[Computed tomographic colonography: applications, advantages and disadvantages]. / Colonografía tomográfica computarizada: aplicaciones, ventajas e inconvenientes.

INTRODUCTION: Complete preoperative study of the colon is required in the management of colorectal cancer, due to the frequent association of primary colonic neoplasms with colonic adenomas (28%) and/or synchronous carcinomas (5%) of the colon. We present a series of patients who underwent computed tomographic colonography, the indications for this procedure, and the results. PATIENTS AND METHODS: We performed a descriptive prospective study. Between May 2003 and August 2004, 50 computed tomographic colonographies were performed in 50 patients with suspected stenosing colorectal cancer and incomplete conventional colonoscopy. RESULTS: Fifty computed tomographic colonographies were performed. The findings were as follows: three were normal (6%), and in the remainder, one was a false positive for a suspected neoplastic pelvic mass (3.125%) and two were false positives (11.7%) for colonic polyps. Fifty percent of the findings (n = 32) were related to peritoneal metastases and colonic neoplasms. There were 12 technical complications [lack of cleaning of the colon (5), lack of distension (2), little air insufflation (5)]. Patient complications included vegetative manifestations in one (vomiting) and rectal bleeding in another. The overall complication rate was 27.4% (23.4% corresponded to technical complications and the remaining 4% were patient-related). There was no mortality related to the procedure. CONCLUSION: Because computed tomographic colonography is safe, effective and well tolerated by the patient, it should be considered as a technical alternative in the study of stenosing neoplasms of the proximal colon with incomplete colonoscopy. In addition, it allows other associated findings, both intra- and extracolonic, to be obtained and improves the diagnostic and therapeutic management of the patient.

Treatment of long-standing extensive perianal hidradenitis suppurativa using double rotation plasty, V-Y plasty and free grafts.

BACKGROUND: Perianal hidradenitis suppurativa is a chronic recurrent inflammatory, suppurating, and fistulizing disease of apocrine glands, adjacent anal canal skin, and soft tissues. The standard treatment used for extensive cases is a staged surgical procedure allowing the wound to heal by secondary intention or the delayed use of skin grafts. CASE PRESENTATION: A long-standing case, disabling for the patient, with extensive involvement of the buttock region, treated in one stage, which for reconstruction required the use of sliding plasties and free skin grafts, is reported. RESULTS: The outcome was satisfactory. Primary closure after wide excision using plastic-surgery techniques may help us resolve complex situations and obtain good results and a rapid recovery. CONCLUSION: The method of closure with a combination of skin flaps and skin graft in one stage can be considered a valid surgical option for a group of patients with extensive perianal hidradenitis.

Short myotomy for vigorous achalasia.

Vigorous achalasia has been considered an indication for surgery, in which a thoracic approach is recommended for extending the myotomy along the whole of the oesophageal body to the point where manometry shows high-amplitude waves. Clinical results and postoperative manometric findings in 16 patients with vigorous achalasia undergoing abdominal surgery with myotomy limited to the lower oesophageal sphincter (LOS) were analysed to assess whether extended myotomy is necessary in surgery for this form of achalasia. The clinical results were excellent or good in all cases. Surgery induced a significant decrease (P < 0.01) in the diameter of the oesophagus as determined radiologically. The most significant postoperative manometric changes were a decrease in the resting pressure of the LOS and oesophageal body, a lowering of wave amplitude at all levels of the oesophagus, and a reduction in the proportion of repetitive waves. The results suggest that vigorous achalasia can be treated surgically in the same way as classical achalasia and question, at least from a therapeutic viewpoint, the use of the term vigorous achalasia.

Role of Helicobacter pylori infection and duodenogastric reflux in the pathogenesis of alkaline reflux gastritis after gastric operations.

