[Laparoscopic adrenalectomy. Lateral transabdominal tecnique "step by step" and analysis of 41 consecutive patients]. / Adrenalectomía laparoscópica. Técnica transabdominal lateral "paso a paso" y análisis de 41 pacientes consecutivos.

Since the initial report in 1992, laparoscopic adrenalectomy has proved substantial advantages over the conventional procedure in terms of decreased postoperative pain and hospital stay, allowing earlier return to normal activity. The technical details are in permanent evolution and the most widely accepted laparoscopic surgery for the adrenal gland is the transabdominal lateral approach. We hereby describe step by step the way we perform the lateral approach after 41 consecutive cases.

Adrenalectomía laparoscópica. Técnica transabdominal lateral “paso a paso” y análisis de 41 pacientes consecutivos / No disponible

Desde su descripción en 1992, la adrenalectomía laparoscópica ha demostrado ventajas sustanciales sobre la cirugía convencional en términos de dolor postoperatorio, estancia hospitalaria y retorno del paciente a su actividad sociolaboral cotidiana. Los detalles técnicos están en permanente evolución y el abordaje más aceptado en la actualidad es el transabdominal con el paciente en decúbito lateral. En esta revisión se describe paso a paso nuestro modo de realizar la técnica para hacerla más reproducible, a la luz de 41 casos intervenidos(AU)

Since the initial report in 1992, lapa-roscopic adrenalectomy has proved substantial advan-tages over the conventional procedure in terms of de-creased postoperative pain and hospital stay, allowing earlier return to normal activity. The technical details are in permanent evolution and the most widely accepted laparoscopic surgery for the adrenal gland is the transabdominal lateral approach. We hereby describe step by step the way we perform the lateral approach after 41 consecutive cases(AU)

Pancreatitis crónica autoinmune: una entidad de difícil diagnóstico diferencial / Chronic autoimmune pancreatitis: an entity of difficult differential diagnosis

No disponible

Clinical value of CEA and CA125 regarding relapse and metastasis in resectable non-small cell lung cancer.

BACKGROUND: The aim of the present study was to evaluate the value of serum Carcinoembryonic Antigen (CEA) and CA125 antigen assay for monitoring the activity of non-small cell lung cancer (NSCLC) after curative surgical resection. PATIENTS AND METHODS: Serum CEA and CA 125 were determined preoperatively and at every postoperative visit, in 113 patients with NSCLC (TNM stages I, II, IIIA). Both markers were assayed by magnetic particle enzyme immunoassay. RESULTS: Tumor recurrence was more frequent in patients with preoperative CA 125 levels above the cut-off (15 U/ml) (28 out of 47) (59.5%) than in those with low values (18 out of 66) (27.2%) (p < 0.001). The 36-month disease-free survival was lower for patients with elevated CA 125 (37%) than among those with low levels (72%) (p = 0.006). High CA 125 was an independent predictor of the risk of postoperative recurrence (Hazard Ratio: 3.02)(95% CI: 1.41-6.49). No relationship was detected between preoperative serum CEA and risk of recurrence. High preoperative CA125 indicated elevated risk for disseminated recurrence (Hazard Ratio: 7) (95% CI: 2.39-20.51), but not for locoregional failure. No significance was detected for CEA, either in locoregional or disseminated recurrence. Forty-six subjects (40.7%) developed tumor recurrence. At the diagnosis of relapse, serum CEA was elevated in 16 patients (34.7%) and CA125 in 26 (56.5%). Sensitivity was higher in the case of disseminated recurrence (63% for CA125 and 43.3% for CEA) and decreased in locoregional relapse (43.7% for CA125 and 18.7% for CEA). The specificity was 97% for CEA and 59% for CA125. CONCLUSION: Serum CA125 is a useful prognostic marker in NSCLC. The predictive information is especially useful to estimate the risk of disseminated recurrence. Serial determinations of CEA and CA125 during the postoperative follow-up do not show enough sensitivity/specificity to recommend their use for diagnosis of tumor relapse.

Intraductal pancreatic carcinoma associated with pancreas divisum.

