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Introducción: desde su introducción en 1991, la cirugía antirreflujo por vía laparoscópica ha ido adquiriendo gran popularidad hasta convertirse en el procedimiento de elección de la enfermedad por reflujo gastroesofágico. Objetivo: identificar y analizar de forma retrospectiva las causas de conversión del abordaje laparoscópico en la cirugía de la enfermedad por reflujo gastroesofágico y de la hernia de hiato. Material y métodos: desde 1993 a agosto de 2007 se han efectuado en nuestro centro 606 cirugías antirreflujo por vía laparoscópica, encontrando 296 mujeres y 310 varones con una edad media de 53,3 años. La indicación fundamental fue la existencia de un reflujo gastroesofágico resistente al tratamiento médico con hernia de hiato asociada. De forma preoperatoria se van a efectuar estudios manométricos y pH-métricos, endoscopia oral y tránsito esofagogastroduodenal. La técnica quirúrgica de elección fue mayoritariamente la funduplicatura tipo Nissen-Rossetti. Resultados: la estancia media postoperatoria fue de 2,7 días, realizándose conversión a cirugía abierta en 43 casos (7%). Las conversiones fueron más frecuentes en la primera década de la curva de aprendizaje (26 vs. 17 p < 0,016), y menores en el grupo de cirujanos expertos en cirugía laparoscópica avanzada (15vs. 28, p < 0,017). En 17 casos la conversión fue debida a una complicación intraoperatoria y en 26 casos a dificultades técnicas. Las tasas de perforación esofágica y de neumotórax fueron del 0,8 y 1%, mientras que la tasa de mortalidad y morbilidad fue del 0,1 y 12% respectivamente. Conclusión: la tasa de conversión está dentro de los límites aceptables y ha disminuido con la experiencia.Background: since its introduction in 1991 laparoscopic antireflux surgery has gained great success and popularity among surgeons, and now it is the gold standard for the treatment of gastroesophageal reflux disease (GERD). Aim: to identify and evaluate the causes of conversion in the laparoscopic surgery of GERD and hiatus hernia. Material and methods: since January 1993 to August 2007 606 laparoscopic antireflux procedures were performed in our hospital. There were 296 women and 310 men with a median age of 53.5 years. The main indication for surgery was evidence of intractable or recurrent GERD symptoms after adequate medical treatment with associated hiatal hernia. The preoperative workup included manometry, pH-metry, oral endoscopy, and barium swallow. The surgical technique was mainly the Nissen-Rossetti procedure. Results: mean postoperative hospital stay was 2.7 days. The operation had to be converted to an open procedure in 43 cases (7%). Conversions were more frequent in the first decade of the learning curve (26vs. 17, p < 0.016), and fewer among the group of experts in advanced laparoscopic surgery (15vs. 28, p < 0.017). In 17 cases conversions were due to an intraoperative complication whereas in 26 cases a conversion was done because of technical difficulties. Esophageal perforation and pneumothorax rates were 0.8 and 1%, respectively, and mortality and morbidity rates were 0.1 and 12%. Conclusion: the rate of conversion is acceptable and significantly decreases with surgeon experience.

Zenker's diverticulum arises in the posterior wall of the pharynx, above the cricopharyngeal muscle, secondary to a functional cricopharyngeal disorder. We describe our experience with the management of Zenker's diverticulum from 1985 to this day in a third-level hospital. We review clinical data from 27 patients (78% males) with a mean age of 60.4 years. The most common clinical manifestations were dysphagia, regurgitation, syalorrhea, cough, and weight loss. All cases were diagnosed using an esophagogram. A diverticulectomy with cricopharingeal myotomy was performed in 74% of patients. Complications developed in 5 cases (21%), and the recurrence rate was 4% (1 of 3 cases, where myotomy was not performed).

