Duodenogastric reflux quantification in peptic ulcer surgery: comparison between different surgical techniques.

BACKGROUND: We quantified duodenogastric reflux with 6-hour continuous intravenous infusion of technetium 99m-labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequent quantification in gastric juice. METHODS: For this purpose, 50 patients were studied who had undergone surgery on the stomach with different surgical techniques: bilateral vagotomy plus Heineke-Mikulicz pyloroplasty, bilateral truncal vagotomy plus anterior pylorectomy, proximal gastric vagotomy, antrectomy and Billroth I reconstruction, and antrectomy and Billroth II reconstruction, comparing them with 10 healthy subjects used as a control group. We also studied the existing correlation between the rates of reflux determined by 99mTc-HIDA and those of total bile acids in gastric juice. RESULTS AND CONCLUSIONS: Patients who underwent gastric surgery had significantly greater quantities of duodenogastric reflux (p < 0.001) than had the control group. When the groups undergoing gastric surgery were compared, the patients who underwent resection showed higher reflux rates (p < 0.001) than did the patients who did not undergo resection. We found no differences among the groups of patients who did or did not undergo resection. We also found a highly significant correlation (p < 0.001) between the concentrations of 99mTc-HIDA and bile acids in gastric juice.

Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study.

OBJECTIVE: To compare the results of laparoscopic cholecystectomy (LC) with those of open cholecystectomy (OC) in the treatment of acute cholecystitis. DESIGN: A prospective, nonrandomized trial. SETTING: "Virgen de la Arrixaca" University Hospital, El Palmar (Murcia), Spain. PATIENTS: One hundred fourteen patients underwent LC, and 110 underwent OC. The patients underwent surgery within 72 hours of the onset of symptoms. The patients were selected for LC or OC depending on the surgeon's experience in laparoscopic surgery. MAIN OUTCOME MEASURES: Operating time, rate of conversion from LC to OC, complications, and length of hospital stay. RESULTS: Conversion from LC to OC was necessary in 15% of the patients. The mean operating time was 77 minutes for the OC group and 88 minutes for the LC group (P<.001). Complications occurred in 14% of the patients in the LC group and in 23% of the patients in the OC group, with no significant differences between the 2 groups (P=.06). The number of moderate or severe complications was similar in both groups, whereas mild complications were more common in the OC group (P<.02). The length of the hospital stay averaged 8.1 days for the OC group and 3.3 days for the LC group (P<.001). CONCLUSIONS: Laparoscopic cholecystectomy is a safe, valid alternative to OC in patients with acute cholecystitis. The technique has a low rate of complications, implies a shorter hospital stay, and offers the patient a more comfortable postoperative period than OC.

Laparoscopic cholecystectomy in the treatment of acute cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy has several advantages over traditional cholecystectomy, which make it the treatment of choice for patients with uncomplicated biliary lithiasis. However, in patients with acute cholecystitis, the role of this technique remains controversial and some clinicians regard this condition as a contraindication to laparoscopic cholecystectomy. STUDY DESIGN: Between June, 1991 and July, 1993, a total of 259 patients with cholelithiasis underwent laparoscopic cholecystectomy at the "Virgen de la Arrixaca" University Hospital. Of these patients, 60 underwent laparoscopic cholecystectomy for acute cholecystitis. RESULTS: Conversion to laparotomy was necessary in eight patients (13 percent). Mean operating time was 83 minutes (range, 45 to 180 minutes). Overall mean hospital stay (laparoscopy and conversions) was 3.1 days (range, one to nine days). There was no mortality or injury to the common bile duct in our series. CONCLUSIONS: We believe that laparoscopic cholecystectomy in patients with acute cholecystitis is a safe and effective procedure, in which the patient can benefit from the advantages of laparoscopic surgery without an increase in mortality and morbidity rates.

[Bladder compression by collateral veins]. / Compresión vesical por colaterales venosas.

Many space-filling injuries (e.g. haematoma, abscess, aneurysm, lymphocele, neoplasia etc.) may result in extrinsic compression of the bladder. We contribute one case report of compression of the bladder from collateral venous circulation in a patient who came for a left varicocele.

[Intravesical migration of an artificial urinary sphincter AMS-800: a rare complication]. / Migración intravesical de esfínter urinario artificial AMS-800: una rara complicación.

Presentation of two cases of a patients with urinary incontinence of neurogenic origin treated by means of an artificial urinary sphincter graft AMS-800 who suffered the complication of intravesical migration of the occlusive cuff in one case, and pressure balloon and occlusive cuff in the second one. In the latter, the pressure balloon underwent a process of intravesical calcification. A review of the literature on the etiopathogeny of this complication and management of these patients is conducted.

