Emergency transvaginal hybrid natural orifice transluminal endoscopic surgery.

In a clinical series, 10 consecutive female patients with intra-abdominal infections were successfully treated with natural orifice transluminal endoscopic surgery (NOTES) performed transvaginally. The surgery, which consisted of a hybrid NOTES procedure using a transvaginal approach, was performed on an emergency basis by the surgical team on call. The indications for surgery were acute cholecystitis (n = 6), acute appendicitis (n = 2), and pelvic peritonitis (n = 2) with intra-abdominal infection. The procedure was successfully performed in all patients using a dual-channel endoscope and mini-laparoscopy assistance. This is the first clinical series in which NOTES has been performed on an emergency basis to treat intra-abdominal infections. Transvaginal surgery for intra-abdominal infection is a feasible procedure for groups experienced in the elective NOTES approach.

Multidisciplinary approach and multimodal therapy in resected pancreatic cancer. Observational study.

OBJECTIVE: Analysis and evaluation of a multidisciplinary approach, postoperative results and survival of a group of patients with resected pancreatic cancer after a multimodal therapy. DESIGN: DESCRIPTIVE, prospective and observational study. PATIENTS: Between January 2004 and December 2004, 124 patients with pancreatic cancer were evaluated. In 30 patients pancreatic resection was performed, and they are the object of this study. Results of preoperative evaluation, postoperative morbidity and mortality, and long term survival were studied. RESULTS: Diagnostic evaluation was completed in ambulatory basis in 20% of the patients. In 63% of cases, admission was done in the same day of surgery. In 3 patients (9%), tumor resection was not achieved, therefore, concordance between radiological and surgical resectability rate was 91%. Resectability rate was 24.1%. Surgical Mortality was 3.3%, with a global morbidity rate of 56.6%. Survival at one, two, three and, four years was 76.2%, 56.3%, 43%, y 27.3% respectively. CONCLUSIONS: Technological development and coordination of efforts in multidisciplinary teams offer an accurate evaluation of tumor involvement, and may reduce the number of laparotomies without tumor resection. The application of a systematic and generalized multimodal treatment in pancreatic cancer is progressively showing a tendency of progressive increase in resectability and survival rates in pancreatic cancer.

Transvaginal liver resection (NOTES) combined with minilaparoscopy.

OBJECTIVE: to report on the first liver resection performed on a human being by a transvaginal NOTES approach combined with minilaparoscopy. PATIENTS AND METHODS: a sixty-one-year-old woman with a history of Wertheim s hysterectomy for endometrial carcinoma 10 years ago, and malignant melanoma correctly treated in 2006, had suspected segment-V liver metastasis near the gallbladder by CT-scan and MRI. The indication for a laparoscopic approach was made, and a combined transvaginal and minilaparoscopic resection was offered and accepted by the patient. The procedure was performed by a multidisciplinary team composed of surgeons and gastroenterologists. It involved creating a pneumoperitoneum by placing a Veres needle in the umbilical fundus, followed by the insertion of a 5-mm trocar. A second, 3-mm trocar was placed in the right upper quadrant. A lot of pelvic adhesions were found in the major pelvis, and it was necessary to place a third, 5-mm trocar in the left abdominal side. It was employed only for the adhesions, not for liver resection. Adhesions were removed to reveal the minor pelvis and the vaginal fornix. A colpotomy was performed with a 12-mm trocar placed inside the vagina, which allowed the insertion of the videogastroscope as far as the liver hilum. RESULTS: liver resection (segment-V partial resection) and cholecystectomy were performed by using a combination of working tools inserted through the entry port for the minilaparoscopy and the videogastroscope. The en bloc resection was removed transvaginally through the videogastroscope. There were no postoperative complications, and the patient was discharged after 48 hours. CONCLUSIONS: transvaginal liver resection is possible and safe when performed by a multidisciplinary team. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging modality that seeks to be less invasive, better tolerated, and more respectful of esthetics. It will probably open the way for very important medical and technological innovations.

[Transvaginal cholecystectomy (NOTES) combined with minilaparoscopy]. / Colecistectomía transvaginal (NOTES) combinada con minilaparoscopia.

