[Criteria for the extension of gastric and lymphatic resection in gastric cancer surgery]. / Criterios sobre la extensión de la resección gástrica y linfática en la cirugía del cáncer de estómago.

After a brief historical review where are pointed out the circuMstances of the first successful gastrectomy performed by Billroth (Billroth I), gastroenteroanastomosis by Wölfler, Wölfler and Roux in-Y anastomosis, Billroth II reconstruction and types and techniques of lymphadenectomies, it is exposed the author's experience over 927 gastric cancer, cardias included, explaining the surgical technique performed: gastrectomy according to size, tumor localization and D1 lymphadectomy, evaluating to perform a D2 during operation, obtaining an overlife of 56% after 5 years when tumor was only placed in the stomach, and only of 19% when N1 lymph-nodes where affected and 6% if invasion reached N2 group. Overlife of cardias cancer has moved between 11 and 20%. Some comments are made on the surgeon evaluation of the lymp-nodes afectation and on the advantages and disadvantages of performing a radical or standard lymphadenectomy.

Roux-en-Y syndrome after surgical treatment of alkaline reflux gastritis.

OBJECTIVE: to evaluate the possible existence of the so-called <> in a group of 21 patients who underwent surgery to correct postoperative alkaline reflux gastritis. METHODS: the study group consisted of 15 men and 6 women (mean age 39.2 years). All had undergone Billroth II subtotal gastrectomy (20 for ulcer and 1 for gastric cancer). Alkaline diversion was done with the Roux-en-Y technique 50-60 cm away from the gastrojejunal anastomosis. In all patients bilateral truncal vagotomy at the hiatus was also done. No mechanical alterations in the gastrojejunal anastomosis were found during surgery. Mean follow-up period was 8.2 years (range 6.5-10.7 years), during which clinical, radiological and endoscopic studies were obtained. Gammagraphic study of gastric remnant emptying was done on postoperative day 30. RESULTS: none of the patients had clinical, radiological or endoscopic manifestations that indicated the presence of Roux-en-Y syndrome. Gammagraphic studies of gastric remnant emptying did not demonstrate significant differences between preoperative (T1/2: 7.3 min) and postoperative values (T1/2: 10.1 min). CONCLUSIONS: we found no evidence of disturbances in gastric remnant emptying after Roux-en-Y gastrojejunostomy to treat postoperative alkaline gastric reflux.

Incisional hernias after laparoscopic vs open cholecystectomy.

BACKGROUND: The aim of this study was retrospectively to compare the incidence of incisional hernia formation at trocar sites in laparoscopic cholecystectomy with that after conventional open cholecystectomy. METHODS: In all, 271 patients with cholelithiasis underwent either laparoscopic cholecystectomy (LC group, n = 142) or open cholecystectomy (OC group, n = 129). In the OC group, the surgical approach was to use a right subcostal incision in 20.2%, right transrectal laparotomy in 73.6%, and midlaparotomy in 6.2%. Laparotomy closure was performed by continuous absorbable suture for the peritoneum and discontinuous absorbable stitches for muscle and fascia. Laparoscopic access was achieved by use of four trocars (two 10 mm and two 5 mm). Umbilical port closure was performed by suture of fascia using discontinuous stitches. Closure of the remaining ports was performed by suture of the skin. RESULTS: Both patient groups were statistically similar with respect to general risk factors. Follow-up was performed in 84 (65.1%) OC and 123 (86.6%) LC patients and ranged from 2 to 10 years (mean, 8 years) and 1 to 5 years (mean, 3 years) respectively. Five (5.9%) OC and two (1.6%) LC patients developed incisional hernias, although the difference between groups was not significant. All hernias in OC patients appeared after transrectal laparotomy. The LC hernias appeared at the umbilical port, and one of the patients developed an additional xiphoides port-associated hernia. CONCLUSIONS: The laparoscopic technique showed a lower (although not significantly) incidence of incisional hernias than the open procedure.

Changes in hemostasis after laparoscopic cholecystectomy.

