Importancia de una unidad de cirugía mayor ambulatoria en la formación del residente de cirugía general: experiencia en el Hospital General Universitario de Elche / No disponible

Introducción: La cirugía mayor ambulatoria o cirugía sin ingreso permite, en pacientes seleccionados, realizar un tratamiento quirúrgico eficaz, eficiente y seguro sin la necesidad de ingreso hospitalario. Material y método: El Hospital General Universitario de El checuenta con una unidad de cirugía sin ingreso, con 2 quirófanos propios, y un total de 10 sesiones mensuales destinadas al servicio de cirugía general. En dichos quirófanos se realizan intervenciones de pared abdominal, proctología y patología mamaría benigna. Nuestros residentes tienen establecida una rotación continua durante todos los años de la especialidad. Describimos el tipo y número de intervenciones en las que ha participado cada residente, como cirujano o ayudante, comparando los resultados con los mínimos establecidos en el programa de la especialidad durante el periodo2005-2010.Resultados: Durante el periodo a estudio, el total de intervenciones en las que participaron los residentes fue de 3905 (media de154,41 intervenciones por año y residente). De estas intervenciones el 15% como segundo ayudante, el 35% como primer ayudante y el restante 50% como cirujano principal. Discusión: La participación de los residentes en las actividades de cirugía mayor ambulatoria debe estar presente en los programas de formación de los médicos en formación. Estamos ante una parte importante de la cirugía moderna, y como tal, debe ser igualmente parte importante en la formación del futuro cirujano (AU)

Patients and method: The University General Hospital of Elchehas a unit of major ambulatory surgery, 2 own operating rooms, and a total of 10 monthly meetings destined for the general surgery service. In the above mentioned operating rooms there are realized interventions of abdominal wall, proctology and benign breast pathology. Our residents have a constant rotation established during every year of the specialty. We describe the type and number of interventions in which, every resident, has taken part, as surgeon or assistant, comparing the results with the minimums established in the program of the specialty during the period2005-2010.Results: During the period to study, the total of interventions in which the residents took part was of 3905 (average of 154,41 interventions per year and resident). Of these interventions, 15 % like the second assistant, 35 % like the first assistant and the remaining50 % like principal surgeon. Discussion: The participation of the residents in ambulatory surgery activities must be present in the programs of formation of the doctors in formation. We are before an important report of the modern surgery, and as such, it is necessary to be equally an important part in the formation of the future surgeon (AU)

Neuromodulación de raíces sacras como tratamiento de la incontinencia fecal. Resultados preliminares / Sacral root neuromodulation as treatment for fecal incontinence. Preliminary results

Presentamos nuestra experiencia inicial en el tratamiento de laincontinencia fecal (IF) mediante neuromodulación de raíces sacras(NRS), a través de los resultados de un estudio prospectivo realizadocon 26 pacientes en el que se comparan los valores basales enla escala de continencia de Wexner-Cleveland y en la capacidadpara el retraso de la defecación, con los obtenidos tras un año deterapia con NRS. El estudio inicial de cada paciente incluía anamnesis,exploración general, ecografía y manometría rectal, así comounos diarios de continencia y de calidad de vida específicos para laIF de 3 semanas. Antes de la terapia con NRS, el valor medio en laescala Wexner-Cleveland fue de 15,00 ± 1,81 y el 62,50% de lospacientes tenía una capacidad de retraso de la defecación menorde 1 minuto. Tras un año de terapia con NRS, el valor medio en laescala de Wexner-Cleveland fue de 4,87 ± 2,54 (p = 0,0031) y el75,01% de los pacientes presentaba una capacidad de retraso defecatoriomayor de 15 minutos (p = 0,0018). Hacemos, además,una descripción detalla de la técnica quirúrgica de la NRS, haciendoreferencia a sus indicaciones y finalizamos revisando las distintasopciones terapéuticas para la IF mostrando nuestro algoritmo terapéuticopara esta patología. La NRS es una técnica eficaz para eltratamiento de la IF en pacientes seleccionados que no han respondidoa tratamiento conservador, biofeedback o correcciones anatómicas(esfinteroplastia), con una mínima morbilidad y susceptible derealizarse en un programa de cirugía ambulatoria