OBJECTIVE: we report the case of a 36 years old man with a pancreatic cancer associated to a pancreas divisum presenting as acute and relapsing recurrent pancreatitis. The coexistence of intraductal carcinoma and pancreas divisum is uncommon as let us do analyze its clinical, radiological and therapeutical features. CONCLUSIONS: 1. Pancreatic duct obstruction and pancreas divisum as congenital anomaly may be consider potential etiologies for pancreatic cancer. 2. Widespread use of magnetic resonance xholangiopancreatography and endoscopic retrograde xholangiopancreatography examinations together with brush cytology smears will allow more accurate approach to tumor diagnosis and management. 3. The use of pancreatoscopy in patients suffering from chronic pancreatitis may reveal helpful to discover intraductal neoplasms otherwise misdiagnosed.

Carcinoma pancreático intraductal asociado con páncreas divisum / Intraductal pancreatic carcinoma associated with pancreas divisum

Objetivo: presentar un caso de páncreas divisum con episodios recurrentes de pancreatitis aguda en el seno de una pancreatitis crónica, asociado a un carcinoma intraductal. La incidencia infrecuente de esta asociación sirve de vehículo para la discusión de la misma y exposición de sus parámetros diagnósticos y terapeúticos. Conclusiones: 1. La obstrucción del conducto pancreático y el páncreas divisum como alteración anatómica congénita puede ser un factor predisponente para la aparición de un carcinoma de páncreas.2. El empleo de la resonancia magnética nuclear y la colangiopancreatografía retrógrada endoscópica como pautas diagnósticas de imagen, y la utilización de la citología por cepillado permiten un diagnóstico diferencial y aproximan una pauta terapéutica correcta.3. Probablemente el empleo de la pancreatoscopia de manera habitual en pacientes con pancreatitis crónica pueda diagnosticar este tipo de tumores intraductales inadvertidos para otros procedimientos diagnósticos (AU)

Time-dependency of the prognostic effect of carcinoembryonic antigen and p53 protein in colorectal adenocarcinoma.

BACKGROUND: This study examined the prognostic information regarding the risk of postoperative tumor recurrence obtained by simultaneous determination of preoperative serum carcinoembryonic antigen (CEA) and immunohistochemical expression of p53 protein in tumor tissue from patients with colorectal carcinoma. METHODS: A retrospective study of 174 patients (AJCC/UICC Stages I, II and III) was conducted. Serum CEA levels were determined by an enzyme-linked immunoadsorbent assay. Immunohistochemical expression of nuclear p53 protein was assessed in formalin fixed, paraffin embedded archival tumor tissue. The results of both factors were categorized by clinical and histopathologic variables. The relative prognostic significance of all factors with regard to disease free survival was assessed by Cox proportional hazards regression analysis. The stability of the predictive value of both markers was assessed: 1) by splitting the follow-up into three intervals and performing separate analyses for each period and 2) graphically by plotting the corresponding cumulative hazards ratio along the follow-up. RESULTS: Eighty-two (47%) tumors manifested overexpression of p53 protein and 60 tumors (34.4%) exhibited elevated serum CEA levels (cutoff value of 5 ng/mL). p53 positive immunostaining and elevated CEA levels were associated with low cumulative disease free survival at 60 months' of follow-up, and proved to have independent prognostic significance. Analysis performed in different time periods of follow-up showed that the prognostic effect of both markers was not stable over time. The predictive significance of CEA and p53 changed along the study periods. An elevated preoperative CEA level was an indicator of a high risk of recurrence only during the first 2 years after surgery (hazards ratio, 3.26; 95% confidence interval 95% CI, 1.65-6.42). The presence of p53 immunoreactivity in the primary tumor was an indicator of a high risk of recurrence only after the first year of follow-up (hazards ratio, 4.02; 95% CI, 1.68-9.6). CONCLUSIONS: The serum CEA level and expression of p53 protein provide complementary prognostic information. Time-dependency of the prognostic influence of both parameters should be taken into consideration when establishing postoperative predictive estimations.

Clinical, histopathological, cytogenetic and prognostic differences between mucinous and nonmucinous colorectal adenocarcinomas.

