Selected publications from PubMed
Assessment of a process-based urban river restoration using biological and hydro-geomorphological indicators. The Congost River at Granollers (Catalonia, Spain).
Farguell J, Chavez J, Ochoa L
J Environ Manage. 2024 Oct;369:122424 doi: 10.1016/j.jenvman.2024.122424.
Wilkie's syndrome as a rare upper intestinal obstruction cause.
Besa A, Domínguez-Garijo P, Curell A, Farguell J, Ibarzábal A, Morales X, Momblan D, Turrado V
Surg Open Sci. 2023 Dec;16:155-156 doi: 10.1016/j.sopen.2023.10.010.
EUSEDcollab: a network of data from European catchments to monitor net soil erosion by water.
Matthews F, Verstraeten G, Borrelli P, Vanmaercke M, Poesen J, Steegen A, Degré A, Rodríguez BC, Bielders C, Franke C, Alary C, Zumr D, Patault E, Nadal-Romero E, Smolska E, Licciardello F, Swerts G, Thodsen H, Casalí J, Eslava J, Richet JB, Ouvry JF, Farguell J, Święchowicz J, Nunes JP, Pak LT, Liakos L, Campo-Bescós MA, Żelazny M, Delaporte M, Pineux N, Henin N, Bezak N, Lana-Renault N, Tzoraki O, Giménez R, Li T, Zuazo VHD, Bagarello V, Pampalone V, Ferro V, Úbeda X, Panagos P
Sci Data. 2023 Aug 4;10(1):515 doi: 10.1038/s41597-023-02393-8.
Incisional Hernia Following Open Pancreaticoduodenectomy: Incidence and Risk Factors at a Tertiary Care Centre.
González-Abós C, Pineda C, Arrocha C, Farguell J, Gil I, Ausania F
Curr Oncol. 2023 Jul 25;30(8):7089-7098 doi: 10.3390/curroncol30080514.
Unilateral axilo-breast approach (UABA) with gas insufflation versus open conventional hemithyroidectomy: A prospective comparative study.
Saavedra-Pérez D, Manyalich M, Domínguez P, Farguell J, Rull R, López-Boado MÁ, Vilaça J, Vidal Ó
Cir Esp (Engl Ed). 2023 Feb;101(2):107-115 doi: 10.1016/j.cireng.2022.09.014.
Most surgeons performing abdominal-wall surgery consider the Rives-Stoppa technique to be the gold standard procedure in the open treatment of midline ventral hernias, particularly incisional hernias. In this video, we describe a STEP by STEP Rives-Stoppa retromuscular repair. We start the surgery with a laparotomy as the patient presents with a midline incisional hernia. After that, we perform the dissection of the subcutaneous tissue until we identify the incisional sac which should be left closed to improve postoperative comfort and to reduce adhesion formation. The next surgical step consists in the exposure of the retromuscular pre-fascial space, which is approached through a longitudinal dissection of the rectus sheath along its entire length. The separation of the posterior sheath from the muscular belly laterally continues along an avascular space to reach the external margin of the rectus muscle, thus achieving posterior separation of the components. The distal dissection continues until the arcuate line is reached below the umbilical scar. After wall preparation, two flaps will restore the deep layer of abdominal wall, thus containing the hernial sac and defining a pre-fascial space, from the xyphoid apophysis to the arcuate line, and a preperitoneal retromuscular space. Then we start creating the new abdominal wall. The plasty of the posterior rectus sheath proceeds craniocaudally by means of a continuous monofilament absorbable suture using the small bites technique. Then the mesh is secured on the retromuscular space using biological glue and the anterior sheath is closed. The Rives-Stoppa technique has excellent long-term results, with minimal morbidity in patients with large primary or recurrent incisional hernias and is the gold standard for most surgeons in these cases.