We present our initial experience in the treatment of fecal incontinence (FI) with sacral root neuromodulation (SRN) by reporting the results of a prospective study with 26 patients where baselineWexner-Cleveland scale scores and ability to delay defecationwere compard to results after one year with SRN. The initial studyof patients included history taking, general examination, anal ultrasonography,and manometry, and a three-week diary of continenceand quality of life specific for FI was used. Before SRN themean baseline Wexner-Cleveland score was 15.00 ± 1.81, and62.50% of patients could only delay defecation for less than aminute. After a year with NRS the mean Wexner-Cleveland scorewas 4.87 ± 2.54 (p = 0.0031), and 75.01% of patients could delaydefecation above fifteen minutes (p = 0.0018). We also describethe surgical technique and its indications, and finally reviewthe various therapeutical options for FI and show our algorithmfor this condition. SRN is an effective technique for the treatmentof FI in properly selected patients with no response to medicaltherapies (including biofeedback) or anatomic correction (sphincteroplasty),with efficacy, little morbidity, and a short hospital stay

[Sacral root neuromodulation as treatment for fecal incontinence. Preliminary results]. / Neuromodulación de raíces sacras como tratamiento de la incontinencia fecal. Resultados preliminares.

We present our initial experience in the treatment of fecal incontinence (FI) with sacral root neuromodulation (SRN) by reporting the results of a prospective study with 26 patients where baseline Wexner-Cleveland scale scores and ability to delay defecation were compared to results after one year with SRN. The initial study of patients included history taking, general examination, anal ultrasonography, and manometry, and a three-week diary of continence and quality of life specific for FI was used. Before SRN the mean baseline Wexner-Cleveland score was 15.00 +/- 1.81, and 62.50% of patients could only delay defecation for less than a minute. After a year with NRS the mean Wexner-Cleveland score was 4.87 +/- 2.54 (p = 0.0031), and 75.01% of patients could delay defecation above fifteen minutes (p = 0.0018). We also describe the surgical technique and its indications, and finally review the various therapeutical options for FI and show our algorithm for this condition. SRN is an effective technique for the treatment of FI in properly selected patients with no response to medical therapies (including biofeedback) or anatomic correction (sphincteroplasty), with efficacy, little morbidity, and a short hospital stay.

[Treatment of proctalgia fugax with botulinum toxin: results in 5 patients]. / Tratamiento de la proctalgia fugax con toxina botulínica: resultados en 5 pacientes.

INTRODUCTION: Proctalgia fugax can be defined as transitory but recurrent anal pain. Although its etiology remains unknown, an internal anal sphincter spasm seems to be the most likely, so that the different treatments focus on reducing the pressure of the internal anal sphincter. This study is aimed at evaluating the effectiveness of botulinum A toxin in the treatment of proctalgia fugax. PATIENTS AND METHODS: Prospective clinical trial of patients with proctalgia fugax treated with botulinum A toxin at the Outpatient Clinic attached to the Coloproctogy Unit, University Hospital of Elche, from January 1999 to January 2002. The patients included in the study underwent rectal digital examination, anuscopy, rectoscopy, anal manometry and ultrasonography, barium enema and pelvic CT scan to rule out any organic cause for anal pain. The treatment consisted of 25 IU of botulinum A toxin, with a supplementary dose of 50 IU in those patients with persistence of anal pain episodes within the next two months. The patients were reviewed on the first week, second month, sixth month and first and second year. Anal pain was measured by the patients, using a linear analogue scale from 0 to 10, and continence was assessed at every visit using the Cleveland Continence Grading Scale. RESULTS: Five patients were recluted for the study, with a predominance of females (4 vs. 1). Mean age was 45 years. Length of symptoms prior to the treatment was 13 months (range: 6-18 months). Only one female patient required a second dose of botulinum A toxin to handle the anal pain. All the patients healed and remained free of pain up to finishing the follow-up. There were no local complications. Anal manometry showed an increased MRP (mean resting pressure) in comparison to a control group of patients (114 mmHg vs. 66 mmHg; p < 0.001) that restore to normal values after the treatment (75.65 mmHg). As for the MSP (mean squeeze pressure), it showed no difference with respect to the control group nor did it vary after the treatment. CONCLUSION: Botulinum A toxin offers a high rate of healing with no associate morbidity in the treatment of proctalgia fugax.