In patients undergoing gastric operations, we studied the relationship between data suggesting alkaline reflux gastritis (symptoms, endoscopic alterations and histologic lesions) and two factors that produce chronic gastritis (helicobacter pylori and duodenogastric reflux). Of 225 patients who underwent operations for gastroduodenal gastric ulcer at our General Surgery Unit between 1980 and 1982, 63 agreed to undergo endoscopy and biopsies. Of these 63 patients, 38 agreed to a test to quantify duodenogastric reflux (24 hour gastric pH monitoring associated with the determination of bile acids in gastric juice). According to the clinical questionnaire, patients were classified as symptomatic and asymptomatic. Endoscopy was considered either normal with mucosal lesions or mucosal lesions plus bile. In the histologic study, we considered normal mucosa, superficial chronic gastritis and atrophic chronic gastritis. Furthermore, the presence of atrophy, metaplasia, foveolar hyperplasia and helicobacter pylori was studied. Symptoms, endoscopic alterations and histologic lesions were not significantly related to helicobacter pylori, but were significantly related to the quantity of duodenogastric reflux. The symptomatic patients presented with a greater quantity of reflux than the asymptomatic patients (p < 0.05). The patients with mucosal lesions plus bile who had endoscopy showed a greater quantity of reflux than those with normal endoscopy (p < 0.001) and those with mucosal lesions without bile (p < 0.02 for pH values and p < 0.001 for bile acids). The patients with atrophic chronic gastritis presented with a greater quantity of reflux than those with normal mucosa and superficial chronic gastritis (p < 0.05, respectively), and the patients with atrophy and metaplasia and foveolar hyperplasia had more reflux than those without (p < 0.001, respectively). The patients who were helicobacter positive and negative presented with similar quantities of reflux.

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.

Surgery improves defective oesophageal peristalsis in patients with gastro-oesophageal reflux.

Postoperative manometry was carried out in 12 patients with gastro-oesophageal reflux associated with hypomotility of the oesophageal body. A Nissen fundoplication was carried out in all patients. After a median follow-up of 3.5 years, patients underwent clinical, endoscopic, radiological, manometric and pH-metric evaluation. Manometric results revealed an overall improvement in oesophageal motor function with an increase in the amplitude of deglutition waves and a decrease in the percentage of deglutitions without response. Six of the patients (one with complete motor failure) recovered normal peristaltic function. Non-specific oesophageal motor disorders may be secondary to gastro-oesophageal reflux and are reversible in nature.

[Barrett's esophagus does not revert after medical or surgical therapy for gastroesophageal reflux]. / El esófago de Barrett no revierte tras el tratamiento médico o quirúrgico del reflujo gastroesofágico.

An evaluation was made of 34 patients having Barrett's oesophagus. Medical therapy consisted of antacids, H2 blockers, orthopramides, and postural measures (20 cases, mean follow-up 2.9 years). A Nissen fundoplication was done in 14 cases (mean follow-up 2.5 years). Clinical, endoscopic and histologic evaluation was done in all patients and pH measurements also done in all operated cases. Clinical results have been excellent in 70% of medically treated patients and in 100% of surgically treated ones, pH measurements were between normal limits in all operated patients. However, recovery of the normal epithelium did not occur in any case, except for some partial improvement in one patient treated surgically.

[Cancer of the anus: incidence and behavior of melanoma in our series]. / Cáncer de ano: incidencia y comportamiento del melanoma en nuestra serie.

From January 78, to December 88, we have treated 717 cases of colorectal carcinoma; 136 were located less than 5 cm from the anal margin. There were 117 adenocarcinomas; it was difficult to decide if the origin was the anal canal or the rectal ampulla. The remaining 19 tumors were: 9 malignant melanomas, 6 squamous cell carcinomas, 3 cloacogenic carcinomas, 1 rectal carcinoid, 1 leiomyosarcoma. We point out the high incidence of anal melanoma, 47.36% of total number of anal cancers, excluding adenocarcinomas. The clinical diagnosis was cancer of the anus; melanoma was not suspected in any of the cases. In 5 cases the preoperative biopsy did not diagnose melanoma. Since lesions were considered resectable, surgical treatment was always abdominoperineal resection. Pathological study of the surgical specimen showed lymph node metastases in all cases, in contrast to only 45.87% of adenocarcinomas. When lymph nodes were infiltrated by the tumor there were no differences in survival of patients with malignant melanoma and adenocarcinoma; nevertheless, when comparing the total group of patients with adenocarcinoma there were important differences. Summarizing, the diagnosis of malignant melanoma of the anus, compared to adenocarcinoma, implies a poor prognosis, probably related to the highest tendency to spread to the lymph nodes.

[Blood transfusion worsens the prognosis in colorectal cancer. Preliminary study in a series of 717 cases]. / La transfusión sanguínea ensombrece el pronóstico del cáncer colorrectal. Estudio preliminar en una serie de 717 casos.

We have conducted an investigation on the relationship between blood transfusion and recurrence of resected colorectal cancer and survival of the patients. During the past ten years 717 patients have been surgically treated of colorectal cancer in our hospital; 442 of the cases were Duke's stages B or C, and the resection had been considered radical. In both groups, recurrences were most frequent in patients who received blood transfusions; survival was also lower in this group of patients.

[Motility of the colon: electric and manometric description of the mass movement]. / Motilidad del colon: descripción eléctrica y manométrica del movimiento de masa.

"Mass movement" was described at the beginning of the century by radiologists, who occasionally observed during exploration a sudden transport of barium from one section of the colon to another. In this paper we focused our attention on the electromechanical factors that accompany evacuation through a colostomy, since we thought that these would be the myoelectrical and pressure translation of the "mass phenomenon" described by radiologists. We used an electromyographic recording probe to which a conventional microtransducer probe was affixed by suction. Using this method we made 24-hour recordings in 8 patients with sigmoid colostomy. We observed five large evacuations. When the electrical and pressure phenomena that occurred a few minutes before evacuation were analyzed, two clearly differentiated phases were apparent. The first, which we called the "previous phenomenon", consisted of a succession of contractions and spike potentials over a mean period of 5.6 min. (sigma = 2.22), after which a "large contraction" appeared, with a mean pressure value of 127 mmHg (sigma = 38.77) and a mean electrical value of 10.6 mv. The mean duration of this phenomenon was 24.93 sec (sigma = 6.19) and it was recorded almost synchronically in the three recording points studied. Undoubtedly, these electrical-pressure phenomena resulted from mass transport since in all 5 cases a large discharge through the colostomy was seen.

[Colorectal cancer: are diagnostic delay, degree of spread and survival related? Clinical analysis of 307 cases followed up for more than 4 years]. / Cáncer colorrectal: existe relación entre el retraso diagnóstico, su grado de extensión y la supervivencia? Análisis clínico en 307 casos seguidos más de cuatro años.

It seems logical to think that the longer the interval between the patient's first symptom of colorrectal cancer and operation, the greater the tumoral extension found by the surgeon will be, and the lower the postoperative survival. Nevertheless, there is much evidence to indicate that this may not always be true. We've analyzed the problem in 307 patients operated of colorectal cancer in our service from January 1979 to December 1984 and followed-up until now. We investigated the time interval from the first clinical symptom until operation, and survival. These variables were related to the Duke grade. As regards the preoperative interval, the average (in months) for Duke's grade A was 7.41 (sigma = 16.88), for D it was 7.41 (sigma = 9.47) and for C, 5.13 (sigma = 8.41). There were no statistically significant differences. As for survival, after four years all the grade A patients, 64% of the grade B patients and 35% of the grade C patients followed-up survived. We've found no relation between diagnostic delay and postoperative survival. These results suggest that it is not true that the longer the symptomatic period, the greater the tumoral spread. As such, diagnostic delay is not a good prognostic indicator for predecting tumoral spread or survival.

[Colorectal carcinoma in young adults. Our experience]. / Carcinoma colorrectal en adultos jóvenes. Nuestra experiencia.

Colorectal cancer usually appears in patients over 60 years-old. However, all the series communicate a small percentage of cases in young patients, ranging from 2 to 10% of the total. We have found important discrepancies between authors who have worked on the possible distinctive characteristics of colorectal cancer of the young over the last decade. This motivated us to examine more closely the clinical, follow-up and prognostic features of colorectal cancerous disease in the young as compared to that occurring in the general population. We analyzed retrospectively the clinical histories of our patients with special reference to the following parameters: sex, diagnostic delay (time from the appearance of the first symptom to diagnosis), index symptom, site, Dukes' grade, type of surgical treatment, complications, recurrence and survival. We found that 4.9% of our patients with colorectal cancer were as old as 40 years. The clinical presentation, tumoral site and Dukes grade were similar in the young adult and in the general population. In spite of the fact that there were no differences in these parameters, in younger patients the surgeon was more aggressive, more often performing a radical operation. Perhaps for this reason, this age group had a higher percentage of complications and recurrences. We found no differences in the 4-year survival or in the time survived after surgery.