Introduction: leiomyoma is the most common benign esophageal neoplasm. Surgical treatment (enucleation) has traditionally been the therapy of choice. The advent of minimally invasive techniques has produced an increase in endoscopic approaches to the detriment of open surgery. Objective: the aim of this study was to compare the results obtained with open surgery and with laparoscopic surgery in this kind of pathology. Material and methods: we performed a retrospective study of all leiomyomas operated for in our center between 1986 and 2004, and obtained 9 cases of esophageal leiomyoma. Four were women and five men, between the ages of 40 and 70, with a mean age of 53.5 years. The most frequent symptoms were heartburn (5 cases), dysphagia (3 cases), and retrosternal pain (3 cases). Surgery was in all the cases an enucleation. An open approach was performed in 5 cases (3 thoracotomies and 2 laparotomies), and an endoscopic approach in 4 (2 thoracoscopies and 2 laparoscopies). Results: the mean postoperative hospital stay was 5.12 days (range 2-8 days). This was shorter for endoscopic approaches versus open surgery (3.25 vs. 7 days). There was no case of esophageal mucosal perforation or reconversion. No death, intraoperative complication, or tumor relapse was described. Only 2 patients had complications: post-surgical thoracic pain, and intestinal obstruction by adhesions 8 years after surgery. Conclusion: enucleation is an easier procedure and constitutes the therapy of choice for esophageal leiomyoma. This approach has to be laparoscopic. We think that muscle borders should be closed after enucleation, and that biopsy is not indicated preoperatively.Introducción: el leiomioma es el tumor benigno más frecuente del esófago. Tradicionalmente el tratamiento quirúrgico de estos pacientes consistía en la enucleación. El avance en las técnicas mínimamente invasivas ha provocado un aumento del abordaje endoscópico en detrimento de la cirugía abierta. Objetivo: el objetivo del trabajo fue comparar los resultados obtenidos por vía abierta y por vía laparoscópica en este tipo de patología. Material y métodos: realizamos un estudio retrospectivo de los leiomiomas intervenidos en nuestro centro entre 1986-2004, obteniéndose 9 leiomiomas esofágicos. Cuatro eran mujeres y cinco varones, con unas edades comprendidas entre los 40-70 años, siendo la edad media de 53,5 años. Los síntomas más frecuentes eran pirosis (5 casos), disfagia (3 casos) y dolor retroesternal (3 casos). El tratamiento quirúrgico fue en todos los casos la enucleación. En cinco pacientes se realizó un abordaje abierto (3 toracotomías y 2 laparotomías) y en 4 casos se realizó una laparoscopia (2 toracoscopias y 2 laparoscopias). Resultados: la estancia hospitalaria postoperatoria oscila entre los 2-8 días, con una media de 5,12 días, siendo esta menor en el grupo en el que se realizó cirugía laparoscópica en comparación con el grupo de cirugía abierta (3,25-7 días). No existe ningún caso de perforación de la mucosa esofágica ni de reconversión. Tampoco se describe ningún caso de mortalidad, complicación intraoperatoria ni de recidiva tumoral. Dos pacientes presentan algún tipo de complicaciones: dolor torácico post cirugía, obstrucción intestinal por bridas 8 años después de la cirugía. Conclusión: la enucleación es un procedimiento fácilmente realizable y constituye el tratamiento de elección del leiomioma esofágico. Actualmente el abordaje debe ser laparoscópico. Somos partidarios del cierre de la muscular y bajo nuestro punto de vista la biopsia preoperatoria no está indicada.