Tratamiento de la proctalgia fugax con toxina botulínica: resultados en 5 pacientes / Treatment of proctalgia fugax with botulinum toxin: results in 5 patients

Introducción. La proctalgia fugax es un dolor pasajero en la región anal cuya etiología no está clara, siendo la más defendida el espasmo del esfínter anal interno. Así, están indicados tratamientos que inducen una relajación del esfínter. El objetivo de este trabajo ha sido evaluar la eficacia de la toxina botulínica como tratamiento de la proctalgia fugax. Material y métodos. Estudio prospectivo de pacientes diagnosticados de proctalgia fugax en la consulta de Coloproctología del Servicio de Cirugía General y del Aparato Digestivo del Hospital General Universitario de Elche desde enero de 1999 a enero de 2002. A todos los pacientes se les realizó una exploración física, tacto rectal, anuscopia, rectoscopia, enema opaco, ecografía endoanal, manometría anal y tomografía computarizada (TC) pélvica para descartar cualquier tipo de patología orgánica. Como tratamiento se realizaron infiltraciones con 25 U de toxina botulínica y se reinyectaron 50 U más a aquellos pacientes en los que al segundo mes persistía la proctalgia. Se revisó a la primera semana, al segundo mes, sexto mes, al año y al segundo año. El dolor fue evaluado mediante escala visual analógica de 0 a 10. La continencia se determinó con el Cleveland Score Incontinence. Resultados. Se incluyeron 5 pacientes (4 mujeres y un hombre). La edad media fue de 45 años. La duración de los síntomas previa al tratamiento fue de 13 meses (rango: 6-18 meses). Sólo una paciente requirió una segunda dosis de toxina botulínica, desapareciendo el dolor tras esta segunda infiltración. Todos los pacientes curaron, manteniéndose sin dolor al final del seguimiento. No hubo complicaciones locales. Los hallazgos manométricos mostraron un incremento en la presión máxima basal (PMB) en comparación con el grupo control (114 mmHg frente a 66 mmHg; p < 0,001), recuperándose a valores normales tras el tratamiento (75,65 mmHg). La presión máxima de contracción voluntaria (PMCV) no mostró diferencias con respecto a los valores del grupo control tanto previo al tratamiento como en el seguimiento. Conclusión. La toxina botulínica puede ser considerada como una potencial terapia para la proctalgia fugax dada la alta tasa de curación con mínima morbilidad

Introduction. Proctalgia fugax can be defined as transitory but recurrent anal pain. Although its etiology remains unknown, an internal anal sphincter spasm seems to be the most likely, so that the different treatments focus on reducing the pressure of the internal anal sphincter. This study is aimed at evaluating the effectiveness of botulinum A toxin in the treatment of proctalgia fugax. Patients and methods. Prospective clinical trial of patients with proctalgia fugax treated with botulinum A toxin at the Outpatient Clinic attached to the Coloproctogy Unit, University Hospital of Elche, from January 1999 to January 2002. The patients included in the study underwent rectal digital examination, anuscopy, rectoscopy, anal manometry and ultrasonography, barium enema and pelvic CT scan to rule out any organic cause for anal pain. The treatment consisted of 25 IU of botulinum A toxin, with a supplementary dose of 50 IU in those patients with persistence of anal pain episodes within the next two months. The patients were reviewed on the first week, second month, sixth month and first and second year. Anal pain was measured by the patients, using a linear analogue scale from 0 to 10, and continence was assessed at every visit using the Cleveland Continence Grading Scale. Results. Five patients were recluted for the study, with a predominance of females (4 vs. 1). Mean age was 45 years. Length of symptoms prior to the treatment was 13 months (range: 6-18 months). Only one female patient required a second dose of botulinum A toxin to handle the anal pain. All the patients healed and remained free of pain up to finishing the follow-up. There were no local complications. Anal manometry showed an increased MRP (mean resting pressure) in comparison to a control group of patients (114 mmHg vs. 66 mmHg; p < 0.001) that restore to normal values after the treatment (75.65 mmHg). As for the MSP (mean squeeze pressure), it showed no difference with respect to the control group nor did it vary after the treatment. Conclusion. Botulinum A toxin offers a high rate of healing with no associate morbidity in the treatment of proctalgia fugax

