Gastrointestinal stromal tumors: actin expression, a new prognostic factor?

The aim of this study is to analyze the clinical outcome of gastrointestinal stromal tumors (GISTs) and to determine new prognostic factors. We perform a retrospective study of all the patients diagnosed with GIST in any location and operated on between 2000 and 2008 at our institution. We analyzed 35 patients, 16 males (45.7%) and 19 females (54.3%), with a mean age of 64 +/- 13.8 years. The tumors were located in the stomach in 22 patients (62.9%), in the small bowel in 10 (28.6%), and the retroperitoneum in three (8.6%). Referring to gastric GIST, endoscopy revealed an ulceration in the mucosa in five cases, suggesting an epithelial neoplasm. In all these cases, pathology of the biopsy specimen was nonconclusive. Survival rate at 1 and 5 years was 94.3 and 88.6 per cent, respectively. Disease-free survival at 1 and 2 years was 91.4 and 88.6 per cent, respectively. Analyzing prognostic factors, a lower disease-free survival was observed among patients with constitutional syndrome at diagnosis (P = 0.000), small bowel GIST (P = 0.037), and tumors not expressing actin (P = 0.015). A lower global survival was observed among men (P = 0,036), patients with an abdominal mass (P = 0.033) or with constitutional syndrome (P = 0.007) at diagnosis and tumors at a retroperitoneal location (P = 0.0002). Gastric GIST may be confused with epithelial neoplasms, modifying the surgery. In our patients, masculine gender, constitutional syndrome and abdominal mass at diagnosis, small bowel and retroperitoneal location, and actin negative tumors are bad prognostic factors.

Clinical outcome at ten years after laparoscopic fundoplication: Nissen versus Toupet.

Laparoscopic surgery has become the elective approach for the surgical treatment of gastroesophageal reflux disease in the last decade. Outcome data beyond 10 years are available for open fundoplication, with good-to-excellent results, but few studies report long-term follow-up after laparoscopic fundoplication. We performed a retrospective study of all the patients that underwent laparoscopic Nissen and Toupet fundoplications as antireflux surgery between 1995 and 1998 in our institution. To evaluate the long-term results, a face-to-face interview was performed in 2009. One hundred and six patients were included in the study. Surgical techniques performed were Nissen fundoplication (NF) in 56 patients and Toupet (TF) in 50. Complication rate was 4 per cent in both groups (nonsignificant [NS]). Two patients (4%) of NF required reoperation because of dysphagia. After 10 years, 10 per cent of the patients remain symptomatic in both groups. Fifteen per cent of NF take daily inhibitors of the proton pump versus 14 per cent of TF (NS). Twenty per cent of NF refer dysphagia, all of them without evidence of stenosis at endoscopy or contrasted studies. The satisfaction rate of the patients was 96 per cent in NF and 98 per cent in TF. Laparoscopic Toupet fundoplication seems to be as safe and long-term effective as Nissen, but with a lower incidence of postoperative dysphagia. In our experience Toupet fundoplication should be the elective approach for the surgical treatment of gastroesophageal reflux disease.

[Acute cholecystitis: is it still justified to delay surgery?]. / Colecistitis agudas: ¿está justificado hoy en día diferir la cirugía?

INTRODUCTION: Acute cholecystitis treatment may initially be surgical or conservative with subsequent surgery; we reviewed the cases found in our centre, including their treatment and outcome. MATERIAL AND METHODS: We conducted a retrospective study of treatment in 178 patients with acute cholecystitis during one year. We evaluated variables associated with patient characteristics, as well as clinical data, diagnostic tests, treatment and outcome. RESULTS: The majority (70.2%) was treated conservatively (group A), and 29.8% were operated on in the first 72 h (group B). In group A, 96 patients were treated with antibiotics, 15 with antibiotic therapy and cholecystectomy, and 12 with antibiotics and ERCP. In group B urgent laparoscopic cholecystectomy was performed in 60.4%, and 35.8% had open cholecystectomy. In group A, admission time was 11 days, with satisfactory progress in 79.2%, mortality rate of 5.6% and 10.7% of readmissions. In group B, operation time was 111 +/- 43 min, a mean of 8.7 days hospital stay, and 68% of cases did not require further treatment after surgery. Outcome was satisfactory in all but 7, there was no mortality in this group. We had a return rate of 2%. CONCLUSIONS: A significant proportion of conservative treatment was carried out at the expense of emergency surgery, although in absolute numbers conservative treatment seems to have a higher rate of complications, mortality and hospitalisation time.

