Somatostatin in the management of gastrointestinal fistulas. A multicenter trial.

To evaluate the effectiveness of treatment with total parenteral nutrition (TPN) alone (group A) or combined with continuous intravenous infusion of somatostatin (group B) in postoperative gastrointestinal fistulas, a multicenter, controlled and prospective randomized trial was designed. We present the results obtained after the evaluation of 40 cases (group A, n = 20; group B, n = 20). No significant differences among these treatment schedules were observed in the percentage of closure of fistulas (group A, 81.25%; group B, 85%), but patients treated with total parenteral nutrition plus somatostatin had the fistulas close within a significantly shorter period of time. Moreover, this treatment was associated with a significantly lower morbidity. These preliminary results indicate that somatostatin is a useful therapeutic complement in the conservative treatment of patients with gastrointestinal fistulas.

Prognostic significance of high microsatellite instability in a Spanish series of gastric adenocarcinomas.

In colorectal cancer different levels of microsatellite instability (MSI) have been described. MSI-H (high) characterizes a unique clinical and pathological phenotype known as hereditary non-polyposis colorectal cancer syndrome, whereas MSI-L (low) and MSS (stable) are considered similar phenotypes without pathological implications. MSI has been also described as a frequent genetic alteration in a subset of gastric adenocarcinomas. However, the clinicopathological and prognosis significance of this abnormality in these tumors remains unclear. To investigate the role of genetic instability in gastric carcinogenesis we examined 10 microsatellite loci in 37 patients. MSI-H was found in 37.8% patients. We observed a trend of MSI-H tumors to be associated with elderly patients, intestinal histological type, advanced clinical stages and less aggressiveness with better survival. In conclusion, MSI-H can be considered as a good prognosis factor in a subset of gastric tumors.

Loss of heterozygosity of TP53 is not correlated with clinicopathological variables in sporadic colorectal carcinomas.

We have analyzed the loss of heterozygosity (LOH) of TP53 in a series of 96 sporadic colorectal carcinomas by means of PCR, using two microsatellite sequences (TP53 and Mfd152), to investigate its possible relationship with several clinicopathological variables in the Spanish population. Forty six of the 96 patients (48%) showed loss of one allele of the microsatellite TP53, Mfd152 or both, when compared with normal colorectal mucosae and blood samples of the same patient. This high percentage of LOH seems to corroborate the important role of p53 in sporadic colorectal cancer. However, we have found that LOH on this region is independent of histological grade and tumour location. With regard to tumour Dukes' stage, the fact that a substantial proportion of tumours show LOH on 17p from the first stages of the disease could imply that this alteration is not related with the invasiveness acquisition staging.

Colocutaneous fistula due to polypropylene mesh.

Fistulae due to polypropylene mesh are known to occur if the prosthetic mesh is placed close to a hollow viscus. Some cases of enterocutaneous fistula have been reported but there are few cases of fistula affecting the large bowel. It is important to recognize these cases because they are severe complications of the prosthesis and difficult to manage. We present a case of colocutaneous fistula caused by fragmentation of polypropylene mesh and erosion into the sigmoid colon after recurrent incisional hernia repair.

Postoperative textilomas: review of 14 cases.

BACKGROUND: Textile materials of surgical origin are found in the abdominal cavity in between 1/1300 and 1/1500 laparotomies, in spite of preventive measures. It is very difficult to ascertain the exact incidence due to the lack of descriptions in the literature. METHODS: Fourteen cases of postoperative foreign bodies or textilomas are reported. The cases were collected from two hospital centers between 1985 and 1997. RESULTS: There were 12 intra-abdominal cases, 1 thoracic and 1 paravertebral. In 8 (57.1%) diagnosis was made preoperatively by radiological techniques. The mortality rate was 14.2% with 2 deaths due to multiorganic failure in one case and sepsis in the other. Both patients were over 70, with malignant pathology. The morbidity rate was 21.4%, wall abscesses which evolved favorably being the most frequent cause of complications. CONCLUSIONS: Prevention of this complication is the best treatment. It is advisable to use textile material with radiopaque contrast, to count the pieces of material to be used and perform an X-ray before the laparotomy is closed specially in emergency (bleeding and trauma patients) because in these complex cases the possibility of material being left behind is more advisable.

Self-expanding prostheses as a palliative method in treating advanced colorectal cancer.

