J. A. Lujan Mompean

Laparoscopic versus open appendicectomy: a prospective assessment.

A prospective study of 200 consecutive patients with suspected acute appendicitis was performed to compare open and laparoscopic appendicectomy. Formal randomization was precluded by instrument availability. Some 100 patients underwent laparoscopic appendicectomy (conversion to laparotomy was carried out in five) and 100 had conventional surgery. The groups were similar in sex ratio, age, degree of appendiceal inflammation and antibiotic treatment. The mean duration of open appendicectomy was 46 min and of the laparoscopic procedure 51 min (P not significant). Postoperative complications in patients who underwent laparoscopic appendicectomy included: intraabdominal abscess (two patients), wound infection (one), early bowel obstruction (four all resolved with medical treatment) and umbilical haematoma (two). There were no reoperations in the immediate or late postoperative period. Complications after open operation were: wound infection (seven patients) (P < 0·05), early bowel obstruction (five; three resolved with medical treatment, two required surgery) and haematoma of the Surgical wound (one). The mean hospital stay was 4·8 days for laparoscopic appendicectomy and 6·0 days for the open operation (P < 0·05). There were no deaths.

Gastric surgery and bezoars.

We present a series of 56 patients with gastrointestinal bezoar following previous gastric surgery for gastroduodenal peptic ulcer. The following parameters were studied: factors predisposing to bezoar formation (type of previous surgery, alimentation, and mastication), form of clinical presentation, diagnostic tests, and treatment. A bilateral truncal vagotomy plus pyloroplasty had been performed previously on 84% of patients, 44% revealed excessive intake of vegetable fiber, and 30% presented with bad dentition. The most frequent clinical presentation was intestinal obstruction (80%). This was diagnosed mainly by clinical data and simple abdominal radiology. The main exploratory technique for diagnosing cases of gastric bezoar was endoscopy. Surgery is necessary for treating the intestinal forms, and one should always attempt to fragment the bezoar and milk it to the cecum, reserving enterotomy and extraction for cases where this is not possible. The small intestine and stomach should always be explored for retained bezoars. Gastric bezoars should always receive conservative treatment, endoscopic extraction, and/or enzymatic dissolution; gastrotomy and extraction should be performed when this fails.

Influence of the neo-adjuvant radiochemotherapy as a factor in the surgical treatment of rectal cancer by expert surgeon. A comparative study

Total mesorectal excision and surgeon experience are prognostic factors in rectal cancer surgery, in terms of local recurrence and conservative sphincter surgery. Pre-operative radiation-chemotherapy can even improve those results. The aim of this study is to assess the utility of pre-operative radiation therapy (PRT) on the results of surgical treatment for rectal cancer comparing two consecutive series of patients operated on by surgeons with experience in rectal cancer surgery according to whether they had received PRT. Retrospective review of 118 patients with rectal cancer, divided into two groups: group I, 57 patients without pre-operative radiation-chemotherapy, and group II, 61 patients with rectal cancer who received pre-operative radiation-chemotherapy. Both groups were homogeneous. The short-term results (surgical technique, post-operative stay, post-operative complications) and long-term results (local recurrences, liver metastases and both overall and tumour-related survival) were analysed. The rate of anterior resection in the lower third was significantly higher (p = 0.037) in group II than in group I (56 vs 23%), the rate of abdominoperineal resection in the middle third was significantly lower (p = 0.046) in group II (3.5 vs 21%). The incidence of post-operative complications was similar in both groups, but the rate of anastomotic leaks was higher in group II. The local recurrences was lower in group II (p = 0.002), but the disease free survival and the overall survival was similar in both groups. At the multivariate analysis, the only prognostic factor for the local recurrence was the use of pre-operative radiation-chemotherapy. Besides surgeon experience and total mesorectal excision, a very important prognostic factor is the administration of pre-operative radiation-chemotherapy in cases of locally advanced rectal cancer, as it does not increase post-operative morbidity and mortality and significantly influences the rate of local recurrences and the conservative sphincter surgery.Background and aimsTotal mesorectal excision and surgeon experience are prognostic factors in rectal cancer surgery, in terms of local recurrence and conservative sphincter surgery. Pre-operative radiation-chemotherapy can even improve those results. The aim of this study is to assess the utility of pre-operative radiation therapy (PRT) on the results of surgical treatment for rectal cancer comparing two consecutive series of patients operated on by surgeons with experience in rectal cancer surgery according to whether they had received PRT.Materials and methodsRetrospective review of 118 patients with rectal cancer, divided into two groups: group I, 57 patients without pre-operative radiation-chemotherapy, and group II, 61 patients with rectal cancer who received pre-operative radiation-chemotherapy. Both groups were homogeneous. The short-term results (surgical technique, post-operative stay, post-operative complications) and long-term results (local recurrences, liver metastases and both overall and tumour-related survival) were analysed.ResultsThe rate of anterior resection in the lower third was significantly higher (p = 0.037) in group II than in group I (56 vs 23%), the rate of abdominoperineal resection in the middle third was significantly lower (p = 0.046) in group II (3.5 vs 21%). The incidence of post-operative complications was similar in both groups, but the rate of anastomotic leaks was higher in group II. The local recurrences was lower in group II (p = 0.002), but the disease free survival and the overall survival was similar in both groups. At the multivariate analysis, the only prognostic factor for the local recurrence was the use of pre-operative radiation-chemotherapy.ConclusionBesides surgeon experience and total mesorectal excision, a very important prognostic factor is the administration of pre-operative radiation-chemotherapy in cases of locally advanced rectal cancer, as it does not increase post-operative morbidity and mortality and significantly influences the rate of local recurrences and the conservative sphincter surgery.

