. At present this presentation of hyperparathyroidism is very uncommon. Diagnosis: Brown tumours secondary to parathyroid adenoma. c i r e s p . 2 0 1 3 ; 9 1 ( 1 ) : 5 3

Mujer de 20 anos sin antecedentes de interes es trasladada al servicio de urgencias tras sufrir accidente de trafico. Refiere un golpe en region epigastrica. A pesar de no encontrar alteraciones en la ecografia de urgencias se mantiene en observacion. A las 48 h, el dolor epigastrico aumenta gradualmente de intensidad y se asocia a nauseas y vomitos. En la exploracion abdominal se objetiva dolor epigastrico sin signos de peritonismo. Ante este cuadro clinico se decide realizacion de ecaner donde aparece una lesion lineal hipodensa que atraviesa cuerpo de pancreas, compatible con laceracion o rotura pancreatica junto con liquido libre intraabdominal (fig. 1). Se realiza laparotomia exploradora urgente, donde se confirma rotura pancreatica del 75% de la glandula a nivel istmico con desgarro completo del conducto de Wirsung. Se procede a al cierre del Wirsung y sellado del munon proximal y reconstruccion del munon distal en Y de Roux transmesocolica. Buena evolucion en UCI y planta, con normalizacion de parametros analiticos, fue alta 23 dias despues de la cirugia, encontrandose en la actualidad asintomatica. c i r e s p . 2 0 1 2 ; 9 0 ( 1 0 ) : e 3 9

The syntheses are described of four conformationally restricted derivatives of muramic acid based on the α- d -glucopyrano[2,3- d ]oxazolidine ring system.

Hirschsprung's disease is characterized by absence of ganglion cells in submucosal and myenteric plexus of distal bowel. Most cases become manifest during the neonatal period, but in rare instances, this disease is initially diagnosed in adult age. It usually presents as severe constipation with colonic dilatation proximal to the aganglionic segment. The treatment is surgical, removing the aganglionic segment and restoring continuity of digestive tract. The disease rarely presents as an acute intestinal obstruction. We report a case not previously diagnosed, which presented as a massive colonic dilatation with a maximum diameter of 44 cm, with imminent risk of drilling that forced to perform an emergency surgery. We include a review of existing literature.

ResumenAntecedentesLa afectación esplénica secundaria a un traumatismo abdominal cerrado es frecuentemente tratada mediante esplenectomía. Ante la gravedad de las consecuencias del síndrome postesplenectomía (pérdidas hemáticas, sepsis, etc.) cada vez se tiende más a la preservación del órgano afectado. Presentamos un caso clínico de preservación de bazo tras traumatismo abdominal cerrado con implicación hiliar de dicho órgano, en el que se recurre al papel esencial del Floseal® como agente hemostático.Caso clínicoMujer de 22 años que presenta traumatismo abdominal cerrado tras accidente de tráfico, con diagnóstico de lesión esplénica del polo inferior con compromiso hiliar que implica la vascularización de dicha región. Se procede a la intervención quirúrgica urgente con preservación esplénica mediante esplenectomía parcial y control del sangrado con Floseal® y con el empleo de una malla de refuerzo de ácido poliglicólico. La evolución postoperatoria es satisfactoria y sale del hospital al 5.o día sin incidencias.ConclusiónEl empleo de agentes hemostáticos como el gel de gelatina y trombina (Floseal®) y el uso de mallas envolventes de ácido poliglicólico posibilitan la cirugía de preservación esplénica tras un traumatismo abdominal, representando una alternativa segura y factible a la esplenectomía completa clásica, con el beneficio de la conservación del órgano y de sus funciones.AbstractBackgroundSplenic involvement secondary to blunt abdominal trauma is often treated by performing a splenectomy. The severity of the post-splenectomy syndrome is currently well known (blood loss, sepsis), so there is an increasing tendency to preserve the spleen. The case is presented of splenic preservation after blunt abdominal trauma with hilum involvement, emphasising the role of Floseal® as a haemostatic agent, as well as the use of resorbable meshes to preserve the spleen.Clinical caseA 22-year-old woman presenting with a grade IV splenic lesion secondary to a blunt abdominal trauma after a traffic accident. Partial splenic resection was performed and bleeding was controlled with Floseal® and use of a reinforcing polyglycolic acid mesh. No postoperative complications occurred, being discharged on day 5. The long-term follow-up has been uneventful.ConclusionThe use of haemostatic agents such as thrombin and the gelatine gel (FloSeal®) and the use of polyglycolic acid meshes enable spleen-preserving surgery, making it a feasible and reproducible procedure and an alternative to classical splenectomy.