OBJECTIVE: To report on the first transvaginal cholecystectomy performed on a human being in Spain. PATIENTS AND METHODS: A 35-year-old female with a history of recurrent bouts of biliary pain resulting from gallstones. A surgical procedure was performed by a multidisciplinary team composed of surgeons, gastroenterologists, and gynecologists. It involved creating a pneumoperitoneum by placing a Veres needle in the umbilical fundus, followed by the insertion of a 5-mm trocar. A second 3-mm trocar was placed in the right upper quadrant. A colpotomy was performed, and a 12-mm trocar placed inside the vagina allowed the insertion of a videogastroscope as far as the hilum of the liver. RESULTS: Cholecystectomy was performed by using a combination of working tools inserted through the entry port for the minilaparoscopy and the videogastroscope. The gallbladder was removed transvaginally through the videogastroscope. There were no postoperative complications, and the patient was discharged within 24 hours. CONCLUSIONS: Transvaginal cholecystectomy is possible and safe when performed by a multidisciplinary team working together. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging modality that seeks to be less invasive, better tolerated, and more respectful of esthetics than laparoscopic surgery. It will probably open the way for very important medical and technological innovations over the coming years.

The effect of repetitive magnetic stimulation on localized musculoskeletal pain.

Current magnetic coil stimulators can efficiently activate neural structures without deep electrode placement and the local discomfort associated with transcutaneous electrical stimulation used in pain control. We tested the possibility of reducing pain in patients with localized musculoskeletal processes by applying repetitive magnetic stimulation on the tender body region. Thirty patients were randomized to receive 40 min of real or sham magnetic stimulation. After a single session, real magnetic stimulation significantly exceeded the sham effect: a 101-point pain score decreased by 59% in the treated group and 14% in sham-treated patients (z = -3.26, p = 0.001). The pain relief attained regularly persisted for several days. Results indicate that powerful magnetic coil stimulation can efficiently reduce pain originating from localized musculoskeletal injuries.

Low serum selenium concentration in a healthy population resident in Catalunya: a preliminary report.

Serum selenium levels were determined in 92 healthy subjects [40 men, 52 women; mean age 33.5 +/- 1.6 (s.e.m.) years, range 16-71 years] living in the province of Barcelona, Catalunya, Spain. Only well-nourished individuals with unremarkable clinical history, normal blood chemistry and haematological tests were selected. The subjects were divided into 6 age groups for each sex. Serum samples were analysed using a modification of the standard electrothermal graphite furnace atomic absorption spectrophotometry method to shorten the procedure while maintaining its accuracy. A significant correlation (y = -1.31 + 1.51 x; r = 0.9967, P less than 0.001) was observed between our method and the standard assay method. The mean serum selenium concentration was 60.39 micrograms/l, 95 per cent CI 53.35-67.45 micrograms/l. There were age- but no sex-group differences (P less than 0.001). This result is similar to that found in countries whose low selenium levels have been related to an increased risk of some disease states. Clinical and health implications of this suboptimal selenium status are discussed.

Changes in liver function tests in patients with inflammatory bowel disease on enteral nutrition.

Morphologic and functional hepatic changes occur in inflammatory bowel disease (IBD). Patients with this disease often require the administration of artificial nutritional support. Liver function tests (LFT) derangement is a widely recognized side-effect of total parenteral nutrition (TPN). Therefore, the use of this modality of nutritional support may be an additional factor to cause hepatic damage in IBD patients. However whether or not the same occurs in patients receiving total enteral nutrition (TEN) is not well-established. The aim of the present study was to evaluate the effect of TEN upon LFT in patients with moderate to severe acute attacks of IBD, by means of a prospective, controlled, and nonrandomized design. Forty-nine patients were included; 29 (11 patients with ulcerative colitis and 18 with Crohn's disease) received TEN, and 20 (11 with ulcerative colitis and 9 with Crohn's disease) did not. Both groups were homogeneous regarding age, sex, disease activity index, nutritional status, and length of the study (24.8 +/- 1.3 vs 23.9 +/- 16.8 days). In all cases, weekly measurements of serum alkaline phosphatase, GOT, and GPT were performed. There were no significant differences in LFT at the beginning of the study between groups. The percentage of patients showing derangement of some LFT during the study did not differ between both groups: six of 29 (20.6%) in TEN group vs three of 20 (15%) in control group. Six out of the nine patients (in both groups) who developed LFT derangement had one or more causes, other than TEN for explaining hepatic dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Energy consumption in patients with Crohn's disease. An evolutionary study during hospitalization]. / Consumo de energía en pacientes con enfermedad de Crohn. Estudio evolutivo durante la hospitalización.