AIM: This work presents the results of the use of self-expanding prosthesis as a definitive palliative method for eliminating colorectal obstructions caused by advanced and unresectable tumours. PATIENTS: A total of 41 cases were included (29 men, 12 women) with an average age of 70.12 years (range 46-95 years). All cases were showed symptoms of acute intestinal obstruction. Wallstent prostheses were inserted. RESULTS: Locally unresectable colorectal tumours were disseminated in five cases, metastasis in 28 cases and other tumours in eight cases. In all patients the appropriate insertion was performed, eliminating the obstruction in 38 (92.6%) cases in 24-96 h. The morbidity rate was 6/41 cases (14.6%) with slight rectal discomfort in five and one case of bleeding. Posterior tolerance of the prostheses was good. FOLLOW-UP: Two spontaneous rejections, three episodes of subocclusion because of faecal impact and two obstructions caused by an invasion of tumours occurred. Overall, 33 cases (80.4%) died within 1-18 months, average of 4.5 months survival. CONCLUSIONS: Wallstent endoprostheses is a good alternative avoiding a colostomy and providing a good tolerance and comfort for the patient until death.

[Prospective randomized trial of meropenem versus cefotaxime and metronidazole in the treatment of intraabdominal infections]. / Comparación prospectiva, aleatoria y abierta de meropenem frente a cefotaxima y metronidazol en el tratamiento de las infecciones intraabdominales.

BACKGROUND: The empiric antibiotic treatment of intraabdominal infections is in constant evolution. Monotherapy appears to be a desirable goal because of the simplicity of its administration, lack of toxic effects and wide spectrum. PATIENTS AND METHODS: A multicentre, prospective, randomized, open study was carried out to compare two antibiotic regimens in the treatment of intraabdominal infections in patients undergoing surgery. Ninety-eight consecutive patients were randomly allocated into two groups. One group (GM, n = 51) received meropenem (1 g/8 h) and the other (GCM, n = 47) a combination of cefotaxime (2 g/8 h) plus metronidazol (0.5 g/8 h). Clinical and bacteriological responses were assessed at the end of treatment and at 2-4 weeks. RESULTS: The severity of patients as assessed by the APACHE II score was similar in both groups (GM: 7.2 and GCM: 8.1). Three patients in each group could not be evaluated due to premature interruption of treatment or deviation from the protocol. The mean duration of treatment was 7.4 days in GM and 7.9 days in GCM. A satisfactory clinical response was obtained in 95% of patients in both groups. 31 patients (61%) in GM and 26 patients (55%) in GCM were bacteriologically evaluable. Bacteriological erradication was achieved in 94% of patients in GM and in 92% of patients in GCM. CONCLUSION: Meropenem is a good alternative for single antibiotic therapy in intraabdominal infections of moderate severity.

[Gas gangrene secondary to carcinoma of the colon]. / Gangrena gaseosa secundaria a carcinoma de colon.

Systemic infections due to enteric bacteria can develop in patients with occult intestinal tumours. A patient with a sigmoid adenocarcinoma that developed crepitation and necrosis of soft tissues in gluteous region and thigh of left lower limb is presented. No pus or free fluid was observed in the peritoneal cavity; a sigmoid tumor infiltrating and perforating the retroperitoneum with necrosis of the psoas muscle was found. The infection spread subsequently through the inguinal canals and sciatic foramen to the lower limb. Necrotizing infections of soft tissues without previous trauma or ischemic accident leads to the suspicion of an occult digestive disease.

Wunderlichacute's syndrome due to rupture of a renal angiomyolipoma.

We present the clinical case of a 79 year-old patient with hypertension, treated with anticoagulants and known background of right renal angiomyolipoma that is admitted to the emergency ward due to pain and mass in right flank. The CT revealed retroperitoneal haematoma, active renal intratumoral bleeding and hemoperitoneum. A total emergency nephrectomy was carried out. The patient presented an upper intestinal fistula and died on the sixth day after surgery.

[Massive lithiasis of the intra and extrahepatic bile ducts. Presentation of a clinical case]. / Litiasis masiva de la vía biliar intra y extrahepática. Presentación de un caso clínico.

A case of massive intra and extrahepatic lithiasis in a 52 year-old-man is presented. Diagnosis was confirmed by ultrasonography, CT and percutaneous cholangiography. The value of the different diagnostic procedures is analyzed. The need for elective surgical treatment is insisted on in order to remove the majority of the calculi, treatment of stenosis and adequate biliary drainage. Our case was treated with an hepatico-jejuno-duodenostomy (end to side) on an isolated jejunal loop with sphincteroplasty for drainage of the distal choledochus. In the postoperative period the patient was treated with Methyl-tert-butyl-ether for dissolution of the remaining calculi.

[Nonepithelial malignant degeneration of esophageal duplication]. / Degeneración maligna no epitelial de una duplicación esofágica.