BACKGROUND: The aim of this work was to study hemostasis in laparoscopic cholecystectomy in order to determine if there are any changes that indicate a greater risk of thrombosis. METHODS: The study was carried out in 20 patients who underwent laparoscopic surgery for noncomplicated cholelithiasis. The average age was 59.4 years (range, 34-77). A total of 75% were female. Mean operation time was 70 min (ranges 35-120). Pneumoperitoneum at 14 mmHg was performed on all patients, who were positioned in the 30 degrees reverse Trendelenburg position. Postoperative mobilization was acheived in 24 hs and patients were discharged 48 hs after the operation. The control group was composed of 12 patients, who were evenly distributed by age, sex, and length of surgery. These patients underwent Bassini herniorraphy for inguinal hernia without any complications or relapse. The following hemostatic parameters were studied: prothrombin activity (PA), activated partial thromboplastin time (APTT), fibrinogen (Fg), anti-thrombin III (ATIII), plasma fibrinolytic activity (PFA), euglobulin fibrinolytic activity (EFA), and D-dimer (D-D). Samples were obtained at the following times: (a) under basal conditions the day before surgery, (b) preoperatively, (c) at the end of the operation, (d) 24 hs after the operation, and (e) On the 7th day following the operation. RESULTS: No patient showed any clinical manifestations of thromboembolic disease immediately after surgery or during a medium follow-up period of 16 months (range, 15-18 months). All hemostatic parameters values were within normal range in the basal samples of both groups. In both groups, the mean value of PA showed a significant decrease (p < 0.05) in the second, third, and fourth basal samples, returning to normal levels by the fifth determination. The mean value of fibrinogen decreased slightly in the second and third samples, increasing significantly with respect to the fourth and fifth determinations in both groups (p < 0.05). The mean value of APTT in both groups was slightly enhanced in the second and third determinations in relation to the first and fifth. The global activity of fibrinolysis (PFA and EFA) increased significantly in the third sample with respect to the other determinations in the group who had laparoscopic surgery (p < 0.005). Only EFA increased in the control group (p < 0.05). D-D decreased in the preoperative second determination followed by a significant enhancement immediate postoperatively (third), and 24 hs (fourth) (p < 0.05); it returned to normal basal values on the seventh day. No significant differences were found between the two groups. CONCLUSIONS: These results indicate that laparoscopic cholecystectomy leads to no greater activation of plasma coagulation than low-risk surgery. On the contrary, the increase of fibrinolytic activity in plasma would extend a certain degree of hypocoagulability during surgery, maintaining it for 24 hs and thus possibly reducing thromboembolic risk in patients undergoing this type of surgery.

[Arterial grafts]. / Algunos comentarios sobre injertos arteriales.

After a historical review, pointing out the different types of grafts (tubes, veins, arteries, synthetic material), several haemodynamics facts are commented, that in author's opinion, are closely related with biological process of "neo-intima" development. Technical aspects are evaluated, including extra-anatomical by-pass, infection risk, and proposed solutions when run-off problems occurred when placing a graft, concluding with modern guidances when using this material, such as endotheliation, cryopreserved artery grafts, polyurethane and pyrolytic carbon grafts, negatively charged grafts, biodegradation prosthesis, laboratory artery development, small diameter grafts and endovascular surgery.

Fibrinolytic activity in laparoscopic cholecystectomy.

The aim of this study was to examine the fibrinolytic activity in laparoscopic cholecystectomy (LC) to determine whether changes occur that might indicate a greater risk of thrombosis. The study was carried out in 20 patients who had undergone laparoscopic surgery for cholelithiasis without complications. The average age was 59.4 years (34-77 years). Seventy-five percent were women. The mean operating time was 70 minutes (35-120 minutes). Pneumoperitoneum at 14 mm Hg was maintained in all patients, and they were in 30 degrees reverse Trendelenburg position. Postoperative mobilization was obtained before 24 hours, and patients were discharged 48 hours after surgery. The control group was composed of 12 patients, evenly distributed by age, sex, and length of surgery, who had undergone Bassini herniorrhaphy without complications or relapses. The following hemostatic parameters were studied: plasma fibrinolytic activity (PFA), euglobulin fibrinolytic activity (EFA), tissue-type plasminogen activator (t-PA), fast-acting plasminogen activator inhibitor-1 (PAI-1), and D-dimer (D-D). Samples were obtained at the following times: (1) under basal conditions the day before surgery, (2) preoperatively, (3) at the end of surgery, (4) 24 hours after surgery, and (5) on the seventh day following surgery. No patient had clinical manifestations of thromboembolic disease immediately after surgery or during an average follow-up period of 16 months (range 15-18 months). Analysis of the results of global fibrinolysis showed that fibrinolytic activity was enhanced only in the postoperative period (third sample) of the LC patients. The fraction of euglobulins enhances fibrinolytic activity in both groups in the third sample with regard to the other determinations; the LC patients showed a higher degree of significance (p<0.005). A significant increase of postoperative t-PA in both groups was found, being more significant in the LC group (p<0.005). In the PAI-1 values, no significant differences existed between either determinations or groups. A significant increase in D-dimer (p<0.05) occurred in the immediate postoperative period (third sample) and 24 hours later (fourth sample), returning to normal basal values on the seventh day. No significant differences were found between the two groups. These results seem to indicate that LC produces an increase in the fibrinolytic activity in plasma as a result of the liberation of tissue plasminogen activator from the venous endothelium, which could indicate hypocoagulability during the immediate postoperative period and, therefore, signify less thrombotic risk for patients undergoing this procedure.