Introducción: desde su introducción en 1991, la cirugía antirreflujo por vía laparoscópica ha ido adquiriendo gran popularidad hasta convertirse en el procedimiento de elección de la enfermedad por reflujo gastroesofágico. Objetivo: identificar y analizar de forma retrospectiva las causas de conversión del abordaje laparoscópico en la cirugía de la enfermedad por reflujo gastroesofágico y de la hernia de hiato. Material y métodos: desde 1993 a agosto de 2007 se han efectuado en nuestro centro 606 cirugías antirreflujo por vía laparoscópica, encontrando 296 mujeres y 310 varones con una edad media de 53,3 años. La indicación fundamental fue la existencia de un reflujo gastroesofágico resistente al tratamiento médico con hernia de hiato asociada. De forma preoperatoria se van a efectuar estudios manométricos y pH-métricos, endoscopia oral y tránsito esofagogastroduodenal. La técnica quirúrgica de elección fue mayoritariamente la funduplicatura tipo Nissen-Rossetti. Resultados: la estancia media postoperatoria fue de 2,7 días, realizándose conversión a cirugía abierta en 43 casos (7%). Las conversiones fueron más frecuentes en la primera década de la curva de aprendizaje (26 vs. 17 p < 0,016), y menores en el grupo de cirujanos expertos en cirugía laparoscópica avanzada (15vs. 28, p < 0,017). En 17 casos la conversión fue debida a una complicación intraoperatoria y en 26 casos a dificultades técnicas. Las tasas de perforación esofágica y de neumotórax fueron del 0,8 y 1%, mientras que la tasa de mortalidad y morbilidad fue del 0,1 y 12% respectivamente. Conclusión: la tasa de conversión está dentro de los límites aceptables y ha disminuido con la experiencia.

Importance: Herpes zoster, a frequent complication following autologous hematopoietic stem cell transplantation (HSCT), is associated with significant morbidity. A nonlive adjuvanted recombinant zoster vaccine has been developed to prevent posttransplantation zoster., Objective: To assess the efficacy and adverse event profile of the recombinant zoster vaccine in immunocompromised autologous HSCT recipients., Design, Setting, and Participants: Phase 3, randomized, observer-blinded study conducted in 167 centers in 28 countries between July 13, 2012, and February 1, 2017, among 1846 patients aged 18 years or older who had undergone recent autologous HSCT., Interventions: Participants were randomized to receive 2 doses of either recombinant zoster vaccine (n = 922) or placebo (n = 924) administered into the deltoid muscle; the first dose was given 50 to 70 days after transplantation and the second dose 1 to 2 months thereafter., Main Outcomes and Measures: The primary end point was occurrence of confirmed herpes zoster cases., Results: Among 1846 autologous HSCT recipients (mean age, 55 years; 688 [37%] women) who received 1 vaccine or placebo dose, 1735 (94%) received a second dose and 1366 (74%) completed the study. During the 21-month median follow-up, at least 1 herpes zoster episode was confirmed in 49 vaccine and 135 placebo recipients (incidence, 30 and 94 per 1000 person-years, respectively), an incidence rate ratio (IRR) of 0.32 (95% CI, 0.22-0.44; P < .001), equivalent to 68.2% vaccine efficacy. Of 8 secondary end points, 3 showed significant reductions in incidence of postherpetic neuralgia (vaccine, n=1; placebo, n=9; IRR, 0.1; 95% CI, 0.00-0.78; P = .02) and of other prespecified herpes zoster-related complications (vaccine, n=3; placebo, n=13; IRR, 0.22; 95% CI, 0.04-0.81; P = .02) and in duration of severe worst herpes zoster-associated pain (vaccine, 892.0 days; placebo, 6275.0 days; hazard ratio, 0.62; 95% CI, 0.42-0.89; P = .01). Five secondary objectives were descriptive. Injection site reactions were recorded in 86% of vaccine and 10% of placebo recipients, of which pain was the most common, occurring in 84% of vaccine recipients (grade 3: 11%). Unsolicited and serious adverse events, potentially immune-mediated diseases, and underlying disease relapses were similar between groups at all time points., Conclusions and Relevance: Among adults who had undergone autologous HSCT, a 2-dose course of recombinant zoster vaccine compared with placebo significantly reduced the incidence of herpes zoster over a median follow-up of 21 months., Trial Registration: ClinicalTrials.gov Identifier: NCT01610414.