Published
Jul 2021
Localization studies Preoperative localization is an important step in this surgery. Historically a bilateral neck exploration was performed. Noninvasive preoperative imaging techniques, such as USG, MIBI (99mTc sestamibi scintigraphy) or CT (computed tomography) are commonly used while diagnosing thyroid pathologies. SURGERY Surgery is performed under general anesthesia and the proper positioning of the patient is key to prepare the surgical field. Proper positioning involves a supine position with the neck extended and both arms at the sides. The solitary adenoma normally appears to be enlarged in size and discolored and without injuring the recurrent nerve it is divided from the surrounding tissue. Open MIP This is the most common minimally invasive technique for parathyroidectomy. It is based on a central incision of 2.5 to 3 cm. As it is done with conventional parathyroidectomy platysma is divided and muscles are separated to identify the thyroid gland. With a medial rotation the parathyroid gland can be exposed. Radio-guided parathyroidectomy The patient receives technetium-99m sestamibi 2-4 hours prior to surgery and with a gamma probe an intraoperative localization of the affected gland can be performed. Video-assisted MIP In this approach a small transverse incision of 1.5 to 2 cm is made 2cm above the sternal notch. Once the thyroid gland is dissected and rotated medially a 5-mm endoscope and dissection instruments are inserted through the single incision. Advantages of this technique include a small incision and central access that permits further parathyroid or thyroid resection if necessary. Adenoma size needs to be less than 3 cm. Endoscopic MIP There are two different approaches: the anterior one and the lateral. In the anterior approach, a trocar is used to pass a 5-mm endoscope through a small central incision with CO2 insufflation and two or three trocars are placed for instrumentation. Then the dissection is performed beneath the platysma and muscles are retracted to visualize the thyroid. In the lateral approach, a 12 mm incision is made along the anterior sternocleidomastoid, 4 cm above the sternal notch. Then the dissection plane is created above the prevertebral fascia. Complications Parathyroid surgery has a low complication rate, and minimally invasive surgery decreases the risk of them. – Hematoma: Postoperative hematoma compresses the trachea and causes venous congestion and subsequent airway compromise. – Recurrent Laryngeal nerve injury: Injury to the recurrent laryngeal nerve results in paresis or palsy of the vocal cord causing hoarseness when an unilateral damage is produced or airway occlusion when a bilateral damage is produced. – Hypocalcemia: Most hypocalcemia is transient and permanent hypocalcemia is rare. When this hypocalcemia is not corrected it may cause tetany, cardiac dysrhythmia and seizures.
Published
Jan 2021
Clinical Case Ulcerative colitis is a long-term condition that is characterized by recurring episodes of inflammation and ulcers that are limited to the mucosal layer of the colon and rectum. The pattern of disease activity is characterized by periods of active inflammation alternating with periods of remission. Although ulcerative colitis is primarily treated medically, surgery is sometimes required as patients can become refractory to medical treatment and develop severe complications. There are different scores to define the severity of UC and generally it is classified as mild, moderate or severe. Disease extension Ulcerative proctitis. Left-sided colitis. Pancolitis. Goals of therapy Mucosal healing is associated with long-term clinical remission, corticosteroid-free clinical remission and avoidance of colectomy. To achieve clinical and endoscopic remission there are several classes of medication including mesalamine, immunomodulators, corticosteroids and biologicals. Mild treatment: Mesalamines are the first-line therapy for induction of remission. Selection among formulations for treatment depends primarily on disease extent. Second-line therapies for patients with mild-moderate UC who do not respond to mesalamine are corticosteroids. Clinical response usually takes 7-10 days. Moderate treatment: Agents currently approved for the induction and maintenance of remission of moderate-severe UC include the biologics infliximab, adalimumab, golimumab, vedolizumab, and ustekinumab, in addition to the small-molecule Janus kinase (JAK) inhibitor tofacitinib. Severe treatment: These patients need to be hospitalized and treatment is based on steroids, infliximab, and cyclosporine. Treatment is based on a multidisciplinary approach by gastroenterology, medicine, and surgery teams, given the risk of significant morbidity and mortality.The immediate goal of therapy is hemodynamic stability and clinical improvement. Surgery The most common elective surgery performed for patients with medically refractory is the restorative proctocolectomy with ileal pouch anal anastomosis. Indications for emergency surgery: Colonic perforation Massive gastrointestinal hemorrhage Toxic megacolon Acute fulminant colitis
Published
Sep 2020