In Crohn's disease, weight loss and malnutrition are very frequently occurring problems. One explanation of these findings could be an increased energy expenditure. Eleven patients were studied, of which six were women and five were men, during a hospital stay for an active episode of Crohn's disease. In three patients the small intestine was affected, in five the colon, and in the last three both the ileum and the colon were affected. Van Hees' activity index on admittance was 196 +/- 52 (132-265). The energy expenditure at rest (ECR) on admittance, was 11% higher than that found in the normal population (p: n.s.). The energy expenditure decreased weekly, in a statistically significant way, during hospitalization. No significant relationship was found between the Van Hees activity index and any of the parameters used to evaluate the energy needs. Those patients whose body weight was less than 90% of the ideal body weight, presented pathologically elevated energy needs when the energy expenditure was expressed in kcal/kg (p = 0.003). Fever was the only analyzed parameter which showed a significant correlation with the changes in energy expenditure: measured by the oxygen consumption index (p = 0.003) and by the percentage of REE (p = 0.006).

[A prospective study of the functioning of 2 types of enteral nutrition catheters]. / Estudio prospectivo del funcionamiento de dos tipos de sondas de nutrición enteral.

The problems of disintubation and obstruction of nutritional catheters are common during treatment with enteral nutrition. This prospective study has been designed to evaluate the differences in the frequency of obstruction between two different types of enteral nutrition catheter. Catheter A (Silk, Ibys) with one single lateral outlet, wide, long and with a curved edge, and Catheter B (Nutrisoft M, Kabi-Pfrimmer), with several smaller lateral holes, 46 nutritional periods were studied, divided into two groups: first group, n = 32 (catheter A) and second group n = 14 (catheter B, Nutrisoft M, Kabi-Pfrimmer). There were no significant differences between both groups for the type of diet administered, osmolarity, speed, volume administered, number and duration of interruptions, external fixation, washing of the catheter and duration of the nutritional period. The catheter slipped out in 21 periods (46%). Obstruction of the catheter was the cause of disintubation of the catheter in eight cases, five of the cases with catheter A (15%) and three cases with catheter B (21%); there were no significant differences between the values for both. These results indicate that the frequency of obstruction is similar with both catheters; however, the Silk catheter may have a better tolerance and be easier to intubate, due to its smaller external diameter.

[Energy expenditure of patients with Crohn's disease. Course study during hospitalization]. / Consumo de energía en pacientes con enfermedad de Crohn. Estudio evolutivo durante la hospitalización.

Weight loss and protein energy malnutrition are frequent in Crohn's disease. The increase of resting energy expenditure has been pointed out as the cause of these findings. In this study we report eleven patients with Crohn's disease, six women and five men hospitalized with active Crohn's disease. In three patients the disease involved the small bowel, in five the large bowel and three shared large and small bowel involvement. At the beginning of the hospitalization the activity disease index of Van Hees was 196 +/- 52, range: 132-265. The resting energy expenditure was eleven percent higher than that, of a healthy population (p: n.s). During hospitalization the energy expenditure decreased weekly with statistically significant difference. No relation has been observed between the activity index of Van Hees, and any of the energy parameters studied. Patients with body weight lower 90% of ideal weight, had an increased resting energy expenditure when that was expressed in kcal/kg of weight (p = 0.003). Fever was the sole parameter analyzed with statistically significant relation with consumption of oxygen: with the index of oxygen consumption (p = 0.03) and with the percentage of resting energy expenditure (p = 0.006). In summary, the REE in active Crohn's disease is higher than that of healthy population, although without statistically significance. The REE tends to normalization coinciding with the decreasing of inflammatory activity. Increased energy expenditure has been detected in weight loss patients.