Purpose: The application of mesh-reinforced hiatal closure has resulted in a significant reduction in recurrence rates in comparison with primary suture repair. However, the use of meshes has not completely extended in all the cases of large paraesophageal hiatal hernias (LPHH) due to the complications related to them. The aim of this study is to present our long-term results and complications related to Crurasoft ® mesh (Bard) for the treatment of LPHH., Methods: From January 2004 to December 2014, 536 consecutive patients underwent open or laparoscopic fundoplication for gastroesophageal reflux disease or LPHH at Ramón y Cajal University Hospital. Primary simple suture of the crura and additional reinforcement with a Crurasoft ® mesh (Bard) was performed in 93 patients (17.35 %). Radiologic hiatal hernia recurrence and mesh-related complications were investigated., Results: Of the 93 patients undergoing mesh repair, there were 28 male and 65 female with a mean age of 67.27 years (range 22-87 years). Laparoscopic surgery was attended in 88.2 % of the cases, and open surgery in the rest 11.8 %. Mean operative time was 167.05 min (range 90-370 min). Median postoperative stay was 4.79 days (range 1-41 days). Conversion rate was 8.53 % (7 patients). Intraoperative complications were described in 10.75 % (10 patients), but all of them, except in one case, could be managed laparoscopically. Overall postoperative complications rate was 28 %. Early postoperative complications occurred in 11 patients (12 %), respectively, for grades 2 (6 cases), 3b (1 case) and 5 (4 cases) according to the Clavien-Dindo classification. Late postoperative complications occurred in 15 patients (16 %), respectively, for grades 1 (7 cases), 2 (2 cases), 3b (5 cases) and 5 (1 case) according to the Clavien-Dindo classification. Thirty day-mortality rate was 4.3 %. Mortality rate specific associated with the mesh was 1 %. Reoperation rate was 5.4 %. After a median follow-up of 76.33 months (range 3-130 months), 8 patients (9 %) developed a recurrent hiatal hernia. Mesh was removed in three cases (3.22 %)., Conclusions: In our experience, the recurrence rate in patients with a Crurasoft ® (Bard) is acceptable. However, the rate of postoperative complications and mortality is excessive. The use of meshes in the hiatus keeps on being controversial due to the severe complications related to them. It would be advisable to compare our results in the non-mesh group in terms of recurrences and complications, to determine if meshes in the hiatus should be given in these patients due to its high rate of complications.

A case of Candida parapsilosis endocarditis observed 16 months after BMT is reported. The patient, a 35-year-old female with CML, suffered from Candida parapsilosis fungemia on day +22 after BMT. In spite of treatment with amphotericin B, fluconazole and catheter withdrawal, the same yeast was isolated > 1 year later from a vegetation on an old rheumatic mitral valve. Although the patient remained in complete cytogenetical and hematological remission, in vitro tests showed reduced phagocytic and chemotactic capacity of neutrophils and monocytes. This case stresses the need of prolonged therapy for patients with candidemia after BMT.

A case of acute lymphoblastic leukemia (ALL) in a 16-year-old male with a 47,XYY karyotype is reported. This chromosome aneuploidy was found in both bone marrow (BM) cells and mitogen-stimulated lymphocytes. Immunologic profile of leukemic cells showed a null phenotype. To our knowledge, this is the fifth case reported in the literature.

We have examined the ultrastructural characteristics of peroxidase activity in human bone marrow mast cells. These studies were performed in three patients with systemic mast cell disease, and in another six patients showing bone marrow mast cell hyperplasia. Endogenous peroxidase activity was localized in the perinuclear cisternae and strands of endoplasmic reticulum, but never in the granules. We have also demonstrated the "in vivo" existence of exogenous peroxidase activity in two of the three cases of systemic mast cell disease. The peroxidase internalization involved its binding to the plasma membrane, followed by its incorporation into the cell by a general endocytic process comprising the uptake of dispersed peroxidase-positive material mainly by phagocytosis of granular structures containing peroxidase. The exogenous peroxidase appeared in non-membrane bound granules, vacuoles or aggregates, but we have never seen the enzyme linked to the mast cell granules.