Introduction Breast carcinoma in situ is a heterogeneous group of neoplastic lesions confined to the breast ducts (ductal carcinoma in situ [DCIS]). The diagnosis of DCIS increased dramatically following the introduction of screening. It represents 25% of all new diagnosed breast cancers. The goal of therapy for DCIS is to prevent the development of invasive breast cancer. Therapeutic approaches include surgery, radiation therapy, and adjuvant endocrine therapy. Treatment The options for treatment of these patients are breast-conserving therapy (BCT) or mastectomy. Local treatment Local treatment for DCIS is usually based on breast-conserving therapy followed by adjuvant radiation therapy. (RT). Radiation therapy may be reasonably omitted in a select population of patients with low-risk disease. Mastectomy can be considered in some cases. BCT for DCIS offers a low rate of recurrence with minimal complications. Mastectomy Mastectomy is curative for most patients with DCIS, with only 1 to 2 percent of disease recurrence. The causes of recurrence are inadequate margins, incomplete removal of breast tissue or an unrecognized invasive carcinoma during the surgery. When breast reconstruction is needed it is normally performed immediately. Sentinel lymph node biopsy (SLNB) is indicated in some women that require a mastectomy. The lymphatic drainage pattern is changed after performing a mastectomy so at a later date it is impossible to perform an SLNB if needed (for example if invasive cancer is found unexpectedly in the specimen). As patients who require a mastectomy are those with a higher likelihood of having an invasive cancer they should routinely undergo SLNB. Criteria for BCT 1. Histologically negative margins can be achieved with a lumpectomy. Negative margins are defined by tumor-filled ducts separated by a measurable distance from the inked surface (ie, 2 mm). It is recognized that it may not be possible to achieve these margin widths, particularly with DCIS close to the skin or muscle. 2. Multifocal disease is not a contraindication for BCT unless it is a multicentric disease which means involving two or more quadrants. 3. Cosmetically acceptable resection If patients do not meet BCT criteria, a mastectomy is indicated.. Breast-conserving therapy (BCT) · BCT refers to a lumpectomy to remove the tumor with negative surgical margins. It is usually followed by radiotherapy to treat any residual disease. · Core biopsy, needle, wire, reflector, or seed localization under mammographic guidance prior to surgical excision may ensure complete resection. · RDT is the standard for patients treated with BCT, though it may be reasonable to omit it in selected patients. Pathologic examination · Complete tissue examination. · Exclude invasive carcinoma. · Evaluate the distance of the resection margins. · Check for contiguous or multifocal distribution. Take-home messages · The goal when treating DCIS is to prevent the development of an invasive breast cancer. · BCT and mastectomy have similar cancer-specific survival rates. · Local treatment for DCIS is usually based on breast-conserving therapy followed by adjuvant radiation therapy. (RT) · Complete tissue examination is important when BCT is performed to exclude invasive carcinoma. · With appropriate treatment the prognosis is excellent.
Published
Jun 2020
Introduction The spleen is one of the most commonly injured intra-abdominal organs. Diagnosis and prompt management are key to success and their goal is to avoid potentially life-threatening haemorrhage. The preservation of functional splenic tissue is secondary as usually the attempt to save the spleen is abandoned due to an ongoing hemorrhage that is life-threatening. Emergent and urgent splenectomy remains a life-saving measure for many patients. The spleen is located posterolateral in the left upper quadrant of the abdomen beneath the left hemidiaphragm and lateral to the greater curvature of the stomach. Mechanism of injury Splenic injury most commonly occurs following blunt trauma due to motor vehicle collisions (driver, passenger, or pedestrian). However, blunt splenic injury can also result from falls, sport-related activities, assault or iatrogenic injuries from surgical or endoscopic manipulation. In the latter case, the lesion is caused by a capsular tear, laceration from retraction devices or tension on the spleen. Trauma evaluation In these patients we perform initial resuscitation, diagnostic evaluation and management following the the Advanced Trauma Life Support (ATLS) protocols. In the initial history and physical examination, the patient usually complains of a left upper abdominal, left chest or shoulder pain. They may also present with abdominal tenderness and peritoneal signs. It is also important to determine whether these patients have medical comorbidities requiring antiplatelet or anticoagulant medication as these may impact in management decisions. When evaluating these patients, associated injuries need to be explored. Lower rib fractures, pelvic fractures, spinal cord injury and other visceral lesions might be present. Diagnostic evaluation Focused assessment with sonography for trauma patients (FAST) is a rapid examination that is performed as a screening test in trauma patients. A negative FAST exam does not exclude splenic injury. Signs of splenic injury include a black rim around the spleen which may indicate subcapsular fluid. Other signs are intraperitoneal fluid or fluid in the hepatorenal space. CT-Scan findings Hemoperitoneum: When fluid collections around the spleen are identified in