Resultados de la aplicación de un protocolo de alta ambulatorización en patología hemorroidal en un hospital general desde el punto de vista del paciente / Results of a high ambulatory rate protocol on the treatment of hemorrhoidal pathology from the patient point of view

El tratamiento quirúrgico de las hemorroides ha sido asociado a un periodo postoperatorio doloroso e incómodo que, clásicamente, se ha asociado a una hospitalización prolongada con el único objetivo de controlar el dolor. Actualmente, la técnica más utilizada es hemorroidectomía de Milligan-Morgan clásica, a pesar de que la tasa de ambulatorización de la patología hemorroidal va en aumento, lo que se puede traducir en un mejor control de los síntomas postoperatorios más modificaciones en la técnica quirúrgica. Nuestro centro es una joven institución con gran vocación professional y apoyo a la cirugía ambulatoria. En este contexto se ha puesto en marcha un nuevo protocolo para la ambulatorización de los procedimientos proctológicos. En este campo, la patología hemorroidal es un gran reto. Presentamos los resultados de la aplicación de este protocolo, centrándonos en el punto de vista del paciente (AU)

The surgical treatment of hemorrhoids is been associated with a postoperative painful and uncomfortable time, that classically associated a prolong hospitalization with the only objective of pain control1 . Today the classic Milligan-Morgan resection remains as the most frequent technique2 , despite this the ambulatory rate keep increasing on time, what can be indirectly explained by a better pain control plus recent technique modifications3 . Our centre is a young institution with a great professional vocation and institutional support on the “day-case” or major ambulatory surgery. In this context we initiate a protocol trying to do almost all the proctology surgery on a ambulatory or day-case way, in this onset the hemorrhoidal pathology is a great challenge. We present the data of this protocol, focusing in the patient point of view of the whole experience (AU)

[Subhepatic abscess as a late complication of missed intraperitoneal gallstone after laparoscopic cholecystectomy]. / Absceso subhepático como complicación tardía de un cálculo intraperitoneal abandonado tras una colecistectomía laparoscópica.

Laparoscopic cholecystectomy is the treatment of choice in symptomatic cholelithiasis. Despite its many advantages over the conventional laparotomic approach, accidental perforation of the gallbladder with spilled stones and bile leakage is frequent during this procedure. Complications from missed gallstones are uncommon, although they can sometimes lead to severe consequences. Great effort must be made to achieve laparoscopic retrieval of all the gallstones missed into the peritoneal cavity and conversion to an open procedure should be used only in selected cases. We report a case of subhepatic abscess as a late complication of a missed gallstone during a previous laparoscopic cholecystectomy.

[Primary hepatic actinomycosis]. / Actinomicosis hepática primaria.

Primary hepatic actinomycosis is a rare infection that can clinically be confused with hepatic pyogenous abscesses or neoproliferative processes. We present the case of a 71-year-old man who had previously undergone total gastrectomy for gastric adenocarcinoma. After 4 years of favorable clinical course he presented a space-occupying lesion in the right hepatic lobe. Diagnostic tests were nonspecific and the diagnosis was confirmed by histological study of a biopsy of the lesion obtained through laparotomy. Prolonged antibiotic treatment produced a complete response. The etiopathogenesis and diagnostic-therapeutic options of hepatic actinomycosis are reviewed.

Enfisema submucoso gástrico / Gastric Submucosal emphysema

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Rotura espontánea de la vena ilíaca / Spontaneous iliac vein rupture

Se presenta el caso de un paciente varón intervenido quirúrgicamente por shock hipovolémico secundario a una rotura espontánea de la vena ilíaca común izquierda, tratado con ligadura de la vena. La rotura espontánea de la vena ilíaca es una rara urgencia vascular de etiología incierta, con frecuencia confundida con un sangrado arterial intraabdominal. Se realiza una revisión de los casos descritos en la literatura, comentando las formas más frecuentes de presentación, posibles mecanismos desencadenantes y manejo perioperatorio. Las medidas intensivas de estabilización y un tratamiento quirúrgico urgente son fundamentales para poder reducir la elevada mortalidad de esta causa infrecuente de hemorragia exanguinante (AU)

Splenic and adrenal lymphangiomatosis.

