¿Es la tuberculosis ganglionar una verdadera enfermedad tuberculosa? / Is lymph node tuberculosis a true tuberculosis disease?

Introducción: La presencia de adenopatías intratorácicas es el patrón característico de la tuberculosis pediátrica. Puede interpretarse como una infección o una enfermedad tuberculosa, con las consiguientes diferencias terapéuticas. El objetivo de este estudio fue determinar si los pacientes con adenopatías intratorácicas aisladas presentan diferencias clínicas, diagnósticas y microbiológicas respecto a los pacientes con otras formas de enfermedad tuberculosa. Material y métodos: Se estudiaron todos los pacientes menores de 14 años diagnosticados de enfermedad tuberculosa en Cantabria entre 2005 y 2014. Se clasificaron en dos grupos: pacientes con adenopatías intratorácicas exclusivamente y pacientes que presentaron otras formas de tuberculosis. Se compararon entre ambos grupos los síntomas clínicos, la velocidad de sedimentación globular, el resultado de la prueba de la tuberculina (PT) y el aislamiento microbiológico. Resultados: Se diagnosticaron 81 pacientes con enfermedad tuberculosa. El 38,3% presentó tuberculosis ganglionar intratorácica y el resto otras formas de tuberculosis. La media de edad ± desviación estándar en el momento del diagnóstico fue de 70,46 ± 43,6 meses. Los pacientes con tuberculosis ganglionar resultaron asintomáticos con mayor frecuencia y presentaron diámetros de induración de la PT significativamente mayores. El aislamiento microbiológico se consiguió en un 25,9% del total. No se observaron diferencias significativas en el aislamiento microbiológico entre ambos grupos (el 35,5 frente al 16,13%; p= 0,074). En ningún paciente con adenopatías detectadas mediante tomografía computarizada se aisló Mycobacterium tuberculosis. Discusión: El aislamiento de M. tuberculosis constituye el gold standard para el diagnóstico de enfermedad tuberculosa, estableciendo el diagnóstico diferencial con la infección. En este estudio, los pacientes con tuberculosis ganglionar presentaron un porcentaje de aislamiento microbiológico similar a los pacientes con otras formas de tuberculosis. Según estos resultados, el aislamiento microbiológico de las tuberculosis ganglionares no sería un hallazgo casual, por lo que las formas ganglionares deberían considerarse una enfermedad en lugar de una infección tuberculosa

Introduction: The presence of intrathoracic lymph nodes is the characteristic pattern of pediatric tuberculosis but can be interpreted as infection or tuberculosis disease with different therapeutic approaches. The aim of this study was to determine if patients with isolated intrathoracic lymph nodes had clinical, diagnostic and microbiological features compared with patients diagnosed with other forms of tuberculosis disease. Material and methods: All patients younger than 14 years of age diagnosed with tuberculosis in Cantabria between 2005 and 2014 were included in the study. They were classified into two groups: patients with exclusively intrathoracic adenopathies and those with other forms of tuberculosis. Clinical symptoms, erythrocyte sedimentation rate, tuberculin skin test (TST) results and microbiological isolation between the two groups were compared. Results: A total of 81 patients were diagnosed with tuberculosis, 38.3% had nodal tuberculosis and the rest other forms of tuberculosis. The mean age at diagnosis was 70.46 ± 43.6 months. Patients with nodal tuberculosis were more frequently asymptomatic and had significantly higher TST induration diameters. Microbiological isolation was achieved in 25.9% of the patients and no significant differences in microbiological isolation between the two groups were observed (35.5 vs. 16.13%; p= 0.074). No Mycobacterium tuberculosis was isolated in any patient with lymphadenopathies detected by computed tomography. Discussion: The microbiological isolation is the gold standard of tuberculosis disease. Isolation of M. tuberculosis was not significantly superior in the group of patients with exclusive lymph node tuberculosis suggesting that lymph node tuberculosis should be considered a true tuberculosis disease

[Results of the implementation of a protocol for outpatient management of the paediatric patient with tuberculosis]. / Resultados de la implantación de un protocolo para el manejo ambulatorio del paciente pediátrico con enfermedad tuberculosa.

