Utility of opium seed extract tests in preventing hypersensitivity reactions during surgery.

BACKGROUND: Anaphylaxis during anaesthesia is fatal in 3-9% of patients and analgesics, including opioids, and is the second most common medicament-related cause, although the prevalence is underestimated. We recently found that patients may generate IgE antibodies to opium seeds. OBJECTIVES: To determine the diagnostic accuracy of specific antibodies to morphine, codeine, rocuronium and oil body and aqueous fractions of Papaver somniferum seeds in the diagnosis and prevention of allergy to opioids. METHODS: Patients with hypersensitivity reactions during surgery, and severe clinical allergy (pollen, tobacco), and illicit heroin users were selected. The sensitivity, specificity and predictive values of in vivo and in vitro diagnostic techniques including oil body and aqueous fractions of P. somniferum seeds were measured. RESULTS: We studied 203 patients, with mean age 35.1±17.1 and 200 healthy controls. Patients sensitised to heroin or with hypersensitivity reactions during surgery responded to P. somniferum seed tests. Of patients not known to be sensitised to opioids, the highest positivity was in patients sensitised to tobacco (p<0.001). Opium seed skin tests and IgE, especially the oil body fraction, were more sensitive (64.2%) and specific (98.4%) than morphine, codeine and rocuronium tests for opioid sensitivity. Pollen allergy was not a risk factor for sensitisation to morphine. CONCLUSIONS: Sensitivity to opioids and intraoperative anaphylaxis can be diagnosed by routine tests. IgE and skin tests for the oil body fraction of P. somniferum had the highest sensitivity for sensitisation to opioids.

Correction of distal limb prolapse of a diverting colostomy by stapling under sedation.

AIM: To describe a surgical technique to treat colostomy prolapse as a day case procedure with the patient under sedation and analgesia. METHOD: A 60-mm GIA Universal Stapler is inserted into the lumen of the prolapsed colon at right angles to the contour of the abdominal wall. Several firings are then made to completely divide the prolapsed colon. The instrument is then placed parallel to the skin to remove the prolapsed portion leaving 1-2 cm of bowel above the level of the skin. RESULTS: Two patients underwent the procedure. The operation times were 30 and 13 min. Both took oral liquids 2 h after surgery and solids 2 h later. They were discharged at 24 and 4 h after surgery, respectively. No postoperative pain was reported in either case. At 14 and 6 months of follow-up there has been no recurrence. CONCLUSION: Stapling treatment of prolapsed colostomies has the advantage of being an extra-abdominal procedure. It is performed under sedation and analgesia, the operation time is very short, recovery to normal life is rapid and there is less likelihood of complications by avoiding a laparotomy.

Colorectal cancer in nonagenarians.

AIM: The aim of the study was to analyze the short-term and long-term outcomes of nonagenarians treated for colorectal cancer. METHOD: A retrospective analysis was performed of 74 patients, ≥ 90 years of age, diagnosed with colorectal cancer during the period 1986-2009. Comorbidity, American Society of Anesthesiology (ASA) grade, symptoms, diagnosis, treatment, mortality, morbidity and survival were analyzed. RESULTS: Of the 74 patients, 48 (65%) were women. Twenty-two patients were classified as ASA grade I-II, 26 as ASA grade III and 26 as ASA grade IV-V. Thirty-one (42%) had intestinal obstruction at the time of diagnosis. Twenty-two (30%) patients were diagnosed during the period 1986-2000 and 52 (70%) were diagnosed between 2001 and 2009. Forty-four (59%) patients underwent surgery, of whom 19 (49%) were treated as an emergency. Eleven (25%) patients died postoperatively, with mortality rates of 12% (3/25) for elective surgery and 42% (8/19) for emergency surgery. Surgical mortality for ASA grade I and grade II patients was 5% (1/20) and their 5-year survival rate (postoperative mortality excluded) was 44%, whereas 5-year survival for ASA grade III patients who underwent surgery was 12.5% and surgical mortality was 25% (4/16). There were no survivors beyond 36 months among patients who did not receive surgery. CONCLUSION: Our results indicate that elective and emergency colorectal surgery can be performed with acceptable rates of mortality and morbidity on nonagenarian patients in good general condition with low perioperative risk. The 5-year survival rate was related to ASA grade and to the use of surgery.

[Jejunal mucormycosis in a patient with Hodgkin's lymphoma]. / Mucormicosis yeyunal en paciente con linfoma de Hodgkin.

We report a case of intestinal mucormycosis in a 46-year-old male diagnosed with classical Hodgkin's disease, IV-B stage. During the first phase of chemotherapy he had a massive digestive bleeding event secondary to a jejunal ulcer, and zygomicosis mucor-type was diagnosed by endoscopic biopsy. The patient was treated with antifungal drugs and surgical resection of the intestine involved. At surgery a double covered perforation of the jejunum was seen. Pathological examination confirmed the previous diagnosis. After one year of follow-up the patient is doing well, and his lymphoma is on remission. To our best knowledge this is the second case of intestinal mucormycosis in a patient with Hodgkin's lymphoma reported in the medical literature.

Colorectal resection and primary anastomosis in patients aged 70 and older: prospective study.

OBJECTIVE: To assess the differences in morbidity, mortality, and other immediate postoperative results of colorectal resection with primary anastomosis in relation to age. DESIGN: Prospective study. SETTING: District hospital, Spain. SUBJECTS: 316 consecutive patients who required colorectal resection with primary anastomosis between 1991 and 1995, 155 of whom were aged <70 years and 161 who were 70 years or more. MAIN OUTCOME MEASURES: Mortality, morbidity, and hospital stay. RESULTS: 116 patients aged <70 (75%) were American Society of Anaesthesiologists (ASA) grades I-II compared with 82 (51%) aged > or =70.33 of the younger patients (21%) and 49 of the older (30%) developed complications. The anastomotic leak rate was 14% (n = 21) in the younger group and 16% (n = 26) among those aged > or =70. Median hospital stay was 14 and 15 days, respectively (ranges 8-81 and 1-120). 4 died (3%) among those aged <70 compared with 17 (11%) in the older group (p = 0.009, chi square 6.9). Mortality for elective resections was 6% (15/263) compared with 11% (6/53) for emergencies. There were no significant differences in mortality according to ASA grade between age groups. CONCLUSIONS: People aged 70 or more are not a high risk group for colorectal resection and primary anastomosis as a result of their age alone. Mortality and morbidity depend more on ASA grade and whether the operation was elective or emergency.