Esfinterotomía lateral interna abierta con anestesia local como gold standard en el tratamiento de la fisura anal crónica. Estudio prospectivo clínico y manométrico a largo plazo / No disponible

Introducción: la fisura anal crónica sigue siendo uno de los problemas proctológicos más frecuentes e incapacitantes en la población occidental actual. La esfinterotomía lateral interna abierta es una de las opciones terapéuticas descritas y aceptadas como tratamiento de elección de la fisura anal crónica, ya que reduce la hipertonía esfinteriana (mecanismo etiopatogénico fundamental de la fisura), permitiendo por tanto, disminuir la proctalgia y así la curación de la fisura. Material y métodos: realizamos un estudio prospectivo de 120 pacientes intervenidos por fisura anal crónica con esfinterotomía lateral interna abierta con anestesia local (20 cc mepivacaína al 2%) tratados ambulatoriamente en la consulta de la Unidad de Proctología entre los años 1998-2001. No se requirió estudios preoperatorios, preparación con enemas, profilaxis antibiótica, accesos venosos, ingreso ni observación hospitalaria. Los pacientes fueron revisados a la 1a semana, 2o mes, 6o mes y al año. Resultados: complicaciones precoces (1a semana): 3 hematoma-equimosis de la herida (2,5%), 3 hemorragias autolimitadas (2,5%). No encontramos trombosis hemorroidales, fístulas, abscesos perianales ni mortalidad. Complicaciones tardías (2o mes): 9 pacientes con incontinencia (7,5%) y 3 pacientes (2,5%) con recurrencia de la fisura. Al 6o mes, la incontinencia disminuyó al 5% (6 pacientes), y aparecieron 3 pacientes más con recurren- cia de la fisura (2,5%). Al año se mantuvo la tasa de incontinencia del 5% (a gases y líquidos) y aparecieron otros 3 pacientes con recurrencia de la fisura (2,5%). Recurrencia global del 7,5%. Los hallazgos en la manometría fueron, PMB (presión máxima basal) pre-tratamiento similar a la PMB en pacientes con recurren- cia de la fisura, así como la PMB del grupo control similar a la PMB de pacientes con curación. La PMB en pacientes incontinentes fue más baja que la PMB en pacientes continentes (55 ± 7 frente a 80,7 ± 21). La diferencia entre la PMCV (presión máxima de contracción voluntaria) en pacientes incontinentes y pacientes continentes no fue estadísticamente significativa. Conclusiones: la esfinterotomía lateral interna abierta con anestesia local tiene una tasa de curación a largo plazo y unos índices de morbilidad equiparables a otras técnicas, por lo que puede ser considerada como un tratamiento adecuado y eficaz para esta patología (AU)

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Open lateral internal anal sphincterotomy under local anesthesia as the gold standard in the treatment of chronic anal fissures. A prospective clinical and manometric study.