OBJECTIVE: To assess the results of the implementation of a protocol for the outpatient management of paediatric patients with tuberculosis, and to compare it with the previous approach. MATERIAL AND METHODS: All patients younger than 14 years of age diagnosed with tuberculosis in Cantabria between 2005 and 2014 were included in the study. The pre-implementation period included patients admitted for gastric aspirate collection and to start treatment until 2010 (Pre-group). The post-implementation period was from 2010 onwards, using a protocol established for the outpatient management of these patients, with admission only being for clinical or social reasons, post-implantation period (Post-group). RESULTS: A total of 82 patients were studied: 29 from the Pre-group and 53 from Post-group. The median age was 61 months (IQR 32.5-97.75). All patients in the Pre-group were systematically admitted, compared to 26.4% of the Post-group (P<.001). The mean hospital stay was higher (7.27±7.1 days) in the Pre-group than in Post-group (3.4±11.46 days) (P<.0001). Only in 6.9% of patients from Pre-group were the 3 microbiological samples recommended for diagnosis following the international guidelines were provided, whereas they were provided by 73.58% patients from Post-group (P<.001). Of the cultures performed, 26.6% were positive for Mycobacterium tuberculosis, 37.5% of the Pre-group and 21.6% of the Post-group (P=.121). No significant differences were observed between the groups in other parameters related to treatment such as, therapeutic adherence, treatment not adjusted to the guidelines, treatment withdrawal or relapse.. DISCUSSION: Although guidelines recommend three microbiological samples for culture, no superior microbiological isolation was detected despite the increased number of samples collected. The management in hospital clinics of patients with suspected tuberculosis with stable clinical situation show similar or better clinical and microbiological results to the previous management, with lower hospital admission rate and with the subsequent cost savings.

Espondilodiscitis lumbar: clínica y factores de riesgo en el diagnóstico precoz / Lumbar spondylodiscitis: Symptoms and risk factors in the early diagnosis

La espondilodiscitis lumbar (EDL) es una infección del cuerpo y el disco vertebral cuya clínica en fases iniciales se puede confundir fácilmente con otros cuadros de dolor lumbar de causa menor. Es necesario un elevado grado de sospecha clínica para evitar retrasar su diagnóstico, así como tener en cuenta la presencia de factores de riesgo que pudieran favorecer su desarrollo. La detección y el manejo precoces pueden evitar en gran parte la discapacidad que causa este cuadro. Se presentan dos casos clínicos de EDL asociados a estreptococos del grupo viridans y Enterobacter aerogenes, respectivamente, y se destacan, a propósito de éstos, los pasos clave necesarios para evitar un retraso diagnóstico (AU)

Lumbar spondylodiscitis is an infection of the low back vertebral body and the intervertebral disc space. In early stages it must be differenciated from other minor causes of low back pain. Its diagnosis demands a high level of clinical suspicion, as well as taking into account any risk factor which could favour its development. Early detection and treatment prevent future disability. Two cases, related to Viridians Streptococi and Enterobacter aerogenes, respectively, are described in order to review the key steps to avoid delayed diagnosis (AU)

Obesity surgery results depending on technique performed: long-term outcome.

BACKGROUND: Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. METHODS: This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). RESULTS: One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. CONCLUSIONS: The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75-225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m(2)), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.

Resultados de la aplicación de un protocolo de prevención de la retención aguda de orina trasreparación herniaria / Results of applying a protocol for the prophylaxis of acute urinary retention after hernia surgery

INTRODUCCIÓN: La retención aguda de orina es una complicación frecuente de la cirugía de la hernia inguinal que conlleva un aumento de la estancia hospitalaria, importante cuando dicha cirugía se realiza en régimen ambulatorio o de corta estancia. MATERIAL Y MÉTODOS: Estudio prospectivo de una cohorte de 117 pacientes sometidos a hernioplastia inguinal o crural en régimen de corta estancia entre enero y junio de 2003. Tres cirujanos aplicaron un protocolo de medidas encaminadas a prevenir la retención urinaria y otros tres cirujanos no. CARACTERÍSTICAS DE LA MUESTRA: Edad media 62 años, sexo (varones 107, mujeres 10),antecedente de hipertrofia benigna de próstata 19,tipo de anestesia (local 5, regional 97, general 15)y tipo de cirugía (programada 110, urgente 7).Estudio estadístico: test Chi-cuadrado para comparación de proporciones, con nivel de significación p<0,05.RESULTADOS: Se valoró la repercusión de la aplicación del protocolo sobre incidencia de retención de orina (11,7% en el grupo en el que se aplicó el protocolo y 7,5% en el que no) y los factores que podrían considerarse de riesgo para la aparición de retención (únicamente encontramos diferencias estadísticamente significativas entre los pacientes que referían el antecedente de hipertrofia benigna de próstata (36,8%) y los que no (4,5%)).CONCLUSIONES: Las medidas aplicadas, aunque recomendables, son insuficientes para prevenirla retención de orina postoperatoria, especialmente en los pacientes con disfunción urinaria, por lo que sería conveniente identificar preoperatoriamente a estos pacientes de riesgo para aplicaren ellos otras medidas (AU)