trauma patients this is highly suggestive of hemoperitoneum. Hypodensity: Parenchymal disruptions and also intraparenchymal or subcapsular hematomas are represented as hypodense regions. Contrast extravasation: When contrast extravasation is identified it normally implies active bleeding so an urgent intervention is indicated. Splenic injury grading The American Association for Surgery of Trauma (AAST) has an injury grading scale based on different finding that can be identified either on CT scan or intraoperatively. Grade 1: Subcapsular hematoma <10 percent surface area. Parenchymal laceration <1 cm in depth or capsular tear. Grade 2: Subcapsular hematoma 10 to 50 percent surface área. Parenchymal laceration 1 to 3 cm in depth. Grade 3: Subcapsular hematoma >50 percent of surface area; ruptured subcapsular or intraparenchymal hematoma. Parenchymal laceration >3 cm in depth. Grade 4: Any injury in the presence of a splenic vascular injury or active bleeding confined within splenic capsule. Parenchymal laceration involving segmental or hilar vessels producing >25 percent of devascularization Grade 5: Any injury in the presence of splenic vascular injury with active bleeding extending beyond the spleen into the peritoneum. Shattered spleen. Non-operative management Traditionally, the years the only option to treat patients with splenic lesions was to perform a surgical exploration but this approach has been changing in recent years and currently non-operative management is used to manage 50 to 70 percent of cases, typically in low-grade injuries. This approach is based on the assumption that salvaging functional splenic tissue avoids the risk of surgical and anesthetic complications and postsplenectomy sepsis. Observation The first option in nonoperative management is observation. However, this requires a monitored care setting, either in an intensive care unit or in a lower unit depending on the capabilities of the hospital, the grade of splenic injury, and the severity of other injuries. The duration of observation should be individualized based on the grade of the splenic injury and the patient’s clinical status. Most trauma surgeons recommend follow-up imaging. If observation fails, either splenic embolization or more commonly, operative management is required. Splenic embolization Splenic embolization requires specialized imaging facilities and a vascular interventionalist experienced in celiac artery catheterization and embolization techniques. Surgery Hemodynamically unstable traumatic patients, patients who are not candidates for nonoperative management, and patients in whom non-operative strategies fail require surgical exploration. When surgery is performed, splenic salvage depends on the severity of the lesion, the patient’s clinical status, and the associated injuries. CONCLUSIONS Traumatic splenic injury is a life-threatening situation. In treatment of patients with splenic injury, initial resuscitation, diagnostic evaluation and management is based on protocols for trauma patients (ATLS). For the diagnosis, CT scan findings are splenic hypodensity, subcapsular or intraparenchymal hematoma, active intravenous contrast extravasation or hemoperitoneum. If the patient is hemodynamically unstable and the FAST exam is positive, immediate surgical exploration is required. Management of stable patients must be individualized.
Published
Apr 2020
CASE 1: Transjejunal laparoscopic-assisted ERCP a technique to deal with choledocholitiasis after a Roux-en-Y reconstruction. The patient is a female of 31 years old that undergone a Roux-en-Y Gastric Bypass two years earlier and presented periodic abdominal pain. MRCP showed stones on the biliary common duct. In the preoperative CT scan no internal hernias were found. TREATMENT: It was decided to perform a laparoscopic-assisted ERCP. The first thing to do was to identify the gastro-jejunal anastomosis and the jejunal-jejunal anastomosis. An internal hernia in the Petersen space was found but immediately reduced and closed. Then the cholecystectomy was performed. Once the limb near the Treitz ligament was identified and pulled through a mini-laparotomy, a colonoscope was introduced and a plastic stent was placed in the papilla, which was the reference for the sphincterotomy. After doing that, a 5mm stone came out. Then the bile duct was checked with a fogarty balloon catheter and a cholangiogram. Then enterotomy was closed and it was checked for any biliary lesions. OUTCOME: After the surgery the patient started liquid diet the first day and was dismissed after 4 days. Questions were about the use of colonoscope rather than duodenoscope, absorbable suture, mini-laparotomy and transgastric and totally endoscopic approach for similar cases. CASE 2: Endoscopic tunneled stricturotomy with full-thickness dissection in the management of a sleeve gastrectomy stenosis. The patient was a 28 years old women with a history of a sleeve gastrectomy in 06/2018. (BMI: 35.3) who was presenting dysphagia to solid food. During the progression to solid food she developed food regurgitation and vomiting and that is why upper-GI series were performed (stenosis was identified). To treat this stenosis she underwent 3 endoscopic pneumatic balloon dilatations. Those were not effective and she lost 30kg in 5 months so it was decided to perform an endoscopic tunneled stricturotomy