The pathologist is forced to do an exhaustive study, looking for inadvertent perforations that can change the good prognosis of mucocele. We recommend follow-up of all patients with mucoceles, because sometimes they are associated with colorectal neoplasms and recurrence as pseudomyxoma peritonei.

Objective To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs). Methods This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center. Results Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications. Conclusions An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction. Keywords Pheochromocytoma • Paragangliomas • Presurgical management • Anesthetic treatment • α-blockadeThis article was elaborated by the multidisciplinary adrenal/ paraganglioma team of the Hospital Ramón y Cajal. Madrid (Spain).

Purpose: To identify presurgical and surgical risk factors for postsurgical complications in the pheochromocytoma surgery.Methods: A retrospective study of pheochromocytomas submitted to surgery in ten Spanish hospitals between 2011 and 2021. Postoperative complications were classi ed according to Clavien-Dindo scale.Results: One hundred and sixty-two surgeries (159 patients) were included. Preoperative antihypertensive blockade was performed in 95.1% of the patients, being doxazosin in monotherapy (43.8%) the most frequent regimen. Patients pre-treated with doxazosin required intraoperative hypotensive treatment more frequently (49.4% vs 25.0%, P=0.003) than patients treated with phenoxybenzamine, but no differences in the rate of intraoperative and postsurgical complications were observed. However, patients treated with phenoxybenzamine had a longer hospital stay (12.2±11.16 vs 6.2±6.82, P<0.001) than those treated with doxazosin. Hypertension resolution was observed in 78.7% and biochemical cure in 96.6% of the patients. Thirty-one patients (19.1%) had postsurgical complications. Prolonged hypotension was the most common, in 9.9% (n=16), followed by hypoglycaemia in 6 patients and acute renal failure in 4 patients. 13.0% of complications had a score ≥3 in the Clavien-Dindo scale. Postsurgical complications were more common in in patients with diabetes, cerebrovascular disease, higher plasma glucose levels, higher urinary free metanephrine and norepinephrine, and with pheochromocytomas larger than 5 cm. Conclusion:Preoperative medical treatment and postsurgical monitoring of pheochromocytoma should be especially careful in patients with diabetes, cerebrovascular disease, higher levels of plasma glucose and urine free metanephrine and norepinephrine, and with pheochromocytomas >5 cm, due to the higher risk of postsurgical complications. Introduction:Pheochromocytomas are rare neuroendocrine tumours that produce catecholamines [1]. They are a lifethreatening condition because catecholamine secretion is unpredictable, resulting in hypertension, arrhythmia, and/or other cardiovascular complications [2]. Surgery represents the primary treatment for pheochromocytomas [1]. Due to improvements in perioperative treatment, anaesthesia and surgical techniques, the mortality has dropped markedly in the last thirty years, but the risk of cardiovascular complications remains still high [3]. Intraoperative complications, including hypertensive crisis, hemodynamic instability and tachyarrhythmias, among others, have been reported in 30-50% of the pheochromocytoma surgeries [4][5][6]. The main postoperative major complications are prolonged hypotension and rebound hypoglycaemia [1]. However, postsurgical complications are usually less reported in pheochromocytoma studies, and are usually described in around 20-30% of the patients in recent series [4][7][8][9].Few studies have evaluated the grade of these complications using validate scales as the Clavien-Dindo score [4][10][9][8]. Moreover, studies evaluating risk factors for p...

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Key Clinical MessageAccessory splenectomy should be considered in any patient with recurrence of immune thrombocytopenic purpura, if studies (scintigraphy using heat‐damaged Tc99m‐labeled red blood cells) are suggestive of residual functional splenic tissue. The most common benefit after removal of accessory spleen seems to be the reduction of dose in medical treatment.

Background: paraesophageal hiatal hernia represents 5-10% of hiatal hernias. Its importance is based on the severe complications it may have, including gastric volvulus, and surgical treatment is recommended when a diagnosis is established. Material and methods: a retrospective study of all patients who underwent surgery for paresophageal hernia between 1985 and 2007. Results: we studied 90 cases, 68 females and 22 males with a median age of 67.6 years (37-96). Forty-five patients reported pyrosis, 34 epigastric postprandial pain, and 15 dysphagia; eight patients were diagnosed with gastric volvulus. Eighty-one patients underwent elective surgery and 9 emergency surgery. Forty-seven cases underwent an open procedure and 43 a laparoscopic one; 5 (11.6%) of them required conversion. The techniques performed were D´Or fundoplication in 35 cases, Nissen in 35, Toupet in 14, simple hiatal closure in 2, Narbona in 1, and Lortat-Jakob in 1; in 10 patients a mesh was placed. The complication rate for open procedure was 10.6 and 9.5% for the laparoscopic one (p > 0.05). Median hospital stay was 9.1 days for the open procedure and 3.4 for the laparoscopic one (p < 0.05). As follow-up, we analyzed 84 patients. After a median follow-up of 12 years (1-19), 15 patients were still symptomatic (17.8%), with recurrence in 8 cases (5 required reoperation). The satisfaction rate was 95.5% Conclusion: equivalent results were observed after laparoscopic and open surgery and a significant shorter hospital stay in the laparoscopic one. Therefore, we think that laparoscopic surgery should be considered as the election procedure for paraesophageal hiatal hernia.

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Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain Resultados de una encuesta sobre el soporte nutricional perioperatorio en la cirugía pancreática y biliar en España