BACKGROUND: Chronic anal fissure is one of the most frequent proctological disorders in Western populations. Open lateral internal sphincterotomy is one of the therapeutic options accepted as the treatment of choice for chronic anal fissure, since it reduces the hypertonia of the internal anal sphincter (the main etiopathogenic mechanism of fissures), decreases anal pain, and allows the fissure to heal. MATERIAL AND METHODS: We carried out a prospective study of 120 patients operated on for chronic anal fissure with open sphincterotomy under local anesthesia at our Proctology Outpatient Unit from 1998 to 2001. No preoperative studies, bowel preparation, or antibiotic prophylaxis were carried out. All patients were followed up after 1 week, 2 months, 6 months, and 1 year, and underwent an anal manometry before and after surgery. RESULTS: Early complications: 3 hematoma-ecchymosis of the wound (2.5%), 3 self-limited hemorrhage events (2.5%). No hemorrhoidal thrombosis, fistulas, or perianal abscesses occurred. Fissures recurred in nine patients (7.5%) within one year. The initial rate of incontinence of 7.5% at two months dropped down to 5% at six months. The mean resting pressure (MRP) in incontinent patients was lower than in continent patients (55 +/- 7 mmHg versus 80.7 +/- 21 mmHg). The difference in mean squeeze pressure (MSP) between incontinent patients and continent patients was not statistically significant. CONCLUSIONS: Open sphincterotomy under local anesthesia has a long-term rate of healing and a morbidity rate similar to other techniques. It may therefore be considered an effective treatment for chronic anal fissure.

Effectiveness of rubber band ligation in haemorrhoids and factors related to relapse.

PURPOSE: to assess the effectiveness of ambulatory rubber band ligation (RBL) in the treatment of symptomatic internal haemorrhoids and to identify factors related to relapse. PATIENTS AND METHODS: prospective study of 232 patients treated with rubber band ligation for symptomatic haemorrhoids (grade I-III or grade IV with severe contraindication for surgery) from November 1996 to November 2000 at the outpatient clinic. Ligation was performed with a Stille AB (Comedic) ligator and suction pump, placing 1-3 bands per session and with up to three sessions per patient. Effectiveness of treatment was defined as the absence of symptoms and was confirmed by anoscopy by checking the residual scar after the cushions' detachment. Categorical variables were compared using the shi-squared test, whereas Student's t-test was used for continuous variables. Logistic regression was employed to identify clinical factors related to relapse. RESULTS: a total of 331 bands were placed during 235 sessions in the 163 patients who completed follow-up (70%). Mean age was 45.6 years, with males accounting for 64.4%. Most patients (86.5%) had grade II or grade III haemorrhoids. Overall morbidity was 6%. The most frequent complications were rectal tenesmus (11%), slight or mild anal pain (7.4%), dysuria (4.3%) and transient anal bleeding (3.7%). The treatment was effective in 86% of patients after a mean follow-up of 32 months. Efficacy was high for grades I and II (100% and 97.4% ) but decreased for grade III (69.8%; p<0.001) and grade IV (0%; p<0.001). Most relapses occurred within the first 24 months (87%) and were not significantly related to age, gender, duration of symptoms, itching, bleeding, pain, tenesmus or bowel habit, but were significantly related to the presence of prolapse and its grade (p<0.001), and to the involvement of left posterior, right lateral and anterior pedicles (p<0.05). CONCLUSIONS: ambulatory RBL is a safe and effective treatment for grade I, II and III symptomatic haemorrhoids, and is associated with low morbidity. Recurrence is uncommon and occurs mainly within the first 24 months, being related to the presence and grade of prolapse as well as to its location, but bears little relation to the rest of factors analysed.

Eficacia de la ligadura hemorroidal con banda elástica y factores relacionados con la recidiva / Effective ness of rubber band ligation in haemorrhoids and factors related to relapse

