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.

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.

[Treatment of retinal angiomatous proliferation (RAP). A retrospective study]. / Tratamiento de la proliferación angiomatosa retiniana (RAP). Estudio retrospectivo.

PURPOSE: To assess the follow-up and response to treatment in patients with RAP. METHODS: A retrospective follow-up study of patients with RAP diagnosed between March 2002 and August 2005. Baseline and subsequent angiograms and optical coherence tomography results were reviewed and RAP classified according to the 3 stages described by Yannuzzi. The changes observed and the best visual acuity were assessed separately for each of the 4 different treatments used: Transpupillary thermotherapy (TTT), Photodynamic therapy (PDT), combined treatment with PDT and Intravitreal triamcinolone (IVT), and combined treatment with PDT, IVT and direct laser photocoagulation of the vascular intraretinal lesion (DLPh.). RESULTS: Fifteen eyes of 14 patients with RAP were studied (mean age, 77.5 years). The mean follow-up was 15.9 months and the mean number of treatments was 2.5. The final visual acuity was worse in 7 (46.7%), stable in 7 (46.7%) and better in 1 (6.6%). Visual acuity improvement, in regard to the treatment used, was: TTT group: 2 out of 14 (14.2%): PDT group: 1 out of 5 (20%); PDT + IVT group: 2 out of 5 (40%) and DLPh. + PDT + IVT group: 3 out of 5 (60%). CONCLUSIONS: The final prognosis for RAP, in terms of visual acuity, was generally poor. However the best treatment was the combined treatment with DLPh + PDT + IVT, while the worst was TTT.

Early graft thrombosis after endovascular aortic aneurysm repair with aortouni-iliac endografts.

Endovascular repair of aortic aneurysm has become a viable treatment option in selected patients. However, despite the minimally invasive nature ot this treatment a significant incidence of vascular complications has been reported. Here, we report two cases of acute limbs ischemia due to endograft thrombosis in patients treated with aortouni-iliac devices and we review the etiologic factors related with these events and the treatment options. We suggest that the presence of atherosclerotic plaques within the outflow arteries and coexistent infrainguinal arterial occlusive disease (poor runoff) is an underestimated factor in the risk of graft thrombosis, especially in patients treated with aortouni-iliac devices and we advocate the use in the early follow-up surveillance after endovascular repair of aortic aneurysm of noninvasive test such duplex scanning, segmental pressures and ankle-brachial indices to asses the presence or progress of coexistent occlusive disease. We also suggest that some adverse outcomes ascribed to device failure might be more properly charged to inappropriate patient selection.

[Minimally invasive surgery of the inguinal hernia]. / Cirugía mínimamente invasiva de la hernia inguinal.

The minimally invasive approach to the inguinal hernia shows advantages with respect to previous conventional approaches in bilateral and recurrent inguinal hernias; while the initial results were bad, new problems were added deriving from the laparoscopic approach. The aim of this article is to describe the surgical technique and analyse the preliminary results of our series of 600 totally extra-peritoneal hernioplasties, performed at the University Clinic of Navarra. The most frequent complication (25.7%) was the accidental rupture of the peritonea. There were no associated intra-abdominal complications. In the follow-up there were 9 relapses (1.5%) and 13 reinterventions. Eleven (1.8%) of the patients developed transitory neuropathic pain in the femoral cutaneous area. In our experience the totally extra-peritoneal approach is a technique that is especially indicated in relapsed and bilateral hernias. The advantages present, in terms of pain and postoperative discomfort, recovery of physical and labour activity, and the good results with respect to relapses and neuropathic pains, encourage us to indicate it not only in relapsed or bilateral inguinal hernias but also in primary ones.

[A new device for vitreous biopsy]. / Nuevo dispositivo para biopsias vítreas.

PURPOSE/METHODS: Description of a simply-made device for obtaining vitreous biopsies. RESULTS/CONCLUSIONS: This new device allows the surgeon to control aspiration, thereby enabling the obtention of many vitreous biopsies both diluted and undiluted.

The role of transjugular intrahepatic portosystemic shunt prior to abdominal tumoral surgery in cirrhotic patients with portal hypertension.

