P. Parrilla Paricio

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.

Perioperative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery in advanced ovarian cancer

INTRODUCTION Diffuse peritoneal dissemination in advanced ovarian cancer can be treated using optimal effort surgery involving peritonectomy procedures and the administration of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC). OBJECTIVE To report on our experience in the treatment of advanced ovarian cancer using peritonectomy procedures and HIPEC through the fast track program. PATIENTS AND METHOD From September 2008 until May 2010, forty-six patients with primary advanced (stage III-C) or recurrent ovarian cancer have been included in the fast track protocol if they had optimal cytoreduction CC-0 or CC-1 accompanied by HIPEC and there had no more than one digestive anastomosis. RESULTS The mean peritoneal cancer index (PCI) was 12.35 (3-21). The median operation time was 380 min (200-540). Optimal surgery CC-0 was achieved in 38 of the 46 patients and CC-1 in the remaining 8. Mean postoperative hospital stay was 6.94 ± 1.56 days (3-11). Major morbidity rates were 15.3%. Paralytic ileus was the most frequent of these. There was no mortality related to the procedure. CONCLUSION Surgery with peritonectomy procedures and HIPEC in advanced ovarian carcinoma is possible under fast track surgery programs in patients with low volume peritoneal carcinomatosis. Prospective and randomized studies are needed.

Improving the Waiting List by Using 75-Year-Old Donors for Recipients With Hepatocellular Carcinoma

The best treatment for hepatocellular carcinoma (HCC) associated with liver cirrhosis is liver transplantation and the best results are obtained when the tumors fulfill the Milan criteria. However, although the number of transplants is increasing, the organ deficit is growing, which lengthens time on the waiting list, increasing the risk of tumor progression of and exclusion from the list. The use of elderly donors is a valid option for patients on the transplant waiting list with HCC, reducing time on the waiting list. We report our experience with patients transplanted for HCC associated with hepatic cirrhosis using livers from donors >75 years of age. Our preliminary results supported the use of elderly suboptimal donors making it possible to give priority to these patients. All patients in the series achieved good graft function after a follow-up of 2 years with a 100% disease-free survival rate. More extensive long-term studies are needed to confirm these findings.

Tratamiento de la hidrocefalia mediante la derivación ventriculopleural

Introduccion La derivacion ventriculoatrial y la ventriculopleural (DVP) son metodos alternativos a la derivacion ventriculoperitoneal para el drenaje del liquido cefalorraquideo (LCR) en pacientes con hidrocefalia. La DVP ha sido poco utilizada por su riesgo de insuficiencia respiratoria por neumotorax o derrame pleural; sin embargo, la presencia actual de valvulas con dispositivos antisifon para los sistemas de derivacion estandar previene el desarrollo de estos derrames pleurales. El objetivo es analizar los resultados de nueve DVP en 8 pacientes con las nuevas valvulas de DVP para evitar el drenaje excesivo de LCR. Material y Metodo Entre 1988 y 2000 se han realizado nueve DVP en 8 pacientes con hidrocefalia. Ocho valvulas eran de presion diferencial y una, reguladora de flujo. Ademas, seis (el modelo Sophy) son programables externamente. La indicacion de la DVP fue, en 4 casos, la presencia de adherencias peritoneales; en dos, la presencia de ascitis persistente, en uno la obstruccion de la valvula ventriculoatrial, y en el ultimo, la infeccion de la derivacion peritoneal por una peritonitis. El noveno caso corresponde al recambio de una valvula previa obstruida. Resultados Tras un seguimiento medio de 22 meses, todas las derivaciones funcionan de forma adecuada y ningun paciente presenta sintomas de hidrocefalia, excepto un caso que preciso recambio valvular por obstruccion de la misma a los 6 meses. No se presento morbimortalidad asociada a la tecnica quirurgica. Solo un paciente mostro sintomas transitorios de drenaje excesivo de LCR, lo que fue corregido regulando el gradiente de la valvula magnetica. Un paciente fallecio a los 36 meses por un procedimiento no relacionado con el drenaje pleural. Conclusiones El uso de valvulas de nuevo diseno designadas para prevenir el sobredrenaje de LCR presenta unos resultados satisfactorios, por lo que la DVP debe considerarse como una alternativa al drenaje peritoneal.