Objetivo: evaluar la eficacia del tratamiento ambulatorio de las hemorroides internas sintomáticas mediante ligadura con banda elástica (LBE) e identificar factores clínicos asociados a la recidiva. Pacientes y métodos: estudio prospectivo de 232 pacientes con hemorroides internas sintomáticas grados I-III, y grado IV con contraindicación funcional grave para la cirugía tratados en consultas externas (noviembre de 1996 a noviembre de 2000). Se realizó ligadura de los pedículos con un portabandas Stille A B® (Comedic) mediante aspiración con vacío (1-3 ligaduras por sesión y hasta 3 sesiones por paciente). La eficacia del tratamiento se valoró según la remisión de la sintomatología, confirmando por anuscopia la obliteración de las hemorroides y la cicatrización mucosa. Se empleó la prueba de t de Student para el contraste de variables cuantitativas y la prueba de 2 de Pearson para las cualitativas. Para determinar las variables relacionadas con la recidiva se empleó la regresión logística. Resultados: se colocaron 331 ligaduras (235 sesiones) en los 163 pacientes que completaron el seguimiento (70 por ciento de "adhesión" al protocolo). La edad media fue de 45,6 años, con predominio de varones (64,4 por ciento). La mayoría (86,5 por ciento) fueron grados II y III. La morbilidad global fue del 6 por ciento, siendo lo más frecuente el te nesmo rectal (11 por ciento), dolor leve y autolimitado (7,4 por ciento), disuria (4,3 por ciento) y rectorragia (3,7 por ciento). Tras un seguimiento de 32 meses la eficacia global fue del 86 por ciento, siendo mayor en los grados I-II (100 y 97,4 por ciento) que en los grados III (69,8 por ciento; p<0,001) y IV (0 por ciento; p<0,001). La mayoría de recidivas (87 por ciento) ocurrió en los primeros 24 meses. No hubo relación significativa entre recidiva y factores como edad, sexo, tiempo de evolución, rectorragia, prurito, secreción, dolor, tenesmo y ritmo intestinal, mientras que sí la hubo con la presencia de prolapso defecatorio y el grado del mismo (p<0,001), y la afectación de los pedículos anterior, lateral derecho y posterior izquierdo (p<0,05).Conclusiones: la LBE ambulatoria es un método eficaz y seguro para el tratamiento de las hemorroides sintomáticas grados I, II y III, con escasa morbiblidad. La recidiva es baja, ocurre fundamentalmente durante los primeros 24 meses, y sólo se relaciona con la presencia de prolapso y grado del mismo, y con la localización de los pedículos afectos (AU)

Dolor abdominal y fiebre en mujer de 36 años con tumoración quística en hemiabdomen derecho / Abdominal pain and fever in a 36-years old woman with a cystic tumor in the right abdomen

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¿Es la hernioplastia con tapón de polipropileno según técnica de Lichtenstein la primera opción en el tratamiento de la hernia crural? / Is the Lichtenstein procedure involving a polypropylene plug the technique of choice in femoral hernia repair?

Introducción. La utilización de la técnica del plug de Lichtenstein se ha convertido en el patrón de referencia del tratamiento de la hernia crural. Pacientes y métodos. Revisamos 120 hernioplastias crurales operadas electivamente en la Unidad de Cirugía Sin Ingreso del Hospital de Elche desde junio 1992 hasta mayo 1998. Se realizó al 100 por ciento de los pacientes hernioplastia de Lichtenstein con plug de polipropileno. El seguimiento medio ha sido de 68 meses. Resultados. La edad media de los pacientes fue 50,3 años, siendo 85 mujeres (72 por ciento). La técnica anestésica empleada fue preferentemente local con sedación (90 por ciento). No hubo mortalidad operatoria. El tiempo quirúrgico medio fue de 32 min.Las complicaciones fueron: 2 seromas (1,6 por ciento), 3 hematomasufusión subcutánea (2,5 por ciento). No se produjeron infecciones de la herida, rechazos de las prótesis ni recidivas. Conclusiones. La hernioplastia con plug de polipropileno según la técnica de Lichtenstein ofrece unos resultados excelentes con índices de morbimortalidad muy bajos y con tasas de recidivas menores a las técnicas herniorráficas clásicas, por lo que se convierte en la técnica de elección en defectos del anillo crural (AU)

Perforación esofágica. Tratamiento quirúrgico mediante sutura primaria / Esophageal perforation. Surgical treatment by primary repair

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[Management of colostomies with plug: clinical aspects and patient evaluation]. / Manejo de las colostomías mediante obturador: aspectos clínicos y evaluación de los pacientes.