INTRODUCTION: Major abdominal surgery can be contraindicated in some cirrhotic patients because of severe portal hypertension. The present study reports our experience of three patients with abdominal tumours prepared for surgery by transjugular intrahepatic portosystemic shunts (TIPS) in order to reduce portal hypertension and the risk of intraoperative bleeding. PATIENTS AND METHODS: Three patients with cirrhosis and portal hypertension diagnosed with a right colon carcinoma, an adenocarcinoma of pancreas and a gastric and sigmoid synchronic tumours in the same patient. Because portal hypertension was the leading cause of surgical contraindication, neoadjuvant TIPS placement was proposed before surgery. RESULTS: TIPS placement was performed without intra-procedure complications. An average reduction of 18 mmHg was achieved in portosystemic gradients. The planned operations were performed with a delay of 14-45 days after TIPS without intraoperative bleeding. Complications occurred in one patient without operative mortality. CONCLUSION: TIPS placement allows a pre-operative portal decompression in cirrhotic patients with portal hypertension and abdominal tumours that require surgical treatment. This procedure reduces the risk of bleeding by reducing the portosystemic gradient and the varices around the tumoral area. This procedure is less invasive than conventional shunt surgery, but it is not free of complications and should be performed by experienced interventional radiologists on selected patients. This is still an experimental indication of TIPS which efficacy must be confirmed in larger series.

Comparison between two warm ischemic models in experimental liver transplantation in pigs.

BACKGROUND: Experimental models of warm ischemia in liver transplantation have been employed to study the mechanisms and treatment of ischemia reperfusion injury. METHODS: We compared a control group without (group A, n = 10) versus two models of warm ischemia of liver transplants in pigs: namely, occlusion of the hepatic artery and portal vein for 30 minutes (group B, n = 23) and extraction of the liver 60 minutes after cardiac arrest (group C, n = 5). Liver function tests, coagulation studies, and liver biopsies were performed during the first 24 hours post-liver transplant. RESULTS: Clamping of the hepatic vasculature in group B produced a significant liver injury compared with the control group: elevation of the ALT and an abnormal 1-hour post-revascularization biopsy similar to that observed in the cardiac arrest group C. The transaminase levels were lower among group A animals (P <.05). But the hepatic synthetic functions as reflected in the protrombin time (PT) were not affected in group B versus group A. The alteration in PT with respect to the initial value was similar among group A and group B animals, which were significantly less than that in group C (P <.05). CONCLUSIONS: Occlusion of the hepatic artery and portal vein, a simple surgical maneuver, causes moderate damage to a liver graft but less alteration of hepatic synthetic function. Clamping of the hepatic vasculture obtains more long-term survivors after OLT than cardiac arrest.

Intestinal T-cell lymphoma associated with celiac disease masked by cavernous lymphangioma.

We present the case of a patient admitted to our emergency ward with a clinical setting of acute abdominal pain and a history of cavernous lymphangioma, diagnosed in another center by exploratory lapartomy. The patient presented complete analysis including serology tests, as well as an abdominal CT scan that revealed multiple large size retroperitoneal cysts. In view of the clinical symptomatology and results of the tests, a second CT scan was carried out upon admission. As a result of the findings obtained, a second exploratory laparotomy was carried out in which intestinal resection of the perforated jejunal loop and largest cysts was performed. Pathological anatomy diagnosed an intestinal lymphoma associated with enteropathy and abdominal cysts compatible with cavernous lymphangioma. In this work we describe both pathologies, the most characteristic aspects are analyzed and the etiology and possible relation between both entities is discussed.

[Role of surgery in the treatment of primary gastric lymphoma]. / Papel de la cirugía en el tratamiento del linfoma gástrico primario.

Primary gastric lymphoma's optimum management remains controversial. We reviewed our series of 23 patients with primary gastric lymphoma treated in our hospital between 1976 and 1998 with surgery as main therapy. Ten patients underwent surgical resection alone, whereas 13 also received postoperative adjuvant therapy, depending on the oncologist-haematologist's recommendations. No differences were found between treatments regarding mortality and morbidity. Clinical-histological features and patients, follow-up are analyzed. No patient died because of lymphoma and there wasn't either local or distant recurrence. We consider that surgery remains a valid option for the primary gastric lymphoma treatment. The introduction of combined modalities of radiation therapy and chemotherapy will depend on the final stage, the tumor histological features, and the feasibility of getting a radical resection.

Sulfonylurea effects on acid and pepsinogen secretion in isolated rabbit gastric glands.

The influence of different sulfonylureas on the rate of acid and pepsinogen secretion was studied in isolated rabbit gastric glands. Neither tolbutamide (10-500 microM), chlorpropamide (10-500 microM), glibenclamide (1-50 microM) nor glipizide (1-50 microM) exerted a secretory effect. In contrast, gliquidone caused a marked and dose-dependent stimulation of acid production in gastric glands incubated under basal conditions and potentiated the stimulatory effect of both histamine and carbachol. Gliquidone also increased the rate of pepsinogen release in gastric glands incubated either under basal conditions or in the presence of cholecystokinin-octapeptide or isoproterenol. The secretory effects of gliquidone were associated with a significant increase in the glandular content of cyclic AMP, caused by a competitive inhibition of low-Km cyclic AMP phosphodiesterase. Our results indicate that, among the assayed sulfonylureas, only gliquidone, in the micromolar range, stimulates acid and pepsinogen secretion through a cyclic AMP-dependent mechanism.

Frequency of congenital hypertrophy of the retinal pigment epithelium in familial adenomatous polyposis.

Congenital hypertrophy of the retinal pigment epithelium is a recognized clinical marker in familial adenomatous polyposis as an expression of the altered gene in this autosomal dominant disease. Ocular lesions could be discovered years before the development of intestinal polyposis. We studied 29 diagnosed patients, 38 relatives (first degree) of familial adenomatous polyposis kindreds and 26 controls (general population). Number, size and bilaterality of pigmented lesions were analysed in order to separate members affected and non affected by intestinal polyposis in familial adenomatous polyposis kindreds. Three of 26 families (23%) had patients with polyposis and normal fundus. Bilaterality and more than 4 lesions improved specificity or sensibility of the fundus examination. However, the best efficacy of the test was obtained with large lesions (sensibility 0.82 and specificity 0.97).

The beta-2 receptor plays a role in the hypotensive effect of L-Dopa

La levodopa ejerce efectos cardiovasculares tanto por conversasión a dopamina como por mecanismos no bien dilucidados. Los receptores beta adrenérgicos intervienen en los efectos de levodopa sobre el Sistema Nervioso Central. La participación de los receptores ß adrenérgicos en el efecto hipotensor periférico de la levodopa motiva el presente trabajo. En ratas anestesiadas (uretano 1 ml/100 i.p. y heparinizadas 300 U.I./Kgi.i.v.) se registró en un polígrafo la frecuencia cardíaca y la presión arterial media intracarotídea, una cánula traqueal facilitó la ventilación pulmonar. Los fármacos se inyectaron mediante un catéter de polietileno en la vena femoral. Grupos Experimentales: Grupo Control: a) Se estudió el efecto de Dopamina (3, 12 a 25µg/100gi.v.) y levodopa (12.5 a 100gi.v.) sobre presión arterial y frecuencia cardíaca. Pretratados con Beta bloqueadores: b) Se estudió la influencia de propranolol (50µg/100g), atenolol (100µg/100g) e ICI118.55(25µg/100g) inyectados 20 min antes sobre el efecto hipotensor de la dopamina y levodopa. La dopamina produjo hipotensión arterial dosis-dependiente (p<0.02) que no se modificó por propranolol, atenolol o ICI118.55. El tratamiento con atenolol no modificó la respuesta hipotensora de levodopa. El propranolol e ICI118.55 aumentaron la presión arterial. Propranolol e ICI118.55 comparten la propiedad de bloquear el receptor ß2. Se sugiere que ese receptor juega un rol fundamental en la hipotensión producida por levodopa

Fructose 2,6-bisphosphate levels and modulation of glycolysis by histamine, cholecystokinin, and forskolin in isolated rabbit gastric glands.

In isolated rabbit gastric glands incubated in the presence of 1 mmol/L glucose, the content of fructose 2,6-bisphosphate (F-2,6-P2) was 5.7 +/- 0.5 pmol/mg dry weight. This value was progressively incremented by increasing glucose concentration in the incubation medium, and was almost doubled at 10 mmol/L glucose. Under these conditions, a close correlation could be established between the levels of F-2,6-P2 and the rate of L-lactate formation (r = .98; P less than .05). Both histamine (0.1 mmol/L) and cholecystokinin octapeptide (CCK-OCT; 0.1 mumol/L) increased L-lactate production, without significant changes in either F-2,6-P2 concentration or the amount of 6-phosphofructo-2-kinase in active form. In contrast, forskolin, which markedly increased the glandular content of cyclic adenosine monophosphate (cAMP), partially blocked glucose consumption and caused a significant reduction in both F-2,6-P2 levels and the proportion of 6-phosphofructo-2-kinase in active form. Furthermore, forskolin partially blocked the rate of glucose uptake by isolated gastric glands. Our results suggest a regulatory role of F-2,6-P2 in the control of the glycolytic flux in response to glucose, but not in its response to histamine or CCK-OCT.

[Lorenzo Sazié]. / Don Lorenzo Sazié.

The first Dean of the University of Chile School of Medicine was Dr Lorenzo Sazié a young and bright French academician, endowed with superb skills in Surgery and Obstetrics. His nomination as Dean (1843) extended until December 1st, 1865 when he died, just a few days after the passing away of Andrés Bello, the Rector of the University of Chile. Sazié's fulfillment as physician, Professor, Dean, Member of the University Council and President of Protomedicatus Court, was outstanding. He organized medical curricula according to French medical scopes, to local resources and to Chilean prevalent diseases. He enabled scientific development by means of a close connection between the School of Medicine and the School of Physical and Mathematical Sciences. Works of both Schools were supposed to be related with matters of public interest and were published in "Revista de Santiago". He also provided subscriptions to the principal European scientific journals. As President of Protomedicatus he applied severe measures to regulate medical and paramedical performances. In addition, as President of the "Junta de Beneficencia de Santiago" he supervised and updated hospital care management and founded several health institutions such as the Madhouse, the Orphan House and the School of Midwifery. As a physician Sazié was a frugal, generous and dedicated man who, regardless of social or economic positions, served everyone with the same devotion. He died from typhoid fever while taking care of his patients during an epidemic outbreak which took place in Santiago in those days.

[Protomedicato in Chile]. / El protomedicato en Chile.

In 1566 Alonso de Villadiego was nominated by the Chilean Cabildo as "Adviser and Examiner in Surgery". By means of this edict, the Spanish Crown paralleled its classical health organization, inspired in rules coming from XIIIth century. The Hospital del Socorro was the focal point of these activities. It turned to be prosperous under the administration of "San Juan de Dios" monks (1617), who rebaptized the Hospital with their name. During the administration of the "Universidad de San Felipe" (1738-1839), the Protomedicato followed the standards imposed by the Cahir of Prima Medicina. Domingo Nevin, Frenchman, and José Antonio Ríos, Chilean, were the first and the last doctors in charge of this task. Ríos conducted the antivariolic campaign, supervised the "Midwifery Law" and controlled the medical and paramedical practice. Afterwards, the Institution plunged into a profound crisis to reflourish in 1833 when it was incorporated within the structure of the School of Medicine. Blest, Cox, Bustillos and Moran were the architects of its splendour. With the foundation of the Universidad de Chile in 1842, its Faculty of Medicine took over the Protomedicato functions. The Institution came to an end in 1892.

[The protomedicate in Spain]. / El protomedicato en España.

Protomedicate, a Royal Medical Court devoted to preserve higher academic proficiency and moral standards in the medical profession, was first conceived by the law-oriented monarch Alphonse X, the Wise one (XIII A C) and fully applied in the Iberian Peninsula and its American Colonies about mid XVIth century. Candidates were required to prove their knowledge and manual skills in the presence of the Protomedical and three examiners appointed by the King. According to legal regulations, surgery candidates had to accomplish a four year practice under the supervision of an experienced surgeon. Protomedicate was a unique, peculiar institution developed in Spanish speaking lands. Whereas in England, France or Italy medical teaching was delivered through scientific Academies, Royal Colleges and rarely in Universities, in Spain it was almost exclusively performed by the Protomedicate.