Volvulus of the small bowel in adults.

The volvulus of the small bowel is a surgical emergency, causing small bowel obstruction. We performed a retrospective study of all the patients diagnosed and treated with small bowel volvulus between 1977 and 2007 at our institution. One hundred twenty-nine patients were analyzed. Thirty-nine patients presented primary volvulus and 90 secondary ones. The most frequent symptom was sudden abdominal pain. CT scan was the best diagnostic method with an accuracy of 83 per cent. Necrotic small bowel loops appeared in 46.5 per cent of the patients. Eighteen patients had postoperative complications (14%). Mortality rate was 9.3 per cent. A higher mortality is observed among patients with previous abdominal surgeries and cardiopathies. Necrotic loops are associated with higher mortality and incidence of surgical complications; patients with diabetes are associated with a higher incidence of necrotic loops. Cardiopathies are associated with more frequent medical and surgical complications. Recurrence rate was 3.9 per cent associated with simple devolvulation. Primary volvulus are more frequent among males and patients with diabetes. Jejunal location is associated with primary volvulus and these correlate with a higher incidence of necrotic loops. Primary volvulus presents a higher incidence of surgical complications. A bowel obstruction with sudden abdominal pain must be suspicious of small bowel volvulus. The main aim is to achieve an early diagnosis to prevent a necrotic small bowel. CT scan is the imaging test with the best diagnostic accuracy. Primary volvulus, the presence of necrotic loops, and patients with cardiopathies, diabetes mellitus, and with previous abdominal surgery are associated with a worse outcome.

Fourth-portion duodenal diverticulum causing massive upper gastrointestinal bleeding.

Most duodenal diverticula are asymptomatic, incidentally discovered at endoscopy or barium studies. Upper gastrointestinal bleeding has been described, but it is an infrequent complication. We describe the 14th case reported in the literature of massive upper gastrointestinal bleeding originating from a duodenal diverticulum.

Clinical outcome at 10 years after laparoscopic versus open Nissen fundoplication.

INTRODUCTION: Laparoscopic surgery has become the elective approach for the surgical treatment of gastroesophageal reflux disease (GERD) in the last decade. Outcome data beyond 10 years are available for open fundoplication, but few studies report long-term follow-up after laparoscopic fundoplication and comparison between laparoscopic and open approaches. MATERIAL AND METHODS: In this study, we performed a retrospective study of all the patients undergoing Nissen fundoplication (open and laparoscopic) for antireflux surgery between 1996 and 1998 at our institution. RESULTS: In total, 166 patients were included: 88 underwent open Nissen fundoplication and 78 the laparoscopic approach. Complication rate was 5% for both groups. Conversion rate for the laparoscopic approach was was 4%. Median postoperative hospital stay was 9.5 days for open surgery and 3 days for laparoscopic 1 (P < 0.001). During the follow-up, 3 patients required reoperation, 1 after laparoscopic Nissen and 2 after open surgery, all of them due to dysphagia, though complementary tests showed normal features. After 10 years, 24% of the patients of the open surgery group (OS) remain symptomatic, and in the laparoscopic group (LS) 11% (P < 0.05). Overall, 16% of OS take dialy proton-pump inhibitors and 7% of LS (P < 0.05). Three patients have undergone an open Nissen fundoplication and 2 a laparoscopic referring mild dysphagia (NS). The satisfaction rate of the patients was 96% for OS and 97% for LS (NS). CONCLUSION: Laparoscopic Nissen fundoplication appears to be at least as safe and long term in effectiveness for GERD as the open approach, with the associated postoperative advantages of a minimally invasive access.

[Caecal volvulus: presentation of 18 cases and review of literature]. / Vólvulo de ciego: presentación de 18 casos y revisión de la literatura.