Prognostic factors of thymomas

Thymomas are uncommon tumours. This study analyses the prognostic value of certain clinical variables and of two different histological classifications. Thirty cases were analysed; 24 were women and six men, with a mean age of 50 years (range 22–69). The pre-operative study included: clinical data (Masaokas and Ossermans clinical classification); chest radiography; and computed axial tomography. Surgery was divided into three categories: total tumour resection, partial resection and biopsy alone. For the pathological study we followed Salyer—Eggleston and Marino—Muller classifications. Follow-up averaged 5.5 years (range: 2–11). As a statistical method we used Kaplan—Meiers survival curves and Coxs regression model. Eleven of the patients had associated myasthenia gravis, this being the most common clinical type. Age, sex, association with myasthenia gravis, surgical technique and Salyer—Egglestons classification showed no prognostic value; conversely, clinical staging and Marino-Mullers classification had a high prognostic value. The first treatment that should be considered is surgery, with an attempt to perform total tumour resection. Myasthenia gravis did not modify the prognosis of the disease. The factors of greatest prognostic significance were clinical staging and Marino—Mullers histological classification.

Antireflux mechanism of nissen fundoplication : a manometric study

To analyze the mechanisms by which Nissen fundoplication controls gastroesophageal reflux, the pre-and post-operative manometric findings in 34 patients were compared. The postoperative assessment showed an increase in both the infradiaphragmatic length and basal pressure of the lower esophageal sphincter and a notable improvement in esophageal motility (increase in the amplitude of the waves and decrease in the mean percentage of deglutitions without response and tertiary waves) in those who preoperatively presented with defective esophageal peristalsis.

Adhesion Response to Different Forms of Treating a Peritoneal Lesion: An Experimental Study in Rats

The authors analyze the adhesion-forming capacity of various forms of treating a peritoneal lesion. There were four groups each of 10 rats, all receiving the same peritoneal lesion. The control group did not receive any treatment for this injury; in the remaining three, the peritoneal lesion was treated with electrocoagulation, stapling or interrupted suture. The animals were killed after 30 days and adhesions quantified according to a specially designed score which assessed the number of adhesions, their site, vascularization, thickness and tenacity. Electrocoagulation significantly generated the smallest number of adhesions. The application of stapling or suture stimulated the formation of adhesions to a larger extent, manual suture more so than the stapling.

Factores pronósticos del cáncer de vesícula

Introduccion y Objetivo El carcinoma de vesicula es la lesion maligna mas frecuente del tracto biliar. Sin embargo, la supervivencia a los 5 anos es inferior al 5%. El objetivo de este estudio es analizar la influencia de varias variables clinicopatologicas en la supervivencia en una serie de 226 pacientes con carcinoma de vesicula. Pacientes y Metodos Los resultados son analizados retrospectivamente y los factores pronosticos son identificados mediante un analisis estadistico univariante y un modelo de regresion de Cox. Todos los pacientes fueron intervenidos y se realizo una intervencion quirurgica potencialmente curativa en 67 casos (29,6%). En 63 pacientes (27,9%) el diagnostico fue incidental al estudiar una vesicula extirpada por un proceso patologico benigno. El estadio TNM fue 0 en 7 casos (3,1%), I en 19 casos (8,4%), II en 21 casos (9,3%), III en 61 casos (27%) y IV en 118 casos (52,2%). Resultados La supervivencia global a los 5 anos fue del 17,3%. En el analisis univariante, las variables con influencia significativa fueron la presencia de ictericia, la perdida de peso, la palpacion de una tumoracion abdominal, el momento del diagnostico, la tecnica quirurgica, el sistema de estadificacion TNM y las tres variables de dicho sistema (T: tamano, N: adenopatias, M: metastasis a distancia). En el analisis multivariante tuvieron una asociacion significativa con la supervivencia las tres variables del sistema TNM y la tecnica quirurgica. Conclusiones El factor pronostico mas importante es la estadificacion TNM del tumor y, actualmente, con la realizacion de la colecistectomia radical en los estadios II y III, la tecnica quirurgica se ha convertido en el otro factor pronostico importante.

Angiodisplasia múltiple de intestino delgado. Un reto diagnóstico y terapéutico

Resumen La hemorragia digestiva de intestino delgado es poco frecuente y supone un dificil reto para el medico. Aproximadamente el 30-40% de las hemorragias digestivas localizadas en el intestino delgado son debidas a la angiodisplasia, una malformacion vascular. Presentamos el caso de un paciente con angiodisplasia multiple de intestino delgado que preciso la realizacion de una enteroscopia y una exploracion con capsula endoscopica para su diagnostico, y que fue tratado exitosamente con octreotida por via subcutanea. En resumen, en casos dudosos o con hemorragia persistente, la capsula endoscopica puede mejorar el rendimiento diagnostico de la enteroscopia para las lesiones vasculares gastrointestinales hemorragicas como la angiodisplasia. Los tratamientos endoscopico (coagulacion con laser) y farmacologico (somatostatina o analogos) son alternativas validas a la cirugia en casos no operables o irresecables.