Anal intraepithelial neoplasia in a sexually transmitted diseases outpatient clinic: correlation with cytological screening.

BACKGROUND: High-grade anal intraepithelial neoplasia (AIN) is currently considered a precursor of anal cancer. The population most susceptible to AIN is men who have sex with men (MSM), especially if they are infected by HIV. OBJECTIVES: We analysed the population diagnosed with AIN and evaluated anal cytology as a method of screening the at-risk population. METHODS: We undertook a retrospective review of patients diagnosed with AIN by means of a surgical biopsy between 2008 and 2010. We analysed the risk factors of the population affected and the degree of agreement with the cytology performed previously. RESULTS: During the study period 41 patients were diagnosed with AIN and seven with anal canal carcinoma in situ; 77% were men, most MSM. A history of receptive anal intercourse was found in 81% of the patients and in 71% there was an association with anogenital warts; 32 patients were HIV-positive, most of them men. Of the patients with anal dysplasia of any type in the cytology, 90% had some grade of AIN or carcinoma in situ in the later biopsy. The degree of agreement between the cytology and the biopsy was 94% in the high-grade dysplasias and 50% in the low-grade dysplasias. CONCLUSIONS: Anal cytology in at-risk populations has a high degree of agreement with the biopsy when performed surgically, though less in low-grade dysplasias, which must always be studied. More studies evaluating the degree of progression of AIN to anal cancer are necessary.

[Active lower gastrointestinal bleeding due to appendiceal ulcer]. / Hemorragia digestiva baja grave activa por úlcera apendicular.

We present a case of severe lower gastrointestinal bleeding due to appendiceal ulcer associated with intake of enteric coated aspirin. Urgent colonoscopy revealed the location and characteristics of the source of bleeding during the acute episode, allowing effective treatment through simple appendicectomy to be performed.

[Bilateral hydronephrosis secondary to ileocolic Crohn's disease]. / Hidronefrosis bilateral secundaria a enfermedad de Crohn ileocólica.

Unilateral hydronephrosis can complicate a far from negligible number of patients with Crohn's disease. Bilateral hydronephrosis associated with Crohn's disease is a much more unusual entity. In the other hand, the treatment for this condition is still controversial. We present the case of a 44 year old female with several bowel obstruction episodes caused by ileocolic Crohn's disease. During the last episode she was also diagnosed of bilateral hydroureter and hydronephrosis. After the resolution of the bowel obstruction and the placement of a double J catheter in both ureters, the patient was operated. Ileocolic resection and bilateral ureterolysis with omental wrapping were performed. Although urinary and wound infection complicated the postoperative course, and a enterocutaneous fistula had to be medically treated one year later, the patient is now free of symptoms and her renal function is normal.

Use of octogenarian livers safely expands the donor pool.

BACKGROUND: The increasing number of recipients on the waiting list for orthotopic liver transplantation (OLT) and the scarcity of donors contribute to recipient pretransplantation mortality. One important measure to increase the donor liver pool would be to accept the previously discarded donors who are more than 80 years old. METHODS: From November 1996 to May 1998, four liver grafts from octogenarian donors (89, 87, 82, and 85 years old, respectively) were used for OLT. Pretransplantation donor and recipient characteristics and the evolution of recipients after OLT were analyzed. RESULTS: The donors did not present cardiac arrest or hypotension, and only low doses of vasopressors were required in three of them. Intensive care unit stay of the donors was from 12 to 24 hr. Cold ischemia time was from 4 hr to 8 hr 40 min. Mild microsteatosis was present in three donors and associated macrosteatosis of < 10% in one of these. Macroscopic appearance and consistency were normal in all four grafts. Posttransplantation evolution and follow-up were uneventful. Three recipients were alive and well at 24, 16, and 7 months; the second of these died at 16 months of recurrent viral C cirrhosis after a first OLT. CONCLUSIONS: The liver donor pool can be increased if liver grafts are accepted without an age limit but in good condition (hemodynamic stability, short intensive care unit stay, good liver function, soft consistency, cold ischemia time <9 hr, and no severe steatosis). Octogenarian donors should be individually assessed in the absence of these ideal conditions.