Lymphangiomatosis is a rare syndrome that can affect different organs, although simultaneous splenic and adrenal involvement is exceptional. We report the case of a young female with a symptomatic massive splenomegaly and no-nhypersecreating bilateral adrenal masses incidentally discovered that represented a diagnostic challenge. The management of adrenal incidentalomas is controversial, as the presence of large sized bilateral masses are highly indicative of malignancy. Despite the different diagnostic techniques available, it is sometimes impossible to reach an accurate preoperative diagnosis. Elective splenectomy and left adrenalectomy were performed, preserving the functioning of the right adrenal gland, radiologically similar to the left one, to prevent the development of definitive adrenal insufficiency. Postoperative evolution has been favourable without initial increase of the size of the right adrenal lesion. However, the persistence of this mass obligated long-term follow-up and shall assist us in better understanding the behavior of this bening lesion.

Miofibroblastoma de mama en un paciente varón / Myofibroblastoma of the breast in a male patient

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Management of lower gastrointestinal bleeding in colonic diverticular disease.

AIM: To evaluate the clinical course, diagnostic approach, therapeutic measures and results, in a series of 13 patients with colonic bleeding diverticula. MATERIAL AND METHODS: From 1973 to 1995, 72 patients were admitted with the diagnosis of lower gastroin testinal bleeding. Thirteen presented a colonic diverticula bleeding. Mean age was 65.2 years. Medical history, symptoms, diagnosis, treatment (conservative or surgical) and pathology were recorded. RESULTS: Main bleeding time was 3 days. Eight patients needed blood transfusion. All patients underwent colonoscopic examination and it was diagnostic in every patient. Four patients underwent surgery: one case, because of massive hemorrhage and the other three cases due to bleeding recurrence. Pancolectomy was performed in one patient, ileal resection in another and the other two were treated with a sigmoidectomy and a left hemicolectomy. Pathology analysis corroborated colonic diverticula diagnosis. There was no postoperative mortality. Bleeding recurrence did not occur either in postoperative period or in the follow-up. CONCLUSIONS: Colonic diverticular bleeding usually stops spontaneously, obtaining high rates of preoperative diagnosis with colonoscopy. Less than a third of the cases requires surgical resection.

Diagnostic and treatment of Zenker's diverticulum: review of our series pharyngo-esophageal diverticula.

BACKGROUND/AIMS: Clinical aspects and preneoplastic potential of Zenker's diverticulum justify its surgery. The clinical signs of the patients and the size of the diverticulum determine the surgical technique. METHODOLOGY: Between January 1974 and December 1995, 32 patients underwent surgery in our department. In order to compare the surgical technique, we divided the patients into 3 groups: group A (cricopharyngeus myotomy: 15 patients (46.9%)), group B (myotomy with diverticulectomy: 15 patients (46.9%)) and group C (myotomy with diverticulopexy: 2 patients (6.7%)). The chi-square test was used for statistical analysis, p < 0.05. RESULTS: Local or regional anaesthesia was used in 7 patients from group A (46.6%); 5 patients from group B (33.3%) and all the patients from group C (100%). General anaesthesia was used in 8 patients from group A (53.4%), 10 patients from group B (66.7%) and 0 patients from group C (0%). The overall mortality was 0%. The mean postoperative stay in group A was 6 +/- 2 days (3-10 days); in group B was 11.6 +/- 6.4 days (5-25 days) and in group C was 3.5 +/- 0.7 days (3-4 days). The mean postoperative stay in patients with local or regional anaesthesia was 5.3 +/- 1.6 days (3-9 days) and in patients with general anaesthesia, 10.9 +/- 6.1 days (4-25 days). No statistically significant difference was found between the anaesthetic technique and the surgical technique (p = 0.193), between the surgical technique and the mean postoperative stay (p = 0.596) and between the anaesthetic technique and the mean postoperative stay (p = 0.166). CONCLUSIONS: Cricopharyngeus myotomy is the main surgical technique, however, in diverticula longer than 3 cm of diameter it is mandatory to associate diverticulectomy. Diverticulopexy is indicated in patients of advanced age with a high surgical risk. Local or regional anaesthesia facilitates the identification of the diverticulum intraoperatively and reduce the mean postoperative stay, however, there is no statistical significant difference.