[Experience in surgical management of rectal prolapse in two hospitals in Mexico City]. / Experiencia del tratamiento quirúrgico del prolapso rectal en dos hospitales de tercer nivel en la ciudad de México.

BACKGROUND: Rectal prolapse is defined as a falling out of place of the rectum through anus. Surgery is the treatment of choice to reverse abnormal anatomy and to improve anorectal function. OBJECTIVE: To review the experience in recent years of surgical management of rectal prolapse in the Hospital Central Militar and Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubiran. METHODS: All patients with rectal prolapse who underwent surgical treatment between January 1993 through December 2008 at two institutions in Mexico City were included. Clinical information was obtained of the clinical files in both hospitals. Main study variables were age, sex, degree of prolapse, morbility and type of surgery performed. RESULTS: Fifty seven patients were included, predominantly female (59.6%) with a mean age of 45 years. The most frequent diagnosis was complete rectal prolapse. Fifteen patients (26%) were treated by perineal procedure and 42 (74%) through abdomen: 17 (40%) open and 25 (60%) laparoscopic. Morbidity rate was lower in the laparoscopic group with less length of hospital stay and a lower blood loss, but with higher recurrence rate. CONCLUSIONS: Although the laparoscopic surgery showed advantage related with a less morbility, blood loss and hospital stay, it showed higher recurrence rates."

Prevalence and clinical features of indeterminate colitis in Mexico: a 17-year study.

BACKGROUND: Indeterminate Colitis (IC) is diagnosed after colectomy when macroscopic and microscopic features were not sufficient to allow a definite diagnosis of either the classical types of Ulcerative Colitis (UC) or Crohn's disease (CD). Epidemiological data from some series have reported that IC is diagnosed in between 9% and 20% of colectomy specimens. AIM: To determine the prevalence of IC in Mexican patients and to describe their clinical features. MATERIAL AND METHODS: We carried out a retrospective database analysis of all patients diagnosed with inflammatory bowel disease (IBD) who underwent colectomy between January of 1990 and December of 2006. Demographic data, clinical, laboratory, and histopathological results were analyzed. RESULTS: We found 80 patients in the database who had undergone total colectomy whose average age was 44.8 years. IC was found in 7 patients (8.7%) from colectomy specimens among Mexican patients with IBD, with a mean age at diagnosis of 33.6 years. Subgroup analysis showed that a younger age at diagnosis and toxic megacolon were factors of statistical significance associated with IC. CONCLUSIONS: The prevalence of IC was 8.7% in our group. A younger age of onset and toxic megacolon were the most important associated factors in patients with IC.

[Synchronous diverticulitis: a case report.]. / Diverticulitis sincrónica: informe de un caso.

Diverticular colonic disease is not as common in developing nations as in western and industrialized societies, accounting for approximately 130 000 hospitalizations per year in the United States, being diverticulitis the most frequent complication. Synchronous presentation of this complication is very rare, with only one case reported in literature. We present a patient who presented with diffuse abdominal pain. Colonoscopy was performed identifying a mass in the sigmoid colon and a perforation in the cecum. Patient underwent total abdominal colectomy with ileorectal anastomosis and protective loop ileostomy. Histopathologic examination revealed synchronous complicated diverticular disease of the sigmoid and cecum. In this report we disclose this type of atypical presentation of diverticular disease and establish that the approach taken is safe and feasible.

[Pelvic angiomyxoma. A case report from National Institute of Medical Sciences and Nutrition, Salvador Zubiran.]. / Angiomixoma pélvico. Informe de un caso en el Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán.

An angiomyxoma is a pelvic neoplasia compound of myofibroblasts. This is a case report of a 41 years old female patient, who presented with a painful, pelvic mass, identified by a tomography with malignant characteristics. Total surgical excision was performed and coursed with good evolution time.

[Hereditary non-polyposis colorectal cancer associated with hereditary gastric cancer. A case report.]. / Cáncer colorrectal hereditario no polipósico asociado a cáncer gástrico hereditario. Informe de un caso.

