Absceso subretiniano por Nocardia en paciente inmunodeprimido: a propósito de un caso / Subretinal abscess due to Nocardia in an immunosuppressed patient: A case report

La nocardiosis sistémica es una enfermedad poco frecuente. Su diseminación por vía hematógena al globo ocular lo es aún todavía más, con muy pocos casos documentados, por lo que su sospecha como posible diagnóstico en caso de absceso subretiniano no es la norma. Sin embargo, con unos antecedentes de inmunodepresión y enfermedad pulmonar, la imagen de fondo de ojo es enormemente indicativa. Presentamos el caso de un varón de 45 años inmunosuprimido, sin clínica pulmonar, que inició con una masa subretiniana que por su evolución es compatible con un absceso, diagnosticado etiológicamente en última instancia mediante vitrectomía como infección por Nocardia cyriacigeorgica, un patógeno emergente. Sumamos así nuestro caso, con sus peculiaridades, a otros para documentar una enfermedad que por su infrecuencia puede ser tardíamente diagnosticada (AU)

Systemic nocardiosis is a rarely occurring pathology, but its hematogenous spread across the eye is even less likely to occur, with only a few recorded cases. Therefore, it is not usually taken into account when a subretinal abscess is being considered for a diagnosis. However, when confronting a case with a history of immunosuppression and pulmonary disease, the examination of the ocular fondo may be a very successful approach. With such aim we introduce the case of a 45-year-old immunosuppressed male, without a history of pulmonary disease, whose subretinal mass evolution is accordant with an abscess. In the end, being etiologically diagnosed by means of a vitrectomy, it was concluded that the abscess was due to an infection of Nocardia cyriacigeorgica, an emergent pathogen. Thus the aforementioned case is to be considered in the present study, along others, in order to shed more light on a disease which may not be readily diagnosed on account of its infrequency (AU)

Subretinal abscess due to nocardia in an immunosuppressed patient: a case report.

Systemic nocardiosis is a rarely occurring pathology, but its hematogenous spread across the eye is even less likely to occur, with only a few recorded cases. Therefore, it is not usually taken into account when a subretinal abscess is being considered for a diagnosis. However, when confronting a case with a history of immunosupression and pulmonary disease, the examination of the ocular fundus may be a very successful approach. With such aim we introduce the case of a 45-year-old immunosupressed male, without a history of pulmonary disease, whose subretinal mass evolution is accordant with an abscess. In the end, being etiologically diagnosed by means of a vitrectomy, it was concluded that the abscess was due to an infection of nocardia cyriacigeorgica, an emergent pathogen. Thus the aforementioned case is to be considered in the present study, along others, in order to shed more light on a disease which may not be readily diagnosed on account of its infrequency.

Present state of the Mini-Invasive Surgery (MIS) in esophageal and gastric cancer.

The purpose of this review is to stress the role of the Mini-Invasive Surgery (MIS) in the treatment of the esophagogastric malignant illnesses, supporting ourselves on the most relevant publications of the literature as well as on our own experience in this subject. In short, although no randomised prospective study has proven the MIS advantages in relation to the traditional surgery in the esophagectomy due to cancer, some authors preferently indicate this approach to selected and informed enough patients, who present the following: - High grade dysplasia, preferently choosing from laparoscopic transhiatal esophagectomy (LTE). - Carcinoma in situ, preferently choosing the LTE vs thoracoscopy. - Esophageal tumour locally advanced, in resectable patients with contraindication for a thoracotomy or, in initially non-resectable patients with tumoral reduction after neo-adjuvant chemo-radiotherapy. The arguments given by the authors are the postoperative spectacular improvement in relation to the comfort and quality of life and, the absence of oncological negative effects in the long-term followup. Concerning gastric cancer, the MIS, as exeresis surgical tool in the so-called <> gastric forms, is such a definite and oncological approach as the traditional approach, and superior to this as far as quality of life is concerned. When the MIS is used for treating locally advanced forms of gastric cancer, it is as safe as the laparotomic way and it seems to obtain the same oncological outcomes in the long-term.

Long-term results of laparoscopic extended surgery in advanced gastric cancer: a series of 101 patients.