INTRODUCTION: Caecal volvulus is the second most frequent location of colonic volvulus after sigmoid colon. It usually shows up as bowel obstruction. MATERIAL Y METHOD: We review our experience of 18 cases of cecal volvulus treated in our centre between 1987 and 2007. RESULTS: We studied 8 males (44.4%) and 10 females (55.6%), with a mean age of 63.3 years. As an associated factor it was noted that 10 patients (55.6%) were bedridden. The most common clinical signs were abdominal distension and tenderness, constipation and vomiting. Simple abdominal X-rays have a low diagnostic accuracy, though they reveal a bowel obstruction. Only 1 patient underwent elective surgery. In 10 patients (55.6%) a right hemicolectomy was performed, in 3 (16.8%) cecostomy, in 3 cecopexy and in 2 (11.2%) devolvulation only. There were complications in 3 patients (16.8%), 2 prolonged ileus and 1 wound infection. There were no recurrences. CONCLUSIONS: Caecal volvulus is an emergency pathology, requiring surgical treatment. Right hemicolectomy is the treatment of choice both in viable and gangrenous colon. Caecostomy is an alternative treatment in the high risk patient with a viable colon.

[Primary small bowel adenocarcinoma]. / Adenocarcinoma primario de intestino delgado.

INTRODUCTION: Primary small bowel adenocarcinoma is an uncommon tumour, with non-specific symptoms that cause a delay in the diagnosis and consequently a worse outcome for the patient. We analyse our experience in the management of this disease. MATERIAL AND METHOD: We performed a retrospective study of our experience with 17 patients diagnosed with primary small bowel adenocarcinoma, excluding all the cases suggesting secondary involvement of the small bowel from an adenocarcinoma in other locations. RESULTS: We analysed 9 females (53%) and 8 males (47%) with a mean age of 61.8 years. Tumour location was duodenum (8 cases), jejunum (5) and ileum (4). Those with duodenal tumours underwent 4 pancreaticoduodenectomies, 3 gastroenterostomies and 1 diagnostic biopsy; 6 bowel resections with lymphadenectomy, 2 en-bloc resections and 1 by-pass were performed on those with jejuno-ileal tumours. There were complications in 3 patients (18%). General survival was 18 months; in duodenal and jejunal tumours it was 15 months vs. 58 in ileal ones (p = 0.048). Survival was 48 months in the absence of lymph node metastases vs. 11 in those with (p = 0.067). In those tumours infiltrating the retroperitoneum, survival was 15 months compared to 23 when not affected (p = 0.09). CONCLUSIONS: Curative treatment consists of small bowel resection. Retroperitoneal infiltration was a non-resectability criterion in our series. Ileal location is associated with a better outcome. Advanced stages, lymph node metastases, non-resected cases and retroperitoneal infiltration tended to be associated with a poor prognosis in our group.

[Meckel's diverticulitis. Report of 10 cases]. / Diverticulitis de Meckel. Presentación de 10 casos.

BACKGROUND: Meckel's diverticulitis is an infrequent disease that must be considered in the differential diagnosis of acute abdominal pain. CLINICAL CASES: We present 10 cases of Meckel's diverticulitis diagnosed at Hospital Ramón y Cajal (Madrid) between 1985 and 2007. There were eight males and two females with a mean age of 27.5 years. Nine cases presented as a pain in the right lower quadrant suspicious of acute appendicitis, and one case presented as bowel obstruction. Appendectomy + diverticulectomy were performed in those cases with preoperative diagnosis of appendicitis, and diverticulectomy and adhesion release in the patient diagnosed with bowel obstruction. CONCLUSIONS: Meckel's diverticulitis is a rare pathology. Intraoperatively, when the appendix is macroscopically normal, the abdominal compartment must be explored in order to exclude other inflammatory processes such as Meckel's diverticulitis.

Late gastrointestinal complications after pelvic radiotherapy: radiation enteritis.

