Long-term outcomes after robotic sacrocolpopexy in pelvic organ prolapse: prospective analysis.

OBJECTIVE: To evaluate the feasibility and long-term outcomes of our initial series of robot-assisted laparoscopic sacrocolpopexy. METHODS: We conducted a prospective analysis of our series of robotic sacrocolpopexy. INCLUSION CRITERIA: patients with grades III and IV cystocele and or other symptomatic pelvic organ prolapse. We performed a transperitoneal four-trocar technique with the Da Vinci robotic system using two polypropylene meshes for fixation to the sacral promontory. The primary outcome was recurrence; secondary outcomes included operating room time, blood loss, conversion to open surgery, complications and length of stay. RESULTS: 31 consecutive procedures were included. Mean patient age was 65.2 (50-81) years. Mean operating room time was 186 (150-230) min. We converted 1 case to laparoscopy (3.2%). There were two major complications (1 acute myocardial infarction and 1 reoperation for excess tension with syncopes), two minor complications (1 wound infection and 1 ileus) and no recurrences at a mean follow-up of 24.5 (16-33) months. CONCLUSIONS: Robotic sacrocolpopexy could possibly improve with experience after overcoming the learning curve. There is no doubt it is a reproducible technique, but its safety and efficacy still need to be proven. Our initial series demonstrated good outcomes and no recurrences at 24.5 months of follow-up.

Lactate metabolism during laparoscopic cholecystectomy: comparison between CO2 pneumoperitoneum and abdominal wall retraction.

Recent reports have implicated CO2 pneumoperitoneum for laparoscopic surgery in the occurrence of postoperative mesenteric ischemia. With this kind of surgery, the increase in blood lactate levels has been attributed to anaerobic metabolism, probably due to tissue ischemia induced by high intraabdominal pressure (IAP). The aim of this study was to evaluate the metabolic repercussion of CO2 pneumoperitoneum during laparoscopic cholecystectomy (LC). This was a prospective randomized study of CO2 pneumoperitoneum (PP group, n = 19) versus abdominal wall retraction (AWR group, n = 15). Demographic data were collected preoperatively. Four-trocar LC was performed with either a CO2 pneumoperitoneum (IAP of 12 mmHg) or abdominal wall retraction (abdominal wall pressure 6-10 kp). Intraoperative and postoperative blood samples were collected and lactate levels determined by enzymatic analysis. Repeated measures analysis of variance (MANOVA) was used for statistical analysis. Significance was evaluated at p < 0.05. The groups were shown to be homogeneous. Lactate concentration, expressed as mean (SD), went from 25.4 (14.4) mg/dl at baseline to 18.9 (13.6) mg/dl 4 hours after surgery in the PP group and from 19.4 (6.1) mg/dl at baseline to 17.8 (14.7) mg/dl in the AWR group. No significant differences were found between groups intraoperatively (p = 0.116) or postoperatively (p = 0.99). Our study did not show significant differences in blood lactate levels during LC with CO2 pneumoperitoneum compared to the same procedure with abdominal wall retraction.

Quantitative study of metals in bile from patients with cholelithiasis.

OBJECTIVE: Biliary lithiasis is a multifactorial phenomenon that is decisively influenced by the composition of bile. We analyzed the presence of eight metals in bile and compared their concentrations in healthy persons and patients with cholelithiasis. METHODS: We studied bile from 119 patients who underwent cholecystectomy because of symptomatic cholelithiasis, and from 25 control subjects in whom the gallbladder was removed for reasons other than cholelithiasis. Metal concentrations were analyzed by atomic absorption spectrophotometry. The subjects were divided into subgroups according to age, sex and type of stone. RESULTS: Bile from patients with cholelithiasis contained significantly less of the essential element magnesium (Mg) and the toxic element lead (Pb) than bile from control subjects. Calcium (Ca) and strontium (Sr) concentrations were also lower in patients with gallstones than in the control group, although the differences were not significant. CONCLUSIONS: Biliary concentrations of Mg and Pb were significantly lower in patients with cholelithiasis than in the control group. The biliary excretion of Ca and Sr was lower in patients than in controls, although the differences were not statistically significant.

[From the laboratory to the clinic: CFTR and the therapeutic options for cystic fibrosis]. / Del laboratorio a la clínica: CFTR y opciones terapéuticas para la fibrosis quística.

Cystic fibrosis is a common lethal heritable disorder, caused by a defect in a chloride channel protein, namely CFTR. After the identification of the gene and its product by positional cloning (on chromosome 7), CFTR has been characterized as a low conductance (8-10 pSiemens) linear chloride channel, which appears to regulate other apical transport proteins. Two therapeutic options are reviewed: gene transfection and drug therapy. So far, clinical studies have shown that gene transfection cannot effectively restore CFTR function. Simultaneously, several drugs including genistein, phenylimidazothiazoles and gentamicin have been found to activate mutant CFTR, thus, being suitable for single or combined (with gene transfection) treatment.