OBJECTIVE: To assess the clinical and biological significance of histological typing of colorectal carcinomas. PATIENTS AND METHODS: The retrospective analysis of 142 consecutive patients who underwent surgical resection of a mucinous (MC; n = 27; 19%) or a nonmucinous (nMC; n = 115; 81%) colorectal adenocarcinoma was carried out. The two groups were compared in terms of the clinical features, p53 gene expression (antiserum CM1), proliferating cell nuclear antigen (PCNA) labeling index, DNA ploidy (by flow cytometry), histopathological features, prognosis and recurrence rate. RESULTS: The two types of tumors differed with respect to patient age, location, morphology, pattern of genetic lesions and type of tumor recurrences. Twenty-five percent of the patients with MC and 9% of those with nMC (p = 0.04) were under 50 years of age. The incidences of right MC and left MC were similar, while the majority of the nMC were located on the left side (p = 0.04). The MC were of higher grade and their margins more infiltrative than those of the nMC (p = 0.001 and p = 0.01, respectively), p53 nuclear staining was observed less frequently in the MC than in the nMC (30% vs 55%; p = 0.03). The PCNA labeling index was higher in the nMC (46% vs 21%; p = 0.05). We observed no significant differences with respect to tumor stage, incidence of vascular invasion or prevalence of lymphocytic infiltration. The prognosis was similar in both groups, although their recurrence patterns differed, with a tendency toward locoregional recurrence in the cases of MC. CONCLUSION: These findings suggest that, despite their similar prognoses, these two types of lesions are epidemiologically, phenotypically and genotypically different and, thus, result from distinct carcinogenic pathways.

Pouch excision for recurrent serrated adenomas following restorative proctocolectomy for juvenile polyposis: report of a case.

PURPOSE: The study contained herein was undertaken to report the case of a patient with juvenile polyposis in whom multiple and rapid recurrence of mixed polyps, with progressive predominance of the adenomatous component, developed in a diverted ileoanal pouch. METHODS: The case of this patient with juvenile polyposis was reviewed. Despite regular surveillance and polypectomies, extensive and multiple recurrences of serrated polyps developed. RESULTS: Because the pouch was never cleared of polyps, a compromise to remove the pouch was decided on. Such a case has not been reported previously. CONCLUSION: Mixed juvenile polyposis may affect any level of the gastrointestinal tract. The ileal pouch and any rectal remnant may incidentally need surgical excision.

The value of Hughes-Cardiff classification in the management of perianal Crohn's disease.

PURPOSE: The aim of this study was to assess the value of Hughes' pathogenic classification in the prognosis and management of perianal Crohn's disease (CD). PATIENTS AND METHODS: This classification differentiates between purely inflammatory lesions and their mechanical or septic complications, and defines the presence of ulceration (U), fistula (F) and stricture (S), which are assigned a score of 0, 1 or 2 according to the severity and associated conditions, proximal intestinal involvement and disease activity (A, P and D). Of a series of 96 patients with CD, 12 underwent 16 procedures involving anesthesia to treat symptomatic anal lesions. Patients presenting with severe pain were explored and treated by surgical drainage or, in cases in which there was no demonstrable sepsis, by gentle dilation or infiltration with steroids. For superficial, non-specific fistulas, conventional fistulotomy was performed, and long-term seton drainage was implanted for complex fistulas. Strictures were treated by gentle dilation. Uncontrolled sepsis or proctocolitis was managed by proximal stoma creation or proctocolectomy. RESULTS: The association of cavitating ulcers (U2) and contiguous active rectal involvement (P1) was a contraindication for rectal preservation, making proctectomy or stoma creation the most feasible therapeutic option. The etiology of most, but not all, complex fistulas (F2) was the progressive cavitation of U2, whilst F1 was either of cryptoglandular origin or the result of epithelialized fissures (U1). The treatment was also adjusted to this association, and it was confirmed that most of the severe lesions (F2) and S2) were secondary to U2. CONCLUSIONS: Hughes' pathogenic classification: 1) makes it possible to set up an easily stored registry of anal and perianal Crohn's disease; 2) identifies predefined lesions, allowing the individualization of therapeutic procedures and the comparison of results, and 3) provides prognostic information.

Medical factors in the morbidity and mortality associated with emergency colorectal cancer surgery.