BACKGROUND/AIMS: The objective of our paper is to report on the remote results of patients with gastric cancer treated by mini-invasive surgery as a surgical tool with the "intention to treat with laparoscopy". METHODOLOGY: Between June 1993 and January 2004, 101 patients comprising 72 men and 29 women with gastric adenocarcinoma were prospectively selected by two hospitals based on prior agreement (the CHU Charleroi, Belgium, and Zumárraga Hospital, the Basque Country, Spain). Patients with adenocarcinoma of the cardia were excluded. Average age of the patients was 67 (37-83). RESULTS: Postoperative mortality within 60 days of operation was of 5 patients; 87 patients were therefore properly followed-up for an average of 41 months (7-129). Average survival time for 10 non-resected patients was 4.5 months. Average survival rate of the 10 palliatively resected patients was 7.1 months. Actuarial 5-year survival rate RO-type surgery was 34%. The global actuarial 5-year survival rate after resective surgery was 29%. CONCLUSIONS: Laparoscopic gastrectomy with any kind of lymphadenectomy is a heavy but safe operation, and produces acceptable mortality and morbidity rates in patients with advanced gastric cancer in a general poor condition. Laparoscopic gastrectomies for locally advanced cancers are equivalent to those reported by laparotomy as far as long-term oncological results are concerned.

Hidatidosis esplénica / Echinococcosis of the spleen

Introducción. Presentamos nuestra experiencia en el tratamiento de la enfermedad hidatídica de localización esplénica. Pacientes y métodos. Se presenta una serie de 7 casos intervenidos por hidatidosis de localización esplénica, en dos hospitales, entre los años 1977- 1997. Resultados. La esplenectomía por quiste hidatídico representa el 1,007 por ciento (7/ 768) de todas las indicaciones de esplenectomía y el 2,95 por ciento (7/237) de los casos de hidatidosis intervenidos. Todos los casos fueron tratados mediante esplenectomía reglada. Discusión. Parece observarse un aumento de la incidencia de diagnóstico de la hidatidosis de localización esplénica durante los últimos años en relación con un mayor empleo de técnicas exploratorias no invasivas (AU)

The current role of laparoscopic surgery in the treatment of benign gastroduodenal diseases.

BACKGROUND/AIMS: The impressive breakthrough in laparoscopic surgery has urged several authors to adopt such an approach in the treatment of both benign and malignant gastric diseases, even though laparoscopic gastric resection has not yet met with widespread enthusiasm. The current work is aimed at illustrating the feasibility and assessing the efficacy of laparoscopic (LGRs) and laparoscopic-assisted (LAGRs) gastric resections in the treatment of non-malignant gastric conditions. METHODOLOGY: As of April 1997, we performed LGRs or LAGRs on a total of 24 patients (M:F = 15:9; mean age: 43 years; range: 19-65 years), among whom 8 presented with chronic gastric ulcer, 4 had benign pyloric stenosis, 8 were affected with recurrent duodenal ulcers no longer amenable to treatment, and 4 with persistent symptomatic biliary reflux. Pre-operatively, all patients underwent blood tests, upper GI endoscopy coupled with biopsy, and barium swallow. Post-operatively, all patients were administered saline solution and water dextrane for the first 5 days; antibiotics (cefuroxim 4 g i.v. daily) and analgesics (paracetamol 6 g i.v. daily) for the first 48 hours. A hydrosoluble swallow was scheduled for the 5th post-operative day. RESULTS: The surgical procedure consisted of a Billroth II distal gastrectomy in 13 cases and total duodenal diversion with Roux-en-Y gastrojejunostomy in 11. Among such patients, 18 underwent a totally laparoscopic procedure, whereas 6 had laparoscopic-assisted gastrectomy, with the use of a Dexterity device in 1 case. The mean duration of the procedure was 150 min (range: 120-200), and blood losses were not remarkable. No intra-operative complication ever occurred. Post-operatively, we observed one case of retrogastric collection and incisional hernia in 1 patient who underwent a laparoscopic-assisted procedure. The abscess was drained percutaneously and hernia conventionally repaired 5 months post-gastrectomy. Post-operative hospital stay was 7 days on the average (range: 5-25). One patient was lost to follow-up. In the remaining cases, no major functional sequelae were observed at a mean follow-up of 19 months (range: 2-41), apart from 2 cases of transient diarrhea. CONCLUSIONS: Laparoscopic surgery appears to be an invaluable tool for the treatment of gastric diseases and LGRs are a valid option in experienced hands and in selected centers, allowing patients to benefit from a less cumbersome hospital stay and fewer functional sequelae. The economic impact of such a practice, however, needs better clarification.