Effects of a tyrosine phosphatase inhibitor on chloride secretion in human intestinal epithelia.

AIMS: Transcellular chloride transport is the key event underlying epithelial hydration in the intestine. Little is known about the role of protein tyrosine phosphatases in the regulation of basal and stimulated secretion in human intestinal epithelia. The aim of our study was to investigate the effects of the protein tyrosine phosphatase inhibitor sodium orthovanadate on vectorial chloride transport in native human colon. METHODS: An electrophysiological technique was used to measure changes in short-circuit current via a dual voltage/current clamp in native human colon mucosa and in T84 (ATCC) human intestinal cells mounted in modified Ussing chambers. RESULTS: Orthovanadate (1 mM) added to the serosal side of native human colon caused a net rise in short circuit current, reflecting the stimulation of serosal-to-mucosal chloride movement. Epithelial cells responded similarly to the same concentration of the compound. The stimulatory effect of orthovanadate was enhanced by pretreatment with the tyrosine kinase inhibitor genistein, but only when orthovanadate was added to the basolateral chamber. In contrast, the synergistic interaction did not occur when epithelial cells were previously exposed to the cAMP agonist forskolin. CONCLUSIONS: We show that tyrosine phosphatases may be involved in the regulation of epithelial chloride transport, and that orthovanadate stimulates secretion in the human colon.

Value of tonometry in postoperative high risk patients with digestive surgery.

Intramucosal pH (pHi) in splanchnic organs is a reliable index of local tissular perfusion, and can be measured by tonometry. At the Surgical Intensive Care Unit we used tonometry to determine tissular perfusion in patients who underwent major digestive surgery. We report a prospective study of 20 patients with elective and emergency surgery. All of them underwent gastric tonometry and 10 of them, who had colonic disease, also underwent sigmoid tonometry. The values below pHi = 7.30 were associated with increased morbidity and mortality.

[Study of the secretion of P substance, neurotensin and somatostatin in healthy adults]. / Estudio de la secreción de sustancia P, neurotensina y somatostatina en adultos sanos.

OBJECTIVE: A study in humans of the profile of physiologic secretion, basal and postprandial of three gastrointestinal peptides has been carried out. METHOD: 20 healthy subjects were studied (9 women and 11 men); any previous digestive pathology has not been included. The study was carried out by determining P substance, neurotensin and somatostatin in plasma by means of RIA I125. The subjects were studied in basal conditions of fasting and the samples were taken at 30, 60 and 90 minutes intervals after the oral intake of a semi-liquid preparation made up of the three immediate principles. RESULTS: It shows the secretion curve of the three gastrointestinal peptides, in a global way and also in relation to sex, age and body weight.

Study of the secretion of substance P, neurotensin and somatostatin in patients with cholelithiasis.

A comparative, case-control study on the pre- and postprandial release of three gastrointestinal peptides implicated in gallbladder motility has been carried out in humans in the attempt to determine their possible role in the pathogenesis of cholelithiasis. Fifty-seven adult patients (40 females and 17 males) with an ultrasound diagnosis of gallstones and 20 healthy subjects (9 females and 11 males) without cholelithiasis or other digestive pathology were studied. Plasma substance P, neurotensin and somatostatin were measured by means of RIA-I125 in basal fasting conditions and 30, 60 and 90 minutes after the oral intake of a semiliquid mixed meal. The levels of secretion of each hormone were compared in patients and healthy controls on an overall basis and in terms of sex, age and body weight. We found a basal and postprandial hypersecretion of substance P in patients with gallstones when compared with controls. Individuals with cholelithiasis showed a moderate decrease in neurotensin secretion after the oral meal. Somatostatin release was unchanged. In conclusion, patients with gallstones may present a functional disorder in the secretion of gastrointestinal hormones involved in gallbladder motility.

[Excision of esophageal leiomyoma using videothoracoscopy]. / Extirpación de leiomioma esofágico mediante videotoracoscopia.

We report the case of a 57 years old male patient presenting with pyrosis and dysphagia. A mid-third esophageal leiomyoma was diagnosed. The tumour was resected through a right video-thoracoscopic approach and simultaneous intraoperative esophagoscopy was performed. The postoperative course was uneventful and six months after surgery neither relapsing symptoms nor radiologic pathological findings were observed. We consider that symptomatic leiomyoma is a good indication for video-assisted thoracoscopic enucleation. The possible postoperative complications (esophageal fistula, esophageal pseudodiverticulum) may be minimized by means of an adequate surgical technique.

[Laparoscopic surgery in the treatment of complicated gastroesophageal reflux]. / Cirugía laparoscópica en el tratamiento del reflujo gastroesofágico complicado.