AIM: To assess the effectiveness of the one-piece disposable plug device Conseal (Coloplast A/S, Espergaerd, Denmark) in colostomy patients, considering clinical and social aspects. PATIENTS AND METHODS: Twenty patients with definitive (perineal-abdominal amputation 17 cases) or transitory (Hartmann in 3 cases) colostomy were studied prospectively. No patient used self-irrigations. All of them completed the study. After obtaining the patient's consent, we analyzed for comfort, leaks, security, easy handling and skin conditions by means of personal interview and clinical examination. RESULTS: Sixteen patients (80%) had previously used conventional colostomy bags, 4 (20%) started to use the plug device during the postoperative period (average 8.7 days). Fifteen patients (75%) preferred to use the plug, whereas 5 (25%) considered the plug was insecure. CONCLUSIONS: Our study suggests that the one-piece disposable plug device improves the quality of life in patients with colostomy, although adequate selection of patients and previous training are mandatory.

Effect of atropine and truncal vagotomy on the exocrine pancreatic function in dogs stimulated with intraduodenal tryptophan.

The purpose of this experimental study was to analyze the effect of different doses of atropine and bilateral transthoracic truncal vagotomy on pancreatic secretion. We chose the dog as our experimental model and used the modified Thomas method to obtain gastric juice, removing the gastric acid with a gastric cannula. An additional duodenal cannula was used for the selective intubation of the greater pancreatic duct in order to obtain pure pancreatic juice. To stimulate pancreatic secretion the pancreas was stimulated with intravenous secretin at a constant dose and intraduodenal tryptophan at gradually increasing doses. The juice was collected at 10-min intervals and volume, output of bicarbonate and protein were determined. The results obtained show that low doses of atropine (0.65, 1.25 and 5 micrograms/kg/h) strengthen the suppressive effect of truncal vagotomy on the hydrobicarbonate secretion. Greatest suppression was found in the highest dosage of atropine in response to the intraduodenal tryptophane at gradually increasing doses. The above results suggest the possible existence of local enteropancreatic cholinergic reflexes that are readily suppressed by atropine and vagotomy. Suppression is not global though, since there is no significant reduction in the pancreatic protein secretion, which shows a dosage-effect curve in response to the gradually increasing doses of intraduodenal tryptophan released by the action of endogenous cholecystokinin. Our hypothesis is that there exists a nonvagal enteropancreatic cholinergic reflex.

[Hepatocarcinoma: a rare form of presentation]. / Hepatocarcinoma: forma infrecuente de presentación.

A case of acute abdomen presenting with pain in the right upper abdomen, pyrexia and leukocytosis is presented. At laparotomy, hepatocarcinoma with necrosis and associated acute cholecystitis was found. This is apparently an unusual report of hepatocarcinoma presenting as acute cholecystitis.

[Immuno-nutritional prognostic factors in acute cholecystitis]. / Estudio de factores pronósticos inmunonutricionales en la colecistitis aguda.

A set of parameters that could be used to identify possible immunonutritional disturbances and serve as clinical evolution markers were measured in 210 patients diagnosed of acute cholecystitis (136 females and 74 males, 64.8 and 35.2% respectively) who were admitted into the Surgery Service of the Hospital General de 1++Elche. The prognostic evaluation indices were: a) Nutritional: hematocrit, hemoglobin, total protein, albumin, transferrin; b) Immunological: total lymphocytes and delayed hypersensitivity reaction test. The results obtained were analyzed and compared to those of the literature in this field.

[Bacteriologic findings as a prognostic factor in the course of acute cholecystitis]. / Hallazgos bacteriológicos como factor pronóstico en la evolución de la colecistitis aguda.

We made a bacteriological study of bile in a consecutive study of 210 patients studied in the General Surgery Department of the General Hospital of Elche (Spain) who underwent cholecystectomy for acute lithiasic cholecystitis, as a prognostic factor in the clinical evolution of these patients. The results obtained led us to the following conclusions. 1. The presence of positive bile culture is a risk factor predisposing to postoperative septic complications. 2. Bile cultures were more frequently positive in patients over 60-years-old. 3. In the early stages of the disease, positive cultures were more frequent. 4. The organism most often isolated was E. coli, so antibiotic treatment should be directed mainly against this agent.