Liver transplantation for Echinococcus granulosus hydatid disease.

The authors report their experience with 6 patients requiring liver transplantation who suffered with liver infestation by Echinococcus granulosus. One patient presented with acute Budd-Chiari syndrome because obstruction of hepatic veins was produced during the first operation; the other 5 patients received liver transplants for terminal chronic liver disease (2 secondary sclerosing cholangitis, 2 secondary biliary cirrhosis, and 1 postnecrotic cirrhosis of the liver). All the patients had been operated previously on for hydatidosis and were at the end of liver functional disorder. Some of the patients had undergone many operations, making the transplantation procedure even more difficult. One patient required a second transplant for primary graft failure; he died 40 days later from cerebrovascular accident. Another patient died 7 months after transplant from pulmonary embolism. The other 4 patients are alive and in optimal condition 37-65 months after transplantation. Hepatic hydatidosis--in principle, a benign disease--can cause hepatic complications that eventually require liver transplantation. The transplantation procedure is more difficult than usual in these cases. Although postoperative complications are frequent, most patients achieve prolonged survival and a good quality of life.

Esophageal resection by cervico-abdominal approach without thoracotomy.

The authors report their experience with transhiatal esophageal resection accumulated during the period between January 1978 and March 1990. Indications for the procedure included cancer of the gastric cardia (26.3%), cancer of the hypopharynx (3.8%), cancer of the esophagus (59.2%), and benign esophageal disease (9.8%). Esophageal substitution was performed using a tubulized stomach (63.6%), ileo-ceco-coloplasty (28.5%), left colon (7.6%), and jejunum (0.3%). The majority of patients with neoplastic disease were found to be in an advanced stage (67.3% of esophageal cancer patients and 69.7% of cancer of the cardia patients with stage III disease). The mean intra-operative volume of blood transfused varied between 533 and 1,220 ml. Sixteen patients required hospitalization in the intensive care unit. The mean length of post-operative hospitalization varied between 16.8 and 20.6 days. Operative complications included hemorrhage (0.3%) and tracheal injury (0.6%). Operative (30 day) mortality was 5.8%. Causes of death included respiratory insufficiency (35.2%), pulmonary sepsis (23.5%), abdominal sepsis (17.8%), and others (undefined, 23.5%). The 5 year survival was 48.5% for cancer of the gastric cardia, 57.1% for cancer of the hypopharynx and 11.8% for esophageal cancer.

Results of surgical treatment of hepatic hydatidosis: current therapeutic modifications.

Hepatic hydatidosis is an endemic disease that affects vast segments of the populations of various countries in the Mediterranean region, South America, the Pacific, and temperate zone nations that possess large numbers of sheep. Four hundred and ten patients bearing 561 hydatid cysts were treated at 2 major hospitals in Madrid, Spain in the period 1974-1989. In order to establish the modifications in diagnostic and therapeutic management introduced as a result of modernization of our clinical facilities and improved technological standards, they were divided into 2 groups: group A corresponded to the period 1974-1984, and group B, corresponded to the period 1985-1989. Since no effective parasiticide agent is available, hepatic hydatidosis must be treated surgically. Today's better knowledge and advancements in liver surgery have made it possible to extirpate the cyst completely with little risk and improved results; hepatic resection should only be considered in exceptional cases; aspiration, drainage procedures, or partial resections of the cyst yield inferior results. We have had no relapse of the hydatid disease in the liver or in any other abdominal site.

[Surgery of cancer of the rectum]. / Cirugía del cáncer de recto.

Surgery of the distal half of the rectum has changed considerably in the last decades; new technical procedures have made possible the conservation of the sphincters in a considerable number of patients. We present the most significant factors of this change in surgical approach. The supporting pilars of the change have been the possibility of automatic sutures (staplers), the reduction of the distal margin and the fact that the rate of complications is similar to that of the abdomino-perineal resection. We review the complications of the surgical treatment (stenosis and fistulas) and the advantages and disadvantages of the instrumental sutures and new surgical procedures.