Laparoscopic antireflux surgery has quickly developed since Bernard Dallemagne carried out the first laparoscopic fundoplication in 1991. However, only preliminary results from institutional series are available. The authors review the indications for laparoscopic antireflux surgery. In addition, technical aspects of several reported laparoscopic antireflux procedures are evaluated. Data from institutional series show that morbidity and mortality rates after laparoscopic antireflux surgery are similar to those reported for open surgery, with a perioperative morbidity rate ranging between 4% and 26% and a mortality rate under 0.6%. Endoscopic dilation for postoperative dysphagia is required in 7%-11% of the cases. In summary, preliminary data show that laparoscopic antireflux surgery may play a predominant role in the treatment of complicated gastroesophageal reflux. Meanwhile, controlled trials with open surgery and medical therapy should be done before the laparoscopic approach is generalized.

[Enteral nutrition in seriously ill patients with digestive tract surgery]. / Nutrición enteral en pacientes graves con cirugía de aparato digestivo.

The results of an enteral nutritional pattern used in 40 seriously ill patients who underwent gastrointestinal tract surgery, are described. The most frequently used route of administration (97.5% of the cases) was a jejunal catheter. We review the types of formula used, the method and time of perfusion, and the association with parenteral nutrition. The mean time of perfusion was 8.6 (5) days and the morbidity rate due to enteral nutrition was 20%. In all cases the complications were minor (externalization of the catheter in 2 cases, proximal reflux of the formula in 1 patient, a catheter break, which was eliminated through the stool without any consequences, in 1 case, diarrhoea in 2 patients, and catheter obstruction in 2 cases). The nutritional results, evaluated by means of clinical chemistry (total proteins, albumin, prealbumin, and transferrin), showed a stabilization of the catabolic process in patients with a poor preoperative nutritional state under severe surgical stress. It can be concluded that enteral nutrition is a useful manner of postoperative feeding in seriously ill patients who undergo gastrointestinal surgery, and that it must often be added to parenteral nutrition to ensure an adequate caloric intake.

[Laparoscopic cholecystectomy: 3 years of experience at a university hospital]. / Colecistectomía laparoscópica: tres años de experiencia en un Hospital Universitario.

We analyse the first 174 patients treated with laparoscopic cholecystectomy (LC) and their follow-up results. Average age was 57 years. Intraoperative cholangiography was not done in anyone. Conversion rate into other forms of intervention was 6.3%. The rate of common bile duct injury has been null. Total morbidity was 6.3%. Two cases of pulmonary embolism and two biliary leakages stand out in the postoperative morbidity. There was no death. After a follow-up period of up to 36 months, only 1 case of residual choledocholithiasis was registered, and it was cured with endoscopy. In this series morbid-mortality figures are low. LC is a safe procedure in the treatment of cholelithiasis, even in older patients.

[Acute cholecystitis and laparoscopic cholecystectomy. Comparison with non-complicated cholelithiasis]. / Colecistitis aguda y colecistectomia laparoscópica. Comparación con la colelitiasis no complicada.

Laparoscopic cholecystectomy has become the treatment of choice for symptomatic cholelithiasis. However, the indication of the laparoscopic approach for acute inflammation of the gallbladder in unclear and further analysis of the results is required. The aim of our study was to compare the results of laparoscopic cholecystectomy after uncomplicated cholelithiasis and after acute cholecystitis. Data from 201 patients who underwent laparoscopic cholecystectomy were collected prospectively. Uncomplicated cholelithiasis was present in 149 patients and 52 individuals had acute cholecystitis. No differences in age, sex distribution or associated diseases were observed between groups. The mean operative time was significantly higher in patients with acute cholecystitis. However, no difference was observed regarding conversion rate (7.3%-7.6%) and morbidity rate (8.7%-9.6%). No mortality has occurred in any group. The average hospital stay after laparoscopic cholecystectomy was greater when acute cholecystitis was present (2.6 days-4.9 days; p < 0.01). But in this case hospitalization was shorter than after elective conversion (8 days; p < 0.001 and p < 0.05). We conclude that patients with acute cholecystitis can undergo laparoscopic cholecystectomy safely, with low morbidity and mortality rates and reduced hospital stay.

[Colangiocarcinoma on a choledochal cyst]. / Colangiocarcinoma sobre quiste de colédoco.

Patients with choledochal cysts have an increased incidence of biliary tract carcinoma. We report a case of adenocarcinoma arising in a type I choledochal cyst which was surgically treated by resection and biliodigestive anastomosis (hepaticojejunostomy).

[Hemoptysis caused by a bronchial artery aneurysm. Apropos a case]. / Hemoptisis por aneurisma de la arteria bronquial. A propósito de un caso.

We discuss the case of a right bronchial artery aneurysm in its intrapulmonary trajectory which manifested itself by repeated mild hemoptysis. Diagnosis was made through selective angiography of bronchial artery and during the same procedure it was treated through transcatheter embolization. We have reviewed the literature and found 17 cases of bronchial artery aneurysms with intrapulmonary or mediastinal localization.