OBJECTIVE: To review the results of the analysis and quantification of the influence of medical factors on the morbidity and mortality associated with emergency surgery for colorectal cancer. PATIENTS AND METHODS: We analyze retrospectively the data for 51 patients who underwent emergency surgery: 34 (67%) to treat acute obstruction and 17 (33%) for perforation. The median follow-up period was 18.5 months (3 to 62 months). RESULTS: The main tumor was located in the right colon in 13 patients (25%), in the left colon in 35 (69%) and in, the rectum in 3 (6%). Primary resection was performed in 94% of the patients: without anastomosis in 35% (18 of 51) and with primary anastomosis in 59% (30 of 51); 6% of the tumors were not resectable. The postoperative morbidity was 41%: 29% (10 of 34) occurring in obstructions and 65% (11 of 17) in perforations. The mortality rate was 14% (9% and 23%, respectively). There were statistically significant associations between mortality and the American Society of Anesthesia grading (p < 0.01) and between both the mortality and morbidity and the score for the acute physiology component of APACHE II (p = 0.01, respectively) and the total APACHE II score (p < 0.01 in both cases). The rate of actuarial disease-free survival was 26% at 36 months. Overall survival was 15% at 62 months. A recurrence rate of 48% (14 of 29) has been recorded. CONCLUSIONS: Emergency surgery for colorectal cancer is associated with a high postoperative morbidity and mortality rate, which correlate with the medical status and, particularly, with the acute physiology score of the APACHE II risk stratification system.

[A comparative study on the prognostic value of the nuclear expression of protein p53 vis-à-vis histopathology in colorectal cancer]. / Estudio comparativo sobre el valor predictivo de la expresión nuclear de la proteína p53 frente a la histopatología en el cáncer colorrectal.

OBJECTIVE: To determine the predictive value of p53 nuclear overexpression in comparison with established prognostic pathological features in colorectal adenocarcinoma. PATIENTS AND METHODS: 61 patients operated on for cure between January 1989 an December 1991 were included. Expression of p53 protein was examined by immunohistochemistry in paraffin-embedded sections. Tumor localization, depth of bowel wall involvement, lymph nodes metastasis, vascular invasion and PCNA Labelling index were studied in all patients. RESULTS: Nuclear staining was detected in 27 (44.2%) cases. Positivity was more frequent in tumors with venous invasion and in rectal cancer. p53-positive tumours exhibited a higher likelihood of relapse and lower survival. After adjustment for the other covariates, p53 overexpression was the only factor showing independent prognostic significance on the risk of recurrence. None of the factors analysed evinced independent significant relationship with the risk of death. CONCLUSION: Nuclear p53 protein overexpression is closely related to the development of postoperative recurrences and has higher predictive value than standard pathological variables.

[Perioperative blood transfusion and prognosis in colorectal cancer. Analysis of a series]. / Transfusión de sangre perioperatoria y pronóstico en el cáncer colorrectal. Análisis de una serie.

The relationship between survival after surgical resection of colorectal carcinoma, and perioperative blood transfusion was studied retrospectively. "Curative" surgery was performed in 164 cases of colorectal cancer--stages B and C--, 72 of them received red-cell concentrates perioperatively. Multiple regression analysis did not show any deleterious effect of blood transfusion on the survival of the surgically treated patients (P = 0.941). The volume of the blood derivative received neither seems to influence their outlook. As it was expected a higher rate of transfusion occurred among rectal cancer patients. Mechanisms and factors involved in this controverted issue are discussed and literature is widely reviewed.

Atypical hepatic tuberculosis presenting as obstructive jaundice.

A 78-yr-old female with a short history of malaise, anorexia, mild pyrexia, and obstructive jaundice is presented. A diagnosis of tuberculosis of the liver and gallbladder was established at laparotomy. In spite of anti-tuberculous therapy, the patient died on the 5th postoperative day. Widespread miliary tuberculosis affecting the lung, kidneys, spleen, and mesenteric lymph nodes was observed in postmortem studies, with strikingly severe involvement of the intrahepatic bile ducts. Saccular dilatation of the bile ducts alternating with areas of stenosis and narrowed intrahepatic bile ducts was seen. A correlation of the radiological and hepatic postmortem findings is discussed. The atypical presentation of tuberculosis in present times and the causes of jaundice in atypical cases of hepatic tuberculosis are discussed. The rarity of gallbladder tuberculosis is pointed out.