[The clinical evaluation of kidney trauma: the practical indications for complementary examinations]. / Evaluación clínica del traumatismo renal: indicaciones para la práctica de exploraciones complementarias.

The aim of the present work is to try to know the clinical data that can provide directions on the attitude to take with patients who seek advise with a suspicion of renal traumatism, thus allowing to select those that may require complementary examination. This is a retrospective revision of 190 cases of renal trauma admitted in our hospital between 1971 and 1992. We rated 3 large syndrome groups based on the patient's major signs and symptoms. The first indication in 71 patients was haemorrhagic syndrome (shock or anaemia); 100 patients had microscopic or gross haematuria non-associated to anaemia; and 6 patients showed painful signs and symptoms. Existence of renal injury should be suspected in patients that came to the hospital with a background of trauma, microscopic or gross haematuria, shock with or without haematuria or intraabdominal lesions; the performance of complementary examinations is necessary in patients with evidence of gross haematuria, microscopic haematuria associated to shock or suspected associated extra-renal intra-abdominal lesions, or shock whether or not associated to haematuria.

[Penile injuries: our experience]. / Traumatismos del pene: nuestra experiencia.

Trauma of the penis is relatively uncommon. Not many centres and even less urologists have extensive experience in the comprehensive management of this type of injury. Revision of the series accrued in our hospital over 20 years, in each case explaining the mechanism of occurrence, treatment applied and results obtained.

[Urologic complications in renal transplantation. Study of 250 cases]. / Complicaciones urológicas en el trasplante renal. Estudio en 250 casos.

OBJECTIVE: The aim of this study is value the incidence of urological complications (fistulae and estenosis) in our serie of renal transplant, to analyze the variables that can influence in their appearance and the treatments used. Likewise, to value the follow-up of theses patients and the survival of the renal graft and of the patient. MATERIAL AND METHODS: 250 renal transplants are carried out between july of 1985 and october of 1998. The relationship among the variables you makes by means of the test chi 2 of Pearson and the test of Fisher; the contrasts of stockings with the t of Student; the survival of the organ and of the patient, by means of the analysis of curved of survival according to the method of Kaplan and Meier; and the comparison among curved of survival was carried out with the test of Cloth and Cox. RESULTS: Of the 250 transplants, 46 patients suffered for complications, 29 urinary fistulae (11.6%) and 21 estenosis (8.4%). The most frequent localization in both complications was the union uretero-vesical. The presence of urinary fistulae didn't influence negatively in a significant way nor over the survival of the implant (p < 0.211), neither over the patient's survival. The estenosis appearance was related in a significant way with the donor's age (p < 0.02). The estenosis presence was not related in a significant way neither with the survival of the implant neither with that of the receiver. CONCLUSIONS: The incidence of urological complications was of 18.4% (11.6% estenosis and 8.4% fistulae). The most frequent localization was the union uretero-vesical. The presence of estenosis correlated with the increase of the age of the donors. The technique of reimplante ureteral didn't influence in the results in a significant way. We don't find any relationship between the appearance of urological complications and the patient's survival.

[Malignant neoplasms of the penis]. / Neoplasias malignas del pene.

OBJECTIVE: To assess the behaviour and management of these uncommon neoplasias. MATERIAL AND METHODS: Between March 1975 and July 1999, a total of 95 malignant neoplasias of the penis were diagnosed and treated by our unit. Patients mean age was 62 years (28 to 87 years). A retrospective analysis of any associated lesions, biological behaviour of the various neoplasias, as well as therapies used is carried out. RESULTS: The squamous carcinoma of the penis (SCP) is the most frequent pathohistological entity entailing 78 cases (82%), followed by verrucous carcinoma (VC) 13 cases (13.5%), basal cells carcinoma 1 case, and melanoma, lymphoma and penile metastasis 1 case each. There is a significant presence of associated lesions with marked predominance of phimosis. The most frequent reason for the call is an injury of the penis (74 cases; 78%). Treatment was mainly partial penectomy (51 patients; 53.7%), followed by conservative treatment in 28 cases (30%). Inguinal lymphadenectomy was performed in 13 patients (14%), due to either a positive nodular biopsy or a persistent adenopathy following antibiotic therapy. CONCLUSIONS: Neoplasias showing superior biological behaviour are basal cell carcinoma of the penis, and verrucous carcinoma. Prognosis in SCP is based on pathological status and node involvement. Patients with pT1 tumours showed no metastatic adenopathies after follow-up regardless of cytological grading, and are therefore candidates to watchful waiting with regular monitoring. Melanoma of the penis is a highly aggressive tumour due to its high metastatic capacity with a poor prognosis.

[Intraperitoneal bladder perforation in emphysematous cystitis]. / Perforación vesical intraperitoneal en el transcurso de una cistitis enfisematosa.