[Ulcerative colitis with segmental involvement]. / Colitis ulcerosa con afección segmentaria.

INTRODUCTION: Ulcerative colitis is a chronic inflammatory disease affecting areas of the colon or the full length. From the endoscopic point of view, ulcerative colitis presents lesions that stretch continuously from the rectum to variable colon segments, a characteristic that is of great value when distinguishing it from Crohn's disease. Continuous involvement, without healthy patches, justifies ending endoscopic exploration once the distal end of the lesion has been reached. OBJECTIVE: To retrospectively study the frequency of segmental lesions in the colonoscopies performed in patients with ulcerative colitis. METHODS: Diagnosis of ulcerative colitis and proctitis was established by clinical, endoscopic, histologic, analytical, and radiological criteria. The indication and number of endoscopies was made on the basis of the clinical criteria of diagnosis, acute episodes, refractoriness or dysplasia screening. The extent of the examination also depended on clinical criteria: the severity of the episode, tolerance to colonoscopy or the degree of cleansing. RESULTS: A total of 155 coloscopies were performed. In 113 colonoscopies (73%) the distal end of the lesion was reached and in 70 (45%) the cecum was reached. Of the 80 patients, 27 (33%) presented ulcerative proctitis at diagnosis. Nine of the 80 patients (11.3%) biopsies were performed in healthy colonic patches, which confirmed histological normality. Six of the 9 patients were receiving no treatment. In all patients except two, the cecum was reached in one or more of the colonoscopies. The distribution of the segmental lesions varied but these were mainly found in the periappendicular region and in the cecum in 6 of the 7 patients in whom the cecum was reached. Of the 80 patients, endoscopic evidence of rectal sparing was found in 5 (6.3%); of these, 4 were receiving systemic or topical treatment. Histological analysis confirmed the absence of inflammatory lesions in these patients. The only patient who was not receiving treatment presented microscopic lesions compatible with ulcerative colitis. CONCLUSIONS: Endoscopic segmental lesions in ulcerative colitis were present in 11.3% of patients. Segmental lesions were most frequently found in the cecum and periappendicular region. Endoscopic and histologic evidence of rectal sparing may be the result of systemic or topical treatment.

Evaluation of aztreonam in the treatment of spontaneous bacterial peritonitis in patients with cirrhosis.

To determine the efficacy of aztreonam in the treatment of spontaneous bacterial peritonitis in patients with hepatic cirrhosis, 14 patients (7 males, 7 females) with 16 Gram-negative infective episodes (12 Escherichia coli and 4 Klebsiella pneumoniae) were treated with aztreonam infusions at doses of 1 gm per 8 hr for a planned 14-day period. Ages ranged from 40 to 75 years with a mean of 57 +/- 10 years. All organisms were highly susceptible to aztreonam (minimal inhibitory concentration less than or equal to 0.06 to 0.12 micrograms per ml). Serum antibiotic levels were 61.9 +/- 25.5 micrograms per ml (peak) and 27 +/- 18.5 micrograms per ml (trough). Ascitic fluid antibiotic levels were 33.6 +/- 22.5 micrograms per ml (peak) and 32.7 +/- 16.8 micrograms per ml (trough). Although the symptoms of infection were controlled within 3 days and ascitic fluid cultures became negative after 48 hr, 10 patients (62.5%) died, with hepatorenal syndrome and digestive tract hemorrhage as the principal causes of death. Three patients developed streptococcal superinfections during treatment; Streptococcus faecalis peritonitis in one case and spontaneous bacteremia due to Streptococcus equinus and Streptococcus mutans in the other two. Aztreonam was well tolerated and clinically and bacteriologically efficacious in controlling the infection. Serum and ascitic fluid levels were considerably higher than the minimal inhibitory concentration for the causative organisms, suggesting that lower doses may achieve suitable therapeutic levels. A negative aspect of the antibiotic therapy was the superinfections. The high mortality rate was attributable to the generally poor underlying condition of the patients.

Ascites increases the resting energy expenditure in liver cirrhosis.