INTRODUCTION: Radiation enteritis is a complication of radiation therapy for pelvic tumours. It appears after a variable period of time and is often progressive. MATERIAL AND METHODS: We analyse our experience of 77 cases (52 females and 25 males) diagnosed with radiation enteritis or proctitis between 1986 and 2006. RESULTS: The most frequent location of radiation injury is ileum (55 patients, 71%), followed by rectum (22 patients, 28%). Twenty-eight patients (36%) were medically managed and 49 (64%) required surgical treatment. In 41 (53%) of the patients the affected region was resected, in 5 (7%) a by-pass was performed and in 3 (4%) a terminal colostomy. Surgical mortality was 4% (3 cases) and the complication rate 9% (7 cases). Twelve patients (16%) presented recurrence of radiation-related illness. Excluding those cases deceased because of tumoral progression, 5-year survival rate was 90% and 10-year survival rate 83%. CONCLUSION: Radiation enteritis must be initially conservatively managed, but in those cases without response, surgery is indicated. Surgical treatment should not be delayed fearing postoperative complications, which are more susceptible to appear in deteriorated patients. If technically possible, the affected region should be resected, because complications may appear later at this damaged location.

[Post trauma diaphragmatic hernia]. / Hernia diafragmática postraumática.

UNLABELLED: Posttraumatic diaphragmatic hernias may occur after blunt or penetrating trauma. Due to coexisting injuries and the silent nature of the diaphragmatic lesions, the diagnosis can sometimes be missed in the acute phase and may present later on with obstructive symptoms due to incarcerated organs in the diaphragmatic defect. MATERIAL AND METHODS: We perform a retrospective study of all operated cases at our institution during the last 20 years. RESULTS: 23 patients were included, 17 men and 6 women. 21 patients presented antecedents of blunt trauma and 2 of penetrating one. 7 patients were diagnosed in acute phase, manifesting as acute abdomen and hemodynamic instability. 13 patients were diagnosed in chronic phase, 4 of them with respiratory symptoms and 9 with bowel obstruction symptoms. 3 patients were asymptomatic and the diagnosis was an incidental finding. 12 patients underwent elective surgery and 11 emergency surgery, 7 of them in acute phase and 4 in chronic complicated one. Abdominal approach was performed in all the patients. Laparoscopic approach was unsuccessfully tried in one patient. The hernia was located in the left hemidiaphragm in 16 patients, in the right one in 6 and in one case the defect was bilateral. Mesh was placed in only 2 cases. Intraoperative mortality appeared in one patient with acute diaphragmatic hernia due to coexisting hepatic lesions and morbidity appeared in only 1 patients, presented as a respiratory sepsis. CONCLUSIONS: Posttraumatic diaphragmatic hernia is a rare clinical entity of difficult diagnosis. In the chronic phase, there is a high risk of visceral strangulation or respiratory symptoms.

Diverticulitis de Meckel: presentación de 10 casos / Meckel's diverticulitis: report of 10 cases

Introducción: La diverticulitis de Meckel es una patología poco frecuente, pero que debe considerarse ante un cuadro de abdomen agudo. Casos clínicos: 10 pacientes con diverticulitis de Meckel diagnosticados en el Hospital “Ramón y Cajal”, Madrid, España, entre 1985 y 2007. Se trató de ocho varones y dos mujeres, con edad media de 27.5 años; nueve se manifestaron con dolor en fosa iliaca derecha, sospechándose apendicitis aguda; uno se diagnosticó como obstrucción intestinal. Se realizó apendicectomía + diverticulectomía en los pacientes con diagnóstico preoperatorio de apendicitis, y diverticulectomía con liberación de bridas en quien se sospechó obstrucción. Conclusiones: La diverticulitis de Meckel es una patología poco frecuente. Cuando el apéndice es de características normales, se debe explorar toda la cavidad abdominal para excluir otros procesos inflamatorios, entre ellos la diverticulitis de Meckel.