Contribution of one case report of a 69-year old diabetic male patient with neurogenic bladder. The patient developed emphysematous cystitis and peritonitis secondary to intraperitoneal perforation of the bladder. Emphysematous cystitis is an uncommon clinico-radiologic entity more frequent in diabetic and female patients and the elderly. Early diagnosis and treatment may avoid a fatal outcome. The paper includes a review of this condition.

[Management of obstructive uropathy in pregnancy]. / Manejo de la uropatía obstructiva en el embarazo.

INTRODUCTION: Obstructive uropathy in pregnant women is a relatively common condition. It can be difficult to assess due to the frequency with which physiologic dilation of the upper urinary tract is seen in pregnant women. PATIENTS AND METHOD: Over the past 3 years 40 pregnant women with symptomatic obstructive uropathy were seen in our service. RESULTS: Most pregnant women responded to conservative treatment (pain killers and antibiotics). In the remaining group, instrumentation was necessary through the urinary route: double J ureteral catheterism (10 patients: 6 due to uterine compression and 4 to lithiasis), percutaneous nephrostomy (4 patients: 2 due to ureteral catheter obstruction impossible to replace, and two due to urinary sepsis), or ureterorenoscopy (1 patient with lithiasis). CONCLUSIONS: The single most common cause for obstructive uropathy in our experience is ureteral compression due to a gravid uterus. Choice therapy in most cases is conservative treatment. When in spite of conservative treatment signs and symptoms persist, urinary by-pass with antibiotic prophylaxis must be performed. Ureterorenoscpy as a diagnostic and therapeutical approach should be taken into consideration in pregnant women with ureteral lithiasis. Incidence of pre-term labour was not higher than usual.

[Can PSA density predict the response to alpha-blockers in benign prostatic hyperplasia?]. / Puede la densidad de PSA predecir la respuesta a los alfa-bloqueantes en la hiperplasia benigna de próstata?

INTRODUCTION AND OBJECTIVES: In BPH there is a growth of both glandular and stromal components. Most of adrenoceptors sites are in the fibromuscular stroma. So the higher is the stromal/epithelial ratio, the more effective will alpha-blockers be. There in an indirect way of stimating this ratio without performing a biopsy. Bearing in mind that PSA is produced by the prostatic epithelium, the lower PSA density (PSAd), the higher the stromal/epithelial ratio and the higher alpha-blocker activity. We pretend to study if PSAd is useful for predicting the response to alpha-blockers in BPH. MATERIAL AND METHODS: We studied 75 patients suffering from prostatism and diagnosed of bladder outlet obstruction secondary to BPH through IPSS symptom score, digital rectal examination, PSA, uroflowmetry, and transrectal ultrasound. All of them received Alfuzosin, 5 mg twice daily during 3 months, and then were evaluated again with IPSS and uroflowmetry. RESULTS: A statistically significant improvement was appreciated of the two studied parameters and in both groups of patient with regard to the pretreatment situation. A statistically significant better answer was also appreciated in the group of patient with smaller PSAd in comparison with the higher PSAd patients. CONCLUSIONS: Our results show that PDAd is usefu to estimate the stroma/epithelium ratio, and therefore the clinical response to alpha-blockers.

[Brucellar orchiepididymitis]. / Orquiepididimitis brucelosa.

The brucellosis is an unusual entity whose incidence has diminished due to the improvement in preventive measures. We have carried out a retrospective study of all the patients admitted in our service between 1996 and 1998, with diagnosis of orchitis. Two of the 31 patients admitted for this reason presented a final diagnosis of brucellar orchiepididymitis. Both patients presented clinic of affectation from the general state accompanied by resistance to habitual antibiotic treatment. The patient's epidemic antecedents, accompanied by the suitable clinical evolution took to the suspicion of orchiepididymitis of brucellar etiology, with change in the antibiotic rule. The diagnosis of the process was obtained by means of serologic tests and blood cultures.

Gastrointestinal bezoars.

Of 99 patients with 117 gastrointestinal bezoars, 69 had undergone previous surgery, the most common operation being bilateral truncal vagotomy with pyloroplasty (55 patients). An excessive intake of vegetable fibre was found in 38 patients and poor mastication in 27. Thirty bezoars presented with gastric symptoms and patients had endoscopy as the diagnostic technique; 87 caused symptoms of intestinal obstruction with the diagnosis made by plain abdominal radiography. Medical treatment by enzymic or endoscopic fragmentation was used for 17 of 30 gastric bezoars; surgery was required in the remainder. Intestinal bezoars causing obstruction can be fragmented and 'milked' to the caecum. The stomach should be explored for associated gastric bezoars.