Minimally invasive surgery for gastric cancer.

BACKGROUND: The use of laparoscopic surgery in the treatment of gastric cancer has not yet met with widespread acceptance; thus, it should be regarded as still in the developmental phase. Nevertheless, the laparoscopic approach appears to have some valuable advantages for the management of gastric cancer patients, and it can be expected to have a dramatic impact on public health expenditures. Herein we present the results of our experience with laparoscopic and laparoscopy-assisted gastrectomies for cancer, and we discuss the role of these procedures in current surgical practice. METHODS: Between June 1993 and November 1997, we performed a total of 13 laparoscopic procedures on 13 patients affected with gastric carcinoma. There were eight male and five female patients with a mean age of 65.4 years (range, 42-78). All patients were staged preoperatively with US and CT scan and required to sign a formal consent. RESULTS: Altogether we performed nine D1 laparoscopic total gastrectomies, seven of which were done with a laparoscopy-assisted approach; three D2 laparoscopy-assisted total gastrectomies, associated in one case with a distal pancreasectomy; and one laparoscopy-assisted distal gastrectomy performed on a morbid obese patient. The preliminary laparoscopic staging allowed for a better definition of tumor extension and identification of undetected hepatic metastases in two patients. The mean duration of the intervention was 240 min. Blood losses were as high as 300 cc on average. We recorded one major intraoperative complication, consisting of an inadvertent injury to the proper hepatic artery, which was successfully repaired by the same laparoscopic route. The postoperative course was uneventful in all patients but one, who died of acute hepatic failure on day 6. At a mean follow-up of 27.5 months, 11 patients are still alive. Two of them have hepatic metastases and nine are disease-free. CONCLUSIONS: Although they remain challenging procedures, laparoscopic gastrectomies appear to be oncologically adequate. We believe that a pure laparoscopic approach should be reserved for low-stage lesions (N0, up to T2), while a combined approach is preferable for locally advanced cancer (N1 or higher, T3 or higher). Much work still needs to be done to establish the optimal strategy in both open and laparoscopic surgery, but laparoscopy can be a valuable tool in the decision-making process for patients affected with gastric malignancies.

[The treatment of acute liver failure due to fulminating hepatitis by total or partial orthotopic liver transplantation. The clinical results]. / Il trattamento dell'insufficienza epatica acuta per epatite fulminante mediante trapianto epatico ortotopico totale o parziale. Risultati clinici.

Indications for liver transplant in acute fulminating hepatitis (AFH) are predominantly affected by the high mortality of this spontaneous evolution (80-100%). At present patients with AFH have priority for transplant since they form part of the 0 emergency group according to the National Transplant Organisation. During the period between 1986 and the end of February 1992, a total of 254 liver transplants were performed in 202 patients (52 retransplants). In 26 patients (12.8%) (16 females and 10 males) the indication was fulminating acute hepatitis. Etiology was unknown in 20 patients, secondary to hepatitis B in 4 and to hepatitis A in 1, and was caused by isonazide ingestion in 1 case. The age limits were 3-60 years (X = 31.5 years). An isogroup graft was performed in 16 patients (61.5%), compatible in 3 (11.6%) and incompatible in 7 (26.9%). Due to anthropometric differences, a partial graft was used in 7 patients (26.9%); in 2 of the latter the graft was taken from the same donor ("split-liver"). Placement was always orthotopic with resection of the retrohepatic vena cava in 25 patients and its preservation in 1 (left lobe of split-liver). Peroperative (30 days) mortality was 23% (6/26); 2 due to cerebral death, 2 due to sepsis, 1 due to multisystemic insufficiency (MSI) and 1 due to acute pancreatitis. Four patients (15.3%) died some time after transplant; 1 after 5 months due to broncho-pulmonary complications, 1 after 7 months due to subacute hepatitis, 1 after 3 months due to respiratory failure and the last after 5 months due to anoxic encephalopathy and lung infection. Ten patients (39.4%) were re-transplanted; 4 following chronic rejection, 4 due to primary graft no function, 1 due to arterial thrombosis and 1 due to recurrent hepatitis (with cirrhosis). Two of the latter patients died intraoperatively due to coagulopathy and hemorrhage, and 3 following surgery (1 due to sepsis, 1 due to respiratory complications and 1 due to respiratory insufficiency). Two patients underwent a second re-transplant (1 due to chronic rejection and 1 due to recurrent hepatitis) and of these 1 died peroperatively due to sepsis and MSF. Overall mortality was therefore 61.5% (16/26) and the actuarial survival rate of 17 patients (10 living + 7 postoperative deaths) was 68% at 12 months and 52.9% at 36 months. Even if peroperative mortality is relatively high, liver transplant is currently the elective treatment for fulminating acute hepatitis.