The information regarding the association of gastric cancer and type 2 Lynch syndrome is limited. Previous studies have reported that both entities may be present in the same individual in less than 5% of the cases. The most frequent form of hereditary colorectal cancer is the Lynch syndrome or Hereditary Non-polyposic Colorectal Cancer, which is associated with germ-line mutation mostly of two genes, MLH1 and MSH2, which account for almost 90 percent of all identified mutations. The hereditary diffuse gastric cancer syndrome is caused by a germ-line mutation in the E-cadherin (CDH1) gene; only about 50 families with this syndrome have been reported. We present a case report of a patient who was diagnosed with both syndromes.

[Factors associated with survival in liver resection for metastatic colorectal carcinoma]. / Factores asociados a superviviencia en la resecciónhepática por metástasis de cáncer de colon y recto. Experiencia en el Instituto de Ciencias Médicasy Nutrición "Salvador Zubirán".

BACKGROUND: The liver is the organ in which often metastasize primary tumors. Knowledge of the etiology and forms of presentation of metastatic disease is key to deciding on the different treatment options. OBJECTIVE: Describe the surgical management of liver metastases in colorectal cancer and factors that affect the survival of patients. PATIENTS AND METHODS: We reviewed 43 cases of patients with metastatic liver cancer of the colon or rectum, who underwent liver surgery, attended January 1990 to December 2007. We analyzed demographic variables and perioperative associated with the survival of patients. There was the course and type of postoperative complications as well as the direct causes of mortality. RESULTS: Were conducted mostly metastasectomies (n = 25), followed by right hepatectomy (n = 9),and left hepatectomy (n = 9). Surgical mortality was 4.6% (n = 2). The survival rate at 1, 3 and 5 year were 45% (18 patients), 42.5% (18 patients)and 12.5% (5 patients), respectively. The presence of a single metastatic lesion (p = 0.006), size of the lesion larger than 5 cm (p = 0.003), positive lymph nodes (p = 0.002), synchronous tumor (p = 0.04),presence of extra hepatic disease (p = 0.01), positive margin (p = 0.001) and blood loss >2000 mL were significantly associated with a lower survival rate. CONCLUSION: After hepatic resection for metastatic colorectal cancer the presence of more than one tumor, > of 5 cm, with presence of synchronous tumor, nodes and positive margins, extra hepatic disease, as well blood loss > 2000 mL are factors associated with a worse survival.

[Laparoscopic colorectal surgery: third level center experience.]. / Cirugía colorrectal laparoscópica:experiencia en un centro de tercer nivel.

BACKGROUND: The role of laparoscopic surgery in the management of colorectal pathologies is steal unclear. Some new evidence has shown some advantages over open procedures. Because it is a technically demanding procedure, the progress is very low, and used among few colorectal surgeons. OBJECTIVE: To describe the experience of laparoscopic colorectal surgery in a third level referral center, in a fourth year period. We analyzed short and median outcomes, for benign and malignant diseases. MATERIAL AND METHODS: A retrospective review of all colorectal laparoscopic procedures was analyzed in a period between June 2003 and July 2007. Procedures for benign and malignant diseases were included. RESULTS: One hundred and seventy cases were included, 52 (30%) for malignant and 118 (70%)for benign diseases. The main indication for surgery was diverticular disease followed by colorectal cancer and the most common procedure was sigmoidectomy followed by right colectomy. Conversion rate was 8.8% (15 patients) and overall morbidity and mortality were 12%, and less than 1% respectively.Oncologic results were evaluated with a median follow up of 2 years, for a loco regional recurrence rate of 6%. Mean number of nodes retrieved in the pathologic specimen were 15.69 (+/- 3.53). All malignant cases had negative margins. CONCLUSIONS: Laparoscopic colorectal procedures are safe and feasible, in large volume centers showing equivalent results when comparing with open procedures evidenced in world literature,about results of oncologic cases, due to the short follow up period we can t conclude about oncologic outcomes.

Laparoscopic total proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis: initial experience in Mexico.