BACKGROUND: Meckel's diverticulitis is an infrequent disease that must be considered in the differential diagnosis of acute abdominal pain. CLINICAL CASES: We present 10 cases of Meckel's diverticulitis diagnosed at Hospital Ramón y Cajal (Madrid) between 1985 and 2007. There were eight males and two females with a mean age of 27.5 years. Nine cases presented as a pain in the right lower quadrant suspicious of acute appendicitis, and one case presented as bowel obstruction. Appendectomy + diverticulectomy were performed in those cases with preoperative diagnosis of appendicitis, and diverticulectomy and adhesion release in the patient diagnosed with bowel obstruction. CONCLUSIONS: Meckel's diverticulitis is a rare pathology. Intraoperatively, when the appendix is macroscopically normal, the abdominal compartment must be explored in order to exclude other inflammatory processes such as Meckel's diverticulitis.

Paniculitis mesentérica: ¿predictor de una neoplasia? / Mesenteric panniculitis: predictor of a neoplasm

Introduction: Mesenteric panniculitis is a rare disorder characterized by chronic, non-specific inflammation involving the adipose tissue of the bowel mesentery of unknown aetiology. It has been associated with different processes, including digestive and urothelial malignancies. Case report: A 44-years-old man carne to the Emergency Department complaining of mesogastric pain for the last 24 hours. CT sean showed an increased density of the mesenteric adipoid tissue. Mesenteric paniculitis was diagnosed and antibiotic treatment was instaured. The patient recovered uneventfully. Two months later the patient was diagnosed of an infiltrating urothelial carcinoma. Conclusions: Mesenteric panniculitis may be associated with malignancies and other pathologies. It is advisable to perform tests to dismiss the coexistence of these disorders. In those cases, in which associated diseases could not be demonstrated, a frequent follow-up would be advisable to achieve an early diagnosis if these appear.

Introducción: La paniculitis mesentérica es un trastorno poco frecuente caracterizado por inflamación crónica inespecífica del tejido adiposo del mesenterio intestinal de etiología desconocida. Se ha relacionado con diversas patologías, entre ellas neoplasias digestivas y uroteliales. Caso clínico: Varón de 44 años que acude a Urgencias por un dolor mesogástrico de 24 horas de evolución. En la TC abdominal se objetivó un aumento de densidad de la grasa de la raíz del mesenterio. Se diagnosticó de paniculitis mesentérica y se trató mediante antibioterapia. A los 2 meses el paciente es diagnosticado de un carcinoma urotelial infiltrante. Discusión: La paniculitis mesentérica puede estar relacionada con neoplasias y otras patologías. Es conveniente realizar pruebas para descartar la coexistencia de alguna de las enfermedades asociadas. En aquellos casos en los que no se demuestre, sería recomendable un seguimiento periódico.

Colecistitis agudas: ¿está justificado hoy en día diferir la cirugía? / Acute cholecystitis: is it still justified to delay surgery?

Introducción: El tratamiento de la colecistitis aguda puede ser inicialmente quirúrgico o conservador con cirugía posterior, revisamos los casos encontrados en nuestro centro, cómo fueron tratados y la evolución de los mismos. Material y métodos: Realizamos un estudio retrospectivo del tratamiento realizado en 178 pacientes con colecistitis aguda durante un año. Se evalúan variables relacionadas con las características de los pacientes, clínica y exploración, técnicas diagnósticas, tratamiento realizado y evolución. Resultados: El 70,2% es tratado de forma conservadora (grupo A) y el 29,8% es intervenido en las primeras 72h (grupo B). En el grupo A se trataron 96 casos con antibioterapia, 15 con antibioterapia y colecistostomía y 12 con antibioterapia y CPRE. En el grupo B se realizó colecistectomía urgente laparoscópica en el 60,4% de los casos y abierta en el 35,8%. En el grupo A el tiempo de ingreso fue de 11 días, con evolución satisfactoria en el 79,2%, tasa de mortalidad del 5,6% y tasa de reingresos del 10,7%. En el grupo B el tiempo quirúrgico fue de 111+/−43, una media de 8,7 días de ingreso, no precisaron tratamiento además de la cirugía el 68% de los casos. La evolución fue satisfactoria en todos los casos menos en 7, no hubo mortalidad en este grupo. Tuvimos una tasa de reingreso del 2%. Conclusiones: Continuamos realizando una proporción importante de tratamiento conservador en detrimento de la cirugía urgente, en números absolutos este parece tener mayor tasa de complicaciones, de mortalidad y de tiempo de ingreso hospitalario (AU)