A communicating duplication of the distal esophagus was diagnosed in an elderly patient. The lesion was removed and the connection with the esophageal lumen closed. A high grade leiomyosarcoma involving all duplication layers and the right pleural surface was demonstrated. This is the first reported instance of a nonepithelial malignant tumor in an alimentary tract duplication.

Antiemetic efficacy of ondansetron in laparoscopic cholecystectomy. A randomized, double-blind, placebo-controlled study.

OBJECTIVE: to assess the effectiveness of ondansetron in preventing postoperative nausea and vomiting after elective laparoscopic cholecystectomy, and the effect of this anesthetic on hospital stay. METHODS: this randomized, double-blind, placebo-controlled study was done in the General Surgery Service of the Getafe University Hospital. Patients who were scheduled for laparoscopic cholecystectomy to treat uncomplicated cholelithiasis, and who had an ASA status of I-II, were recruited. Before surgery the patients received either ondansetron 4 mg or placebo intravenously. This study was approved by the local ethics committee. RESULTS: 56 patients were included, 29 in the ondansetron group and 27 in the placebo group. In the latter, 4 patients were later excluded because of conversion to open surgery. Postoperative nausea and emetic episodes were experienced by 7% of the patients in the ondansetron group and 47% in the placebo group (p = 0.0007). Oral intake started 7 h after surgery in the ondansetron group and 11 h after surgery in the placebo group (p = 0.04), with a mean difference of 4 h. Hospital stay was 30 h and 48 h respectively (p = 0.01), with a mean difference of 18 h. CONCLUSION: ondansetron given prior to surgery at a dose of 4 mg prevents postoperative nausea and vomiting after laparoscopic cholecystectomy, and reduces hospital stay.

[Diagnostic validity of signs and symptoms defining the diagnosis of acute appendicitis]. / Validez diagnóstica de los signos y síntomas que definen el diagnóstico de apendicitis aguda.

A prospective study of 810 consecutive cases submitted to emergency appendicectomy was performed to determine the predictive value of abdominal pain, nausea, vomiting, fever, abdominal tenderness and total and differential leucocyte count in the diagnosis of appendicitis. Age, sex, time of evolution and degree of inflammation were considered as conditioning factors. Most of the cases were diagnosed within the first 12 h. Pain demonstrated acceptable sensitivity (85.2%) and a high positive predictive value (95.7%) but with an important proportion of false negatives (14.8%). The predictive value of abdominal exploration was 97.6% with a sensitivity of 96.1%. Leucocytosis increased with the degree of inflammation and values above the cut off point established (12,500 leucocytes/dl and 85% segmented) significantly increased the strength of the association. Pain on palpation and leucocytosis with shift to the left increased the sensitivity to 98.1% with false positives of 1.3%. The percentage of acute perforated appendicitis increased from 5 to 15.3% when diagnosis was delayed more than 12 h. Once the clinical manifestations and analytical alterations were established (6 h after initiation of the clinical picture) these did not modify with the time of evolution. The greater the involvement of the appendix the earlier the presentation although, logically, the later the diagnosis the greater the percentage of perforated appendix. The classical criteria of pain, tenderness and leucocytosis with left deviation does not allow the diagnosis of 1.9% of the cases of appendicitis with 1.3% of false positives. Once the clinical manifestations are established, these do not modify with the time of evolution, but the percentage of perforations does increase with time. To reduce this percentage, diagnosis must be made within the first 24 h.

[Pseudomyxoma peritonei]. / Seudomixoma peritoneal.

Pseudomyxoma peritonei is an infrequent clinical entity, characterized by peritoneal implantations organized in cyst of mucine or free peritoneal mucine. Most arise from cystadenoma or cystadenocarcinoma of the ovary and appendix, and fewer from other tumours and locations. It is more common in females, and it is usually diagnosed over the fifth decade. Three cases of pseudomyxoma peritonei are presented, two associated to appendicular carcinoma and one to carcinoma of the ovary, and the data published about this disease are reviewed.

[Epithelioid hemangioendothelioma localized in the small intestine]. / Hemangioendotelioma epitelioide localizado en intestino delgado.

Epithelioid hemangioendothelioma is a unique tumor of adult life which is characterized by epithelioid or histiocytoid endothelial cells. These tumors are rare, and developed preferentially in the dermis and subcutaneous tissues of the distal extremities. They grow in a slowly progressive fashion, have a borderline biological behavior, and a good response to surgical treatment. The authors present a 63-years-old woman with an epithelioid hemangioendothelioma localized in small intestine. The patient had a history of abdominal pain and recurrent rectal bleeding being surgically treated.