Trombosis venosa portoesplenomesaraica secundaria a mutación del gen de la protrombina

Resumen La trombosis del eje portomesaraico es una causa infrecuente de isquemia o infarto intestinal. Ademas de multiples factores adquiridos que contribuyen al desarrollo de este cuadro, recientemente se han implicado factores de riesgo hereditario, especialmente la mutacion del factor V de Leiden y la mutacion G20210A del gen de la protrombina. La mutacion G20210A del gen de la protrombina se encuentra hasta en el 40% de los pacientes con trombosis portoesplenomesaraica. El presente caso ilustra la presentacion inusual e inespecifica de dicha mutacion, en forma de diarreas e imagenes de trombosis de la vena mesenterica superior y porta y cavernomatosis portal. Es muy frecuente el retraso en el diagnostico ya que los signos clinicos, analiticos y la radiologia no apuntan el diagnostico. El paciente recibio tratamiento anticoagulante y mejoro clinicamente, con una repermeabilizacion completa portomesaraica. En la actualidad la tecnica diagnostica de eleccion es la angiorresonancia magnetica o la angiotomografia computarizada, y el tratamiento, la anticoagulacion de manera indefinida. Nuestro caso ilustra que una localizacion inusual o atipica de trombosis venosa puede ser la manifestacion de una trombofilia, lo que recalca la importancia del cribado genetico en estos casos.

Has There Been a Decrease in the Incidence of Uncomplicated Gastroduodenal Peptic Ulcer Surgery

Over a period of 12 years, 1,039 patients were operated on at our hospital for gastroduodenal peptic ulcer. We analyzed the indications for surgery and divided the patients into two groups: subjects o

Reparación de la iatrogenia biliar poscirugía laparoscópica en centros con experiencia en cirugía hepatobiliar

Resumen Introduccion La colecistectomia realizada por via laparoscopica se acompana de una incidencia de lesiones iatrogonicas de la via biliar principal mayor que cuando se realiza por via abierta. Estas lesiones son mas graves, al ser mas altas en su localizacion, afectando a la via biliar intrahepatica y con frecuente desaparicion de tramos completos de la misma, lo que dificulta su diagnostico y tratamiento quirurgico. Pacientes y metodo Se presentan 10 casos de lesiones iatrogenicas de la via biliar principal tras colecistectomia laparoscopica intervenidos en nuestro servicio, tres de ellos con afectacion de la via biliar intrahepatica. En los 7 casos de localizacion extrahepatica se practico una hepaticoyeyunostomia en “Y” de Roux en 4 casos, una coledococoledocostomia terminoterminal sobre tubo en “T” de Kehr en otros 2 casos (en ambos hubo que realizar posteriormente una hepaticoyeyunostomia en “Y” de Roux) y, en el restante, un cierre de una seccion parcial del coledoco sobre un tubo en “T” de Kehr. En los 3 casos de lesion intrahepatica fracaso una primera reconstruccion en “Y” de Roux, precisando un abordaje intrahepatico con tutores multiples y nueva hepaticoyeyunostomia en “Y” de Roux. Resultados Todos los enfermos se encuentran asintomaticos y con unas analiticas normales tras un seguimiento medio de 39,2 meses. Conclusion Las lesiones iatrogenicas de la via biliar principal tras colecistectomia laparoscopica pueden requerir cirugia compleja para su tratamiento, por lo que deben ser referidas a centros con experiencia experiencia en cirugia hepatobiliar, sobre todo si son de localizacion intrahepatica.

Choledochoscopy Reduces Unnecessary Papillary Surgery

We present 200 patients, from the period January 1988 to July 1990, who received surgery for biliary lithiasis and required opening of the common bile duct. The patients were divided into two groups a

Quantification of Duodenogastric Reflux in the Operated Stomach Using 99mTc-HIDA Administered by Continuous Intravenous Infusion as a Duodenal Marker

We quantified duodenogastric reflux using continuous intravenous 99mTc-HIDA infusion, subsequently determining it in gastric juice and correlating it with the reading for total bile acids i