BACKGROUND: Since the introduction of laparoscopic colectomy in 1991, experience in laparoscopic bowel surgery has gradually increased. Several reports from specialized centers have demonstrated that laparoscopic colorectal resections are feasible and safe, providing an acceptable alternative to laparotomy for a variety of diseases. Some studies have shown the feasibility, safety, and good functional outcome of the minimally invasive procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). No known studies have investigated laparoscopic proctocolectomy in México. This report aims to describe the first laparoscopic proctocolectomies with ileal pouch anal anastomosis (IPAA) performed at the Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubirán (INCMNSZ). METHODS: All the patients in the authors' institution who underwent a one- or two-stage laparoscopic total proctocolectomy with IPAA between June 2005 and December 2006 were included in the study. All the operations were performed by the same surgeon, who had already completed the learning curve for colorectal laparoscopic procedures. RESULTS: For the study, 10 patients underwent a laparoscopic proctocolectomy with IPAA by a single surgeon. Eight of the patients underwent a one-stage procedure, whereas two patients with severe colitis underwent a two-step procedure. All the cases were managed with a diverting loop ileostomy. Six patients underwent a standard double-stapled IPAA anastomosis, and two patients with FAP underwent a mucosectomy with a manual IPAA anastomosis. The mean operative time was 187 min, and the mean blood loss was 46 ml. There were two postoperative complications. One patient presented with an early small bowel obstruction due to an internal hernia, which required reoperation. The other complication was a wound infection. The mean return to oral intake was 1.5 days, and the mean length of hospital stay was 3.4 days. CONCLUSION: Although this was not a comparative study and although sample size imposed limitations, with this preliminary data, we conclude that the laparoscopic approach to UC and FAP at our institution is safe, feasible, and effective. However, to achieve the benefits in postoperative outcome, this procedure should be performed only by experienced laparoscopic surgeons.

Nocardia otitidiscaviarum (GAM-5) induces parkinsonian-like alterations in mouse.

Parkinson's disease, a major neurodegenerative disorder in humans whose etiology is unknown, may be associated with some environmental factors. Nocardia otitidiscaviarum (GAM-5) isolated from a patient with an actinomycetoma produced signs similar to Parkinson's disease following iv injection into NMRI mice. NMRI mice were infected intravenously with a non-lethal dose of 5 x 10(6) colony forming units of N. otitidiscaviarum (GAM-5). Fourteen days after bacterial infection, most of the 60 mice injected exhibited parkinsonian features characterized by vertical head tremor, akinesia/bradykinesia, flexed posture and postural instability. There was a peak of nocardial growth in the brain during the first 24 h followed by a decrease, so that by 14 days nocardiae could no longer be cultured. At 24 h after infection, Gram staining showed nocardiae in neurons in the substantia nigra and occasionally in the brain parenchyma in the frontal and parietal cortex. At 21 days post-infection, tyrosine hydroxylase immunolabeling showed a 58% reduction of tyrosine hydroxylase in the substantia nigra, and a 35% reduction of tyrosine hydroxylase in the ventral tegmental region. Dopamine levels were reduced from 110 +/- 32.5 to 58 +/- 16.5 ng/mg protein (47.2% reduction) in brain from infected mice exhibiting impaired movements, whereas serotonin levels were unchanged (191 +/- 44 protein in control and 175 +/- 39 ng/mg protein in injected mice). At later times, intraneuronal inclusion bodies were observed in the substantia nigra. Our observations emphasize the need for further studies of the potential association between Parkinson's disease or parkinsonism-like disease and exposure to various nocardial species.

Nocardia otitidiscaviarum (GAM-5) induces parkinsonian-like alterations in mouse

Parkinson's disease, a major neurodegenerative disorder in humans whose etiology is unknown, may be associated with some environmental factors. Nocardia otitidiscaviarum (GAM-5) isolated from a patient with an actinomycetoma produced signs similar to Parkinson's disease following iv injection into NMRI mice. NMRI mice were infected intravenously with a non-lethal dose of 5 x 10(6) colony forming units of N. otitidiscaviarum (GAM-5). Fourteen days after bacterial infection, most of the 60 mice injected exhibited parkinsonian features characterized by vertical head tremor, akinesia/bradykinesia, flexed posture and postural instability. There was a peak of nocardial growth in the brain during the first 24 h followed by a decrease, so that by 14 days nocardiae could no longer be cultured. At 24 h after infection, Gram staining showed nocardiae in neurons in the substantia nigra and occasionally in the brain parenchyma in the frontal and parietal cortex. At 21 days post-infection, tyrosine hydroxylase immunolabeling showed a 58 percent reduction of tyrosine hydroxylase in the substantia nigra, and a 35 percent reduction of tyrosine hydroxylase in the ventral tegmental region. Dopamine levels were reduced from 110 ± 32.5 to 58 ± 16.5 ng/mg protein (47.2 percent reduction) in brain from infected mice exhibiting impaired movements, whereas serotonin levels were unchanged (191 ± 44 protein in control and 175 ± 39 ng/mg protein in injected mice). At later times, intraneuronal inclusion bodies were observed in the substantia nigra. Our observations emphasize the need for further studies of the potential association between Parkinson's disease or parkinsonism-like disease and exposure to various nocardial species.