[Anatomopathologic changes in the distal esophagus following proximal gastric vagotomy. Experimental study]. / Cambios anatomo-patológicos en el esófago distal tras la vagotomía gástrica proximal. Estudio experimental.

In order to determine the causes of postvagotomy dysphagia, we examined microscopic changes in the lower esophagus after a proximal gastric vagotomy. Forty dogs were divided into 4 groups (n = 10). Group I was used as control. In group II, the effect of denervation was studied by means of transthoracic vagotomy. In group III, the effect of mechanical traction of the lower esophagus was studied, without denervation or surgical manoeuvres. In group IV, the effect of denervation, esophageal traction and the surgical manoeuvres, of proximal gastric vagotomy was examined. No periesophageal hematomas or fibrosis was found. Degenerative nerve phenomena were found with no significant differences in the three groups. In groups III and IV, lesions of the esophageal muscular layer were observed, without significant differences. Chronic inflammatory changes and fibrosis were also encountered being more intense and significantly more frequent in group IV. We conclude that the surgical manoeuvers necessary to obtain denervation of the cardioesophageal function during proximal gastric vagotomy, could be responsible for the appearance of post-vagotomy dysphagia.

[Acute cholecystitis: an evaluation of the factors that determine the start of surgical treatment]. / Colecistitis aguda: valoración de los factores que condicionan el inicio del tratamiento quirúrgico.

The authors studied 100 acute cholecystitis treated between 1984 and 1990. In 71.4% of the cases it was associated with gallstones and 28.6% were primary acalculous cholecystitis. Two percent were postoperative. 77 patients underwent surgery. 14.3% needed an emergency operation due to acute abdominal syndrome and sepsis. In the remaining patients, the surgical procedure was performed days or weeks later according to the course of the disease, the surgeons criteria, and family and social-labour conditions. Based on these criteria, 31.7% had surgery during the first week, 23.8% in the second and 44.5% in the third or later. Cholecystectomy was the surgical procedure performed in 98.7% of the cases. Morbidity rate was 11.6% and mortality 3.9%. Analysis of morpho-clinical grades has been done in relation with the type of cholecystitis, the clinical symptoms and the course of the disease. Finally the different factors used to argue for an early or delayed surgical treatment are discussed.

[Ultrastructural study of the colon after massive intestinal resection in rats]. / Estudio ultraestructural del colon tras la resección intestinal masiva en ratas.

The modifications suffered by the colon after massive intestinal resection (RIM) have been barely studied, especially from the ultrastructural point of view. On the basis of optical microscope studies we planned this experimental study to evaluate fundamentally the ultrastructural changes in the colonic mucosa and its cellular elements. A total of 115 Wistar rats weighing 350 to 550 grams were used. Twenty animals constituted group 0 (controls), 30 underwent intestinal section (group I) and 65 were submitted to resection of 90% of the intestine (group II). After weighing, the animals were sacrificed by groups on days 15, 30, 45 and 60 of the operation to obtain histologic samples of the ascendant colon for study by transmission (MET) and scanning (MEB) electron microscopy. All the animals resected showed statistically significant weight loss (p less than 0.001), an expression of short intestine syndrome. Groups 0 (controls) and I (intestinal section) did not evidence important ultrastructural changes. In contrast, although in the initial electron microscopic scan the colonic mucosal surface offered a normal aspect, at 45 days it presented irregularities, without the appearance of villi. Days 60 there were deep folds and the mucosal surface had acquired a foliaceous aspect similar to that of the surface of the small intestine of the rat. The abundance of microorganisms adhered to the surface, constituting clumps of bacteria, was striking. Transmission electron microscopy confirmed the greater number and height of the enterocytes, covered by well-developed apical microvilli with dimensions that increased throughout the experiment. The cellular nuclei are voluminous and occasionally have various nucleoli. The cytoplasm showed changes that affected fundamentally the mitochondria.(ABSTRACT TRUNCATED AT 250 WORDS)