The purpose of this study was to investigate the effect of ascites on the energy metabolism of patients with liver cirrhosis. The resting energy expenditure was determined in 10 patients with liver cirrhosis and ascites of moderate or large volume. The resting energy expenditure measurement was performed using indirect calorimetry and the resting energy expenditure predictive value was calculated with the Harris-Benedict equation, both before and after removal of ascitic fluid by paracentesis. Metabolic stress factors were absent in all cases. After an interval of 11.2 +/- 7.7 days between measurements, a weight loss of 16.6 +/- 10.3 kg was observed with paracentesis. The resting energy expenditure measured by indirect calorimetry showed a statistically significant decrease from 1682 +/- 291 to 1523 +/- 240 kcal/day (P less than 0.005) after removal of ascites. The repeatability of our indirect calorimetry method only allowed for the analysis of the results in 4 of 10 patients in whom ascites removal produced a consistent decrease in resting energy expenditure. There were no statistically significant differences between the measurements obtained by indirect calorimetry and those provided by the Harris-Benedict equation, but the latter had a moderate reliability in predicting the real resting energy expenditure of every patient. Our results suggest that, far from being an inert volume, ascites may be associated, at least in some patients, with an increased resting energy expenditure and therefore accelerate the appearance of protein energy malnutrition with corresponding complications.

Enteral nutrition in inflammatory bowel disease.

To assess the effect of the addition of enteral tube feeding with polymeric diets to the standard treatment of acute attacks of inflammatory bowel disease a total of 43 patients admitted to hospital (23 with Crohn's disease and 20 with ulcerative colitis) were studied retrospectively. Total enteral nutrition was given to 26 as the sole nutritional supply and to 17 in conjunction with a normal ward diet, when appropriate, according to the severity of attack (control group). Nutritional state was assessed and classified in all patients at admission and at the end of the study, by measuring the triceps skinfold thickness, mid arm muscle circumference, and serum albumin concentration as representative of body fat, muscle protein, and visceral protein, respectively. At admission the three nutritional variables were not statistically different between the groups. There was a significantly positive effect on mid arm muscle circumference in patients on total enteral nutrition compared with the control group, but there was no effect on either triceps skinfold thickness or serum albumin concentration. The percentage of subjects requiring intravenous albumin infusion, however, was significantly less in the group fed enterally than in the control group. In addition, fewer patients in the group fed enterally required surgical treatment compared with the control group, despite the fact that one of the criteria for starting enteral nutritional support was the expectancy that surgery would be needed. Total enteral nutrition was well tolerated and no major side effects arose during its use in patients with acute exacerbations of inflammatory bowel disease.

Vitamin status in patients with inflammatory bowel disease.

The status of water- and fat-soluble vitamins was prospectively evaluated in 23 patients (13 men, 10 women, mean age 33 +/- 3 yr) admitted to the hospital with acute or subacute attacks of inflammatory bowel disease. Protein-energy status was also assessed by means of simultaneous measurement of triceps skinfold thickness, mid-arm muscle circumference, and serum albumin. Fifteen patients (group A) had extensive acute colitis (ulcerative or Crohn's colitis), and eight cases (group B) had small bowel or ileocecal Crohn's disease. Eighty-nine healthy subjects (36 men, 53 women, mean age 34 +/- 2 yr) acted as controls. In both groups of patients, the levels of biotin, folate, beta-carotene, and vitamins A, C, and B1 were significantly lower than in controls (p less than 0.01). Plasma levels of vitamin B12 were decreased only in group B (p less than 0.01), whereas riboflavin was lower in group A (p less than 0.01). The percentage of patients at risk of developing hypovitaminosis was 40% or higher for vitamin A, beta-carotene, folate, biotin, vitamin C, and thiamin in both groups of patients. Although some subjects had extremely low vitamin values, in no case were clinical symptoms of vitamin deficiency observed. Only a weak correlation was found between protein-energy nutritional parameters and vitamin values, probably due to the small size of the sample studied. The pathophysiological and clinical implications of the suboptimal vitamin status observed in acute inflammatory bowel disease are unknown. Further studies on long-term vitamin status and clinical outcome in these patients are necessary.