Antipsychotic drugs and obesity: is prolactin involved?

OBJECTIVES: To correlate the anthropometric indexes (Body Mass Index [BMI] and Waist-Hip ratio [WHR]) with the serum prolactin levels in a heterogeneous population of patients treated with typical antipsychotic (AP) drugs. METHODS: We evaluated BMI, WHR, and fasting serum prolactin of inpatients (n = 105) and outpatients (n = 122) treated with APs, in outpatients receiving other psychotropic drugs (OPDs) (n = 77), and in drug-free subjects (n = 33). Outpatients had free access to food, whereas the inpatient sample comprised people with a monotonous diet of approximately 2000 Kcal daily. RESULTS: Prolactin correlated positively with the BMI in the whole group of AP-treated outpatient men (P = 0.03) and with the WHR in AP-treated inpatient men (P = 0.053). Regarding treatment duration, prolactin and BMI correlated positively in men consecutively treated for more than 1 year (P = 0.023). By contrast, a trend toward a negative correlation between prolactin and BMI was observed in AP-treated outpatient women (P = 0.08). No significant correlation, or even a trend, was observed in the other groups. CONCLUSIONS: Prolactin may be involved in AP-induced weight gain, particularly in men. Future studies should characterize the period of maximal prolactin impact on body weight during AP treatment. Specific populations particularly sensitive to hyperprolactinemia might be identified as well. The negative correlation between prolactin and BMI detected in AP-treated women resembles the dampened prolactin response observed in severe primary obesity.

Medial prefrontal transection enhances social interaction. II: neurochemical studies.

Medial prefrontal cortex (MPFC) transection enhances social interaction in an open arena test. Social interaction enhances dopaminergic activity in the nucleus accumbens (NAC). In the present set of experiments, microdialysis probes were implanted in the NAC, and glutamate, gamma-aminobutyric acid (GABA) and dopamine (DA) were measured during electrical stimulation of the MPFC, after coronal transection caudal to the MPFC and after a systemic injection of amphetamine in transected rats. Electrical stimulation of the MPFC caused a transient enhancement of glutamate release in the NAC, no change in GABA levels and a long lasting increase in DA levels. Medial prefrontal transection did not change basal glutamate or GABA levels in the NAC, but increased basal DA levels. Amphetamine administration decreased GABA levels in medial prefrontal transected rats, had no effect on glutamate and increased DA levels more than in controls. The experiments suggest that glutamatergic activity in the accumbens decreases dopamine release. Medial prefrontal transection reduces glutamatergic tone and enhances dopamine release, which probably decreases GABAergic activity in the NAC. Presumably, GABA inhibition in the NAC enhances social interaction.

Mechanism of the neuroleptic-induced obesity in female rats.