Recurrent acute pancreatitis as a complication of cystic fibrosis: report of one case treated surgically.

We present the case of a young woman previously diagnosed with cystic fibrosis (CF) manifested primarily by respiratory symptoms and pancreatic exocrine insufficiency. Only 0.5% of these patients suffer from episodes of recurrent acute pancreatitis, the majority of which respond to conservative treatment. In this case, recurrent episodes of acute pancreatitis made it necessary to perform a surgical pancreatic drainage procedure.

[The surgical treatment of esophageal leiomyomas: a report of 9 cases and a review of the literature]. / Tratamiento quirúrgico de los leiomiomas esofágicos: aportación de nueve casos y revisión de la literatura.

We report a series of 9 leiomyomas of the esophagus treated surgically. We review the literature, emphasizing diagnostic and therapeutic aspects, calling special attention to the good results obtained by submucosal enucleation of the tumor.

[Orthotopic liver transplantation: results at the "12 de Octubre" Hospital]. / Trasplante hepático ortotópico: resultados del Hospital "12 de Octubre".

The authors report their experience on 132 liver transplants performed on 111 patients. Eighteen have a re-transplantation and in 3 of them a second retransplantation (total re-transplanted patients 21 = 15.9%). Hepatic cirrhosis was the most common indication (57.65%) for transplantation (34.37% of alcoholic etiology). The authors report briefly their operative techniques and the results of their experience. The per-operative mortality (30 days) was 16.21% (18/111). The most important complications were: 9 hepatic arterial thromboses (6.8%), 4 arterial strictures (3.03%), 1 portal stricture (0.75%), 4 portal vein thromboses (3.03%), 5 biliary fistulae (3.78%) (3 following biliary duct-to-duct anastomosis and 2 following hepatic-jejunoanastomosis) and 2 strictures of the choledocus (1.51%). The actuarial survival rate (48 months) is 80%.

Tracheo-colonic fistula: an exceptional complication after total replacement of an esophagus injured by acid.

A 49-year-old woman underwent emergency gastrectomy for suicidal caustic ingestion, followed later by transhiatal esophagectomy and left colonic interposition. A fistula developed postoperatively between the trachea and interposed segment of colon. This exceptional complication was successfully treated by resection of the fistula, closure of the colonic defect and tracheal myoplasty using the sterno-cleidomastoid muscle.

[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.

[Intraoperative cholangiography: its value in simple cholelithiasis]. / Colangiografía intraoperatoria: valor en la colelitiasis simple.

The present study evaluates the benefits of systematic intraoperative cholangiography (CIO) in 144 patients without preoperative suspicion of choledocholithiasis. Eleven (7.6%) of the intraoperative cholangiographies were considered abnormal by the surgeon and the presence of choledocholithiasis (3/11, 27%) was confirmed in only three cases. Pathology of the main bile duct that had been unsuspected preoperatively was found in only 2% (3/144). We conclude that routine intraoperative cholangiography of patients without preoperative suspicion of choledocholithiasis increases the cost of surgery, prolongs operative time, exposes the patient to radiation and sometimes yields false positives (5%) that lead to unnecessary exploration of the choledochus, which is accompanied by a potential increase in morbidity and a real prolongation of the postoperative hospital stay.