Introduction: Acute cholecystitis treatment may initially be surgical or conservative with subsequent surgery; we reviewed the cases found in our centre, including their treatment and outcome. Material and methods: We conducted a retrospective study of treatment in 178 patients with acute cholecystitis during one year. We evaluated variables associated with patient characteristics, as well as clinical data, diagnostic tests, treatment and outcome. Results: The majority (70.2%) was treated conservatively (group A), and 29.8% were operated on in the first 72h (group B). In group A, 96 patients were treated with antibiotics, 15 with antibiotic therapy and cholecystectomy, and 12 with antibiotics and ERCP. In group B urgent laparoscopic cholecystectomy was performed in 60.4%, and 35.8% had open cholecystectomy. In group A, admission time was 11 days, with satisfactory progress in 79.2%, mortality rate of 5.6% and 10.7% of readmissions. In group B, operation time was 111 +/− 43min, a mean of 8.7 days hospital stay, and 68% of cases did not require further treatment after surgery. Outcome was satisfactory in all but 7, there was no mortality in this group. We had a return rate of 2%. Conclusions: A significant proportion of conservative treatment was carried out at the expense of emergency surgery, although in absolute numbers conservative treatment seems to have a higher rate of complications, mortality and hospitalisation time(AU)

Vólvulo de ciego: presentación de 18 casos y revisión de la literatura / Caecal volvulus: Presentation of 18 cases and review of literature

Introducción: el vólvulo de ciego es la segunda localización más frecuente de vólvulos de colon tras el colon sigmoide. Produce habitualmente un cuadro de obstrucción intestinal. Material y método: revisamos nuestra experiencia de 18 casos diagnosticados y tratados de vólvulo de ciego desde 1987 hasta 2007.Resultados: estudiamos a 8 varones (44,4%) y 10 mujeres (55,6%), con una media de edad de 63,3 años. Como factor relacionado encontramos que 10 (55,6%) pacientes tuvieron un encamamiento prolongado. Las manifestaciones clínicas más frecuentes fueron dolor y distensión abdominal, vómitos y ausencia de deposición y ventoseo. La radiografía de abdomen tiene poca rentabilidad diagnóstica, aunque orienta a un cuadro de obstrucción intestinal. Sólo 1 paciente fue intervenido de forma programada. En 10 (55,6%) pacientes se realizó una hemicolectomía derecha; en 3 (16,8%), cecostomía; en otros 3, cecopexia y en 2 (11,2%), desvolvulación simple. Aparecieron complicaciones en 3 (16,8%) pacientes, 2 íleos prolongados y 1 infección de herida. No hubo recidivas. Conclusiones: el vólvulo de ciego es una afección urgente, que suele requerir tratamiento quirúrgico. La hemicolectomía derecha es la técnica de elección tanto cuando el colon es viable como cuando está gangrenado. La cecostomía es una técnica alternativa en pacientes con alto riesgo quirúrgico y colon no isquémico (AU)

Introduction: Caecal volvulus is the second most frequent location of colonic volvulus after sigmoid colon. It usually shows up as bowel obstruction. Material y method: We review our experience of 18 cases of cecal volvulus treated in our centre between 1987 and 2007.Results: We studied 8 males (44.4%) and 10 females (55.6%), with a mean age of 63.3 years. As an associated factor it was noted that 10 patients (55.6%) were bedridden. The most common clinical signs were abdominal distensión and tenderness, constipation and vomiting. Simple abdominal X-rays have a low diagnostic accuracy, though they reveal a bowel obstruction. Only 1 patient underwent elective surgery. In 10 patients (55.6%) a right hemicolectomy was performed, in 3 (16.8%) cecostomy, in 3 cecopexy and in 2 (11.2%) devolvulation only. There were complications in 3 patients (16.8%), 2 prolonged ileus and 1 wound infection. There were no recurrences. Conclusions: Caecal volvulus is an emergency pathology, requiring surgical treatment. Right hemicolectomy is the treatment of choice both in viable and gangrenous colon. Caecostomy is an alternative treatment in the high risk patient with a viable colon (AU)