INTRODUCTION: Acute urinary retention is a frequent complication following inguinal hernioplasty. It can cause a prolonged hospital stay, an important inconvenience in day-case surgery or short-stay surgery. MATERIAL AND METHODS: We undertook a prospective study of 117 consecutive patients who underwent inguinal hernioplasty as a short-stay procedure between January and June 2003. Three surgeons applied a protocol to prevent urinary retention and three other surgeons did not. PATIENTS: Mean age was (62), sex (107 male,10 women), benign prostatic hypertrophy (19),type of anesthesia (local 5, regional 97, general 15)and type of surgery (scheduled 110, emergency 7)were registered. STATISTICAL ANALYSIS: The C2-test was used to analyse differences between groups. P<0,05 was considered statistically significant. RESULTS: We evaluated the influence of the protocol on urinary retention (11,7% in the protocol group and 7,5% in the non-protocol group)and possible risk factors for (..) (AU)

Incidence of incisional hernia following vertical banded gastroplasty.

BACKGROUND: Our aim was to determine which patient-related factors influence the incidence of incisional hernia after vertical banded gastroplasty for morbid obesity. METHODS: We reviewed the medical records of 80 morbidly obese patients operated on between 1986 and 1993. All the operations were performed by only one surgeon, and the midline laparotomy was closed by means of continuous polyglactin 910 suture. Statistical analysis was performed using the Fisher exact test, and significance was assigned for values of P<0.05. RESULTS: Incidence of incisional hernia in: obese 24%, superobese 51% ( P=0.0165), men 40%, women 34% ( P=0.7671), age<50 33%, age>50 50% ( P=0.3137), nondiabetics 31%, diabetics 66% ( P=0.0610), no wound infection 34%, wound infection 37% ( P>0.9999), no anemia 31%, anemia 50% ( P=0.1675), no vomiting 39%, vomiting 32% ( P=0.6350). CONCLUSION: The only patient-related factor that significantly influences the incidence of incisional hernia in morbidly obese patients is body mass index.

Evisceración vaginal seis meses después de histerectomía / Transvaginal evisceration six months after hysterectomy

Presentamos un caso de evisceración vaginal en una mujer posmenopáusica sometida, 6 meses antes, a histerectomía vaginal, cuya reparación se realizó por vía abdominal mediante cierre de la cúpula vaginal y colocación de malla de Gore-Tex® para refuerzo del suelo pelviano. El diagnóstico y la reparación tempranos de este raro problema urgente llevan a evitar la resección intestinal y a una buena recuperación de las pacientes. En la intervención debe valorarse la presencia de defectos del suelo pelviano que contribuyan a la evisceración. (AU)

Transanal full-thickness excision of rectal tumours: should the defect be sutured? a randomized controlled trial.

PURPOSE: It is generally recommended that the defect, after full thickness total wall excision of a tumour located in the extraperitoneal part of the rectum, should be sutured. There is a lack of controlled studies however, supporting this approach. The aim of this study was to compare the results obtained in patients after peranal local excision of rectal tumours whose defect were sutured with those that were not. METHODS: 44 patients were prospectively randomized to group A: The defect is closed; Group B: Defect left un-sutured. Pre-operative test were digital examination, proctoscopy and endorectal ultrasound. Local full-thickness excision was performed mainly with the Transanal Endoscopic Microsurgery (TEM) equipment, but for cases near the anal verge a Parks' retractor was used. Data recorded were operation time, blood loss, hospital stay and early and late complications. The first postoperative assessment was planned at 1 month and then every three months until 18 months of follow-up. Result for 40 patients (21 from group A; 19 from group B) were analysed. There were no differences between groups regarding age, sex, location of the tumour and specimen's size. RESULTS: The intra-operative loss of blood was 22 ml for group A and 39 ml for B, the difference was not significant. The mean operation time was slighter longer for group A (93 min) than for group B (77 min) but not statistically significant. For both group the mean hospital stay was of 4[2-7] days. No differences in early or late complications could be demonstrated. CONCLUSION: The present study suggests that there is no difference between these two practices in terms of intra-operative results and outcome.

Is endosonography useful to select patients for endoscopic treatment of rectal cancer?

AIM: in recent years there have been remarkable advances in the treatment of rectal cancer, stimulated by a general tendency towards conservative treatment, and aided by the development of diagnostic tools that allow the surgeon to select the most suitable tumors for treatment. In some cases, conservative local excision by transanal endoscopic microsurgery (TEM) may be appropriate. We analyzed the value of transrectal endosonography for the preoperative staging of rectal cancer previous to TEM. METHODS: data were collected prospectively from a consecutive series of patients with rectal cancer who underwent TEM between January 1994 and December 1997. RESULTS: the accuracy of rectal endosonography in predicting rectal wall invasion was 72.7%. 18.2% of the tumors were overstaged and 9. 1% were understaged. CONCLUSION: transrectal endosonography is a useful technique for the selection of patients for TEM but is amenable to further improvement.