1. Obesity is an undesirable side effect of neuroleptics which affects 50% approximately of patients under a program of chronic administration. 2. An animal model of neuroleptic-induced obesity and hyperphagia has been developed in female rats treated chronically with sulpiride (20 mg/Kg/ip. for 21 days). However, it is unknown whether or not the hyperphagia is essential for the development of this type of obesity. 3. Sulpiride or vehicle was administered in two experimental conditions: in the first one, food was available in an amount which was three times the previous individual daily food intake; in the second one, the daily food provision was maintained at the individual daily average before starting the treatments. This way hyperphagia was prevented in half of the groups. Besides the body weight gain measurement in all the groups, the serum levels of estradiol, prolactin, glucose and lipids were assessed in the groups with unrestricted food intake. 4. Food restriction prevented the sulpiride-induced weight gain, even though the rats displayed a permanent diestrus which suggests an hyperprolactinemia-induced impairment in the balance of the reproductive hormones that may promote weight gain. However, the basal levels of estradiol were not affected by sulpiride. 5. The high density cholesterol was significantly increased by sulpiride, and the serum glucose levels were significantly decreased, however these changes were only detected during the first week of treatment. 6. The decrease in the serum glucose levels may be an early consequence of hyperinsulinemia. 7. Neuroleptic-induced obesity in rats appears to mimic energy intake, endocrine status and carbohydrate metabolism in humans under chronic neuroleptic administration. However, these rodents did not display the typical changes in blood lipids observed in human obesity.

Effects of lithium carbonate on reproductive hormones in healthy men: relationship with body weight regulation--a pilot study.

1. To test the hypothesis that lithium-induced body weight gain is related to an unbalance in the reproductive hormones, lithium carbonate (900 mg/day) or placebo was administered to healthy men for 1 month. 2. Body weight, skin folds and the serum levels of thyrotropic hormone, tetraiodothyroxine, prolactin, follicle-stimulating hormone, luteinizing hormone, testosterone (T5), dehydroepiandrosterone sulfate (DHEAS), estradiol (E2), cortisol, the ratios E2/T5 and T5/DHEA-S, and blood lipids were evaluated before and during treatment. 3. Body weight, skin folds, hormones and lipids serum levels were not significantly affected by the treatment with Li. These results agree with previous reports of lack of effects of 1 month-Li administration on appetite and body weight in normal male subjects (Chen et al., 1992), and question the appropriateness of studying Li-induced obesity in healthy volunteers, given the short-term administration and low doses of Li that must be used.

Changes in dopamine and acetylcholine release in the rat lateral hypothalamus during deprivation-induced drinking.

Neurochemical changes in the rat lateral hypothalamus during drinking were assessed in 20 min sampling intervals, using in vivo brain microdialysis. Water-deprived animals drank (11 +/- 1 ml) during the hour that water was available. Drinking was maximal (7.8 +/- 0.7 ml) during the first 20 min after water presentation and minimal during the last 20 min (0.5 +/- 0.4 ml). There was a local enhancement in DA turnover evidenced by an increase in the extracellular levels of dopamine (DA) (155 +/- 47% during the second sample after water presentation as compared to predrinking levels) and dihydroxyphenyl acetic acid (DOPAC) (132 +/- 9.7% in the sample that followed water removal). There was also an initial increase in the acetylcholine (ACh) release (145.1 +/- 21.7%) during the first 20 min after water presentation followed by a reduction (50.12 +/- 18%) 20 min later. These changes are congruous with previously published results suggesting that both neurochemical systems are involved in the regulation of water intake. Considering that the exogenous administration of cholinergic drugs in this hypothalamic area elicits drinking, the initial increase in ACh release could be interpreted as one of the neurochemical events driving this behavior. Since the local blockade of D2 receptors has been shown to result in drinking the progressive increase in DA turnover detected in this study, as well as the concomitant reduction in ACh release, could be involved in drinking attenuation.

Amantadine in the treatment of neuroleptic-induced obesity in rats: behavioral, endocrine and neurochemical correlates.

The efficacy of the antiviral agent Amantadine (AM, 5-100 mg/kg/sc, ip or intrahypothalamically, 12.5-100 micrograms bilaterally) in influencing body weight and food intake in drug-free rats, and in preventing neuroleptic-induced weight gain, was assessed in adult female rats. In drug-free rats, acute administration of systemic AM or directly injected in the lateral hypothalamus (LH) displayed a significant dose-dependent anorectic effect (p < 0.001). This effect could be mediated by the brain monoaminergic system, because systemic or local injections of AM increased dopamine and serotonin overflow in the nucleus accumbens and in the LH. Chronic administration of AM significantly decreased body weight gain in drug-free rats only at the dose of 100 mg/kg/sc. Similarly, obesity induced by the neuroleptic drug sulpiride (SUL, 20 mg/kg/ip for 21 days) was prