Clinical and cost effectiveness of sacral nerve stimulation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) has better results and safety than other surgical procedures for faecal incontinence. This prospective study assessed the clinical effectiveness and costs of SNS at a single centre. METHODS: Patients who had experienced one or more episodes of faecal incontinence were studied for up to 5 years by continence diary, anorectal manometry and quality of life questionnaires. Direct medical costs were calculated and the cost-effectiveness of the treatment was analysed. RESULTS: Fifty-seven percutaneous nerve evaluations were performed in 47 patients between June 1999 and February 2006; 29 patients underwent permanent implantation. After a median follow-up of 34.7 (range 2.3-81.2) months, 25 of the 29 patients had a significant reduction in incontinence episodes; 14 patients were in complete remission. At 3-year follow-up, the mean reduction in incontinence episodes was 89 per cent. No change was observed in anal manometric values. Patients reported a significant improvement in quality of life. The introduction of SNS has an incremental cost-effectiveness ratio, below the accepted Spanish threshold. CONCLUSION: The introduction of SNS to the management of faecal incontinence within the Spanish setting is both effective and efficient.

Surgical treatment of lung cancer with adrenal metastasis.

Surgical treatment of adrenal metastasis from non-small cell lung cancer is controversial. Classically this group of patients has been considered incurable, therefore excision of the primary cancer and the adrenal gland has been avoided. However, recent reports show good results in their surgical management. Five selected patients with non-small cell lung cancer and adrenal metastases have been surgically treated. Two of them also presented with brain metastases that were excised, too. One patient with brain and adrenal metastases died 38 months after surgery. The other four patients are alive and with no sign of recurrent disease at 8, 16, 52 and 58 months of follow-up. In highly selected patients in whom both the primary and the metastatic tumors are resectable and in the absence of tumor spread to other organs, surgical treatment seems to be a good therapeutic option.

[Surgical treatment of acute cholecystitis. Results of an early intervention protocol]. / Tratamiento quirúrgico de la colecistitis aguda. Resultado de un protocolo de actuación precoz.

A prospective study of 425 patients operated for gallstones was undertaken in order to assess the applicability of a protocol including early surgery in acute cholecystitis. Acute cholecystitis (AC) was present in 119 patients who had 123 episodes of AC (28%). Of 114 patients diagnosed as having AC, 103 were operated on before 72 h and the remaining before 7 days. There were no significant differences between the AC series and that of 306 patients who underwent an elective operation, in regard to morbidity, mortality or length of hospitalization. Early cholecystectomy can be recommended for the treatment of AC as its results are comparable to those of elective surgery.

Swallowing of hydrochloric acid: study of 25 cases.

INTRODUCTION: Ingestion of hydrochloric acid solutions (Salfumant/Salfuman) constitute a relatively frequent emergency in our environment. It is a strong acid, highly corrosive, the swallowing of which causes a very serious necrosis of the gastrointestinal tract. AIM: We review our experience on emergency treatment of inpatients after the swallowing of watery hydrochloric acid solutions, in order to identify the most important prognosis factor. PATIENTS AND METHODS: During the last thirteen years, 25 patients have been attended in our center with the diagnosis of hydrochloric acid swallowing. The clinical and therapeutical characteristics are respectively analyzed, as well as the high morbi-mortality of these kind of emergencies. RESULTS: Global mortality of the series has been 48% (12 patients). The common characteristic of these 12 patients was the esophagogastric massive necrosis, and the duodenopancreatic frame necrosis. Ten patients who did not present duodenal necrosis or were operated on of later complications, survived. Three patients could be managed with medical conservative treatment. CONCLUSIONS: Hydrochloric acid swallowing constitutes an extraordinary severe emergency, with a high mortality, mainly related to necrosis extension to the duodenopancreatic frame.

[Usefulness of echography with pancreatic stimulation in the evaluation of acute pancreatitis associated with pancreas divisum]. / Utilidad de la ecografía con estimulación pancreática en la valoración de la pancreatitis aguda asociada a un páncreas divisum.

Pancreas divisum is an anatomic variation of the fusion of the pancreatic ducts that appears in 6-10% of the normal population. In recent years, with the development of endoscopic cholangiopancreatography, pancreas divisum has been related to recurrent acute pancreatitis, although its continuous interrelation remains debated. We present a case of acute pancreatitis with pancreas divisum. Echography after pancreatic stimulation with secretin (EEPS) was useful to evaluate the degree of stenosis of the accessory papilla, showing dilatation maintained for 30 minutes of the dorsal duct after stimulation. Postoperative echography with secretin pancreatic stimulation after surgical sphincteroplasty showed no modification in the caliber of the accessory duct, which allowed us to discern the solution to the obstructive problem. We discuss the clinical utility and prognostic value of echography with secretin pancreatic stimulation in the treatment of pancreas divisum.

Massive necrosis of the gastrointestinal tract after ingestion of hydrochloric acid.

OBJECTIVE: To describe our experience of dealing with patients admitted as emergencies after massive ingestion of hydrochloric acid, and to find out the most important prognostic factors. DESIGN: Retrospective review. SETTING: Teaching hospital, Spain. SUBJECTS: 21 patients with massive necrosis of the upper gastrointestinal tract after ingestion of acid who presented during the past 14 years (November 1984-March 1998). INTERVENTIONS: All patients were operated on immediately, 17 without an endoscopic examination. In all cases, the laparotomy showed various degrees of damage to the intra-abdominal oesophagus (from oedema to blackening) and gastric necrosis. Twelve patients also had necrosis of the entire duodenum. In the other nine, the necrosis did not affect more than the pylorus or duodenum. All these 12 patients were treated by a total oesophago-gastrectomy without thoracotomy. Of the 12 patients with total necrosis of the duodenum, 4 did not have resections and in 8, various massive resections of the necrotic structures were done. MAIN OUTCOME MEASURES: Mortality. RESULTS: Fourteen of the 21 patients died during the operation or in the early or late postoperative period. All 12 patients with total duodenal necrosis died, whereas only 2 patients in the other group. CONCLUSIONS: The ingestion of relatively small amounts of water-based solutions of hydrochloric acid of 24% or 32% concentration produces immediate and massive necrosis of the upper digestive tract, which results in high mortality. The poor prognosis might be improved by rapid responses to stop duodenal necrosis.