with full-thickness dissection. TREATMENT: To start the procedure, once the stenosis was identified a submucosal injections is performed 3-5 cm before the stenotic area. Then, an incision was performed to tunnel submucosally. In this part of the surgery is important to stay on the submucosal layer and not go full-thickness. Then a myotomy was performed and in the area marked with both yellow arrows (stapled line) we dissect out performing the full-thickness stricturotomy. After that, we close using clips. We can see a comparison before and after performing the procedure showing a much larger lumen. OUTCOME: The patient had no post-procedure symptoms and during follow-up the patient tolerated diet and no recurrence of the symptoms appeared. At 2 months, we can see the differences in the upper-GI series and in the endoscopy. As a conclusion endoscopic tunneled stricturotomy with full-thickness dissection appears to be safe and effective in the management of stenosis after sleeve gastrectomy. This procedure can be used after conventional techniques such as pneumatic balloon dilatation or stents fail, or may be considered as an initial therapy for sleeve stenosis. Discussion was based on patient selection, indications, myotomy technique and leak rates. CASE 3: From Nissen Fundoplication to RYGB to treat both GERD and morbid obesity Patient was a 31 year-old woman that had an open Nissen fundoplication on 2010 and a surgical revision with a redo of it on 2012. She complained with dysphagia and morbid obesity so an extensive preoperative workout was done. In the Barium swallow, an esophageal dilatation with a cardial stenosis was presented, and also, an additive image on the left side of the esophagus suggestive of an ulceration. The Upper-GI endoscopy revealed an esophagitis grade C and the manometry showed incomplete waves at lower 3rd and inappropriate release of LES. In the pH-metry acid reflux and positive DeMeester score were evidenced. TREATMENT: The procedure starts dissecting the perigastric tissue, that is challenging as it presented high fibrotic component. Then the dissection of the gastric valve and the hiatal region from the right to the left was completed. Once that was performed an small gastric pouch of 20cc was created to reduce the acid production. Then as in a normal RYGB the biliopancreatic is done at 50cm and the alimentary at 150cm. Jejuno-jejunal and gastro-jejunal were handsewn. OUTCOME: No events were presented in the postoperative, patient at two years follow-up has a BMI of 27, No GERD and no IPP. As a conclusion RYGB is a great option to treat GERD in obese patients. We cannot forget dysphagia as a complication of Nissen fundoplication and conversion from Nissen to RYGD allows us to treat dysphagia, GERD and obesity. Different topics were discussed after the presentation of this case as: short gastric pouch, differences with regular bypass, situations where you cannot undo the Nissen fundoplication, mesh indications above others. CASE 4: From RYGB to SADS Patient was a 49 year-old woman with an initial BMI of 57 and it was decided to convert to SADS for weight regain. TREATMENT: The first thing to do was remove all adhesions from previous surgeries and then dissect the Hiss angle. Once this has been done, he identifies the Roux limb and dissects it 25cm after the gastric pouch. The next thing to do was to connect the greater curve with the Hiss angle. He disconnects the previous anastomosis and performs a gastro-gastrostomy. It is important to do it near the lesser curve as after that a Sleeve gastrectomy will be performed using a Bougie of 42 frames as a reference. The transection of the duodenum is performed conserving as much vascularization as it is possible in order to maintain sleeve well irrigated. After that duodenum-ileal anastomosis handsewn was performed. Anastomosis were checked with methylene blue. OUTCOME: The outcome was good and the patient was discharged 2 days after the procedure with no complications. Questions were about rate of complications, length of limbs, roux limb, conversion after RYGB and weight loss after conversion. CASE 5: PETERSEN’S HERNIA AFTER OAGB Patient was a 48 years-old woman with a BMI of 52, she was referring bile reflux with no response to medical treatment. So it was decided to convert mini-gastric bypass to RYGB. TREATMENT: As the surgery started, an internal hernia was identified on the Petersen’s defect, in this case the hernia was protruded from medial to lateral something that is rare as normally it is the other way around. To start the procedure we need to identify the proximal and distal limb of gastrojejunal anastomosis. On the proximal limb of this anastomosis an enterotomy was performed and 75cm of the alimentary limb were measured to perform the jejunojejunal anastomosis. After that the jejunojejunal and Petersen’s defect were closed. After doing that, the transection of biliopancreatic limb from alimentary limb was performed. OUTCOME: The outcome was good and the patient was discharged 1 day after the procedure with no complications. A short term follow-up at 3 months was symptoms free. In this last case, discussion was based on rate bile reflux, biliopancreatic limb length, indications for conversion, causes for bile reflux and hernia defect closures.
Published
Feb 2020
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