[Intramuscular ketorolac compared to subcutaneous tramadol in the initial emergency treatment of renal colic]. / Ketorolaco intramuscular frente a tramadol subcutáneo en el tratamiento inicial de urgencia del cólico renal.

OBJECTIVE: To compare the efficacy and safety of two analgesics (tramadol and ketorolac) for initial emergency treatment of renal colic. METHODS: A prospective study on 48 patients randomly assigned to treatment with ketorolac 30 mg i.m. and tramadol 1 mg/kg s.c. Pain intensity was evaluated by a simple analogic scale ranging from 0-4 (0 = no pain, 1 = mild, 2 = moderate, 3 = severe and 4 = very severe pain). Statistical analyses were performed with Student's test and the chi square test for numerical and qualitative data, respectively. RESULTS: No significant differences were found for the overall efficacy (> 80%) or side effects in both groups. However, a difference was found between both groups for pain score 15 minutes post-injection, which showed i.m. ketorolac to be more effective. CONCLUSION: Both ketorolac (30 mg i.m.) and tramadol (1 mg/kg s.c.) are effective in the initial treatment of renal colic. Both drugs have an efficacy greater than 80% when used separately and almost 100% when used in combination. The analgesic effect of ketorolac is observed earlier than that of tramadol.

Subtotal colectomy vs. intraoperative colonic irrigation in the management of obstructed left colon carcinoma.

PURPOSE: Whether primary anastomosis should be performed after segmental resection with intraoperative colonic irrigation or subtotal colectomy is not yet established in the surgical treatment of obstructive left colon carcinoma. In this prospective, nonrandomized study, we present the results of 66 patients undergoing one-stage surgery for obstructed left colon carcinoma. PATIENTS AND METHODS: We compared two techniques, subtotal colectomy (35 patients) and intraoperative colonic irrigation with segmental resection and immediate anastomosis (31 patients). RESULTS: The mortality rate was similar in both groups, 8.5 percent in the subtotal colectomy group and 3.2 percent in the intraoperative colonic irrigation group. The surgical complication rate was significantly higher in the intraoperative colonic irrigation group (41.9 percent) than in the subtotal colectomy group (14.2 percent; P < 0.05). Mean operating time was significantly lower in the subtotal colectomy group than in the intraoperative colonic irrigation group (P < 0.05). Both groups had a similar mean duration of hospital stay. Ten patients who underwent subtotal colectomy (31.2 percent) presented with diarrhea in the immediate postoperative period, which disappeared spontaneously or with antidiarrheal medication; a disabling diarrhea persisted in two patients only (6.2 percent). CONCLUSION: We believe that subtotal colectomy is the treatment of choice for obstructed left-sided colonic carcinoma. Segmental resection with intraoperative colonic irrigation is more appropriate than subtotal colectomy only in patients with carcinomas of the rectosigmoid junction or with previous anal incontinence to avoid the appearance of postoperative diarrhea.

Laparoscopic vs. open cholecystectomy in patients aged 65 and older.

Laparoscopic cholecystectomy (LC) has displaced open cholecystectomy (OC) in the management of cholelithiasis. However, there are few studies on the role of this technique in patients who run a high risk of surgical complications. We performed a prospective study in 264 patients aged >65 years undergoing surgery for symptomatic cholelithiasis. They were divided into two groups according to the surgical technique performed: OC (131 patients) and LC (133 patients). Conversion from LC to OC was necessary in 11 patients (8.3%). Mean surgery time was 70.9 min for the OC group and 75 min for the LC group. The LC group had a lower rate of postoperative complications (13.53%) than the OC group (23.6%). The incidence of mild complications was similar in both groups; however, the rate of moderate complications was significantly higher in the OC group. Hospital stay was significantly longer in the OC group (9.9 days) than in the LC group (3.71 days). These results suggest that LC should be indicated in elderly patients, as they are better than those obtained with with OC and involve a lower morbidity rate and shorter hospital stay.

[Epidemiologic study of renal parenchymal trauma. 22-year experience]. / Estudio epidemiológico de traumatismos parenquimatosos renales. Experiencia de 22 años.

OBJECTIVE: The results of an epidemiological study on kidney trauma are presented. METHODS: We reviewed the epidemiological factors in patients that had been admitted to hospital for kidney trauma from 1971 to 1992. RESULTS: Blunt trauma (96.3%) was found to be more frequent than penetrating injuries (3.7%). Road traffic accidents were the main cause of kidney trauma (50.53%), which was more prevalent in the male (male to female ratio 3.75:1) and in the younger population (76% were aged 11 to 30 years). Associated extrarenal lesions were more commonly found in patients with severe renal trauma. CONCLUSION: Renal trauma is relatively uncommon and is more prevalent in males in the second and third decades of life. The outcome depends on the degree of severity of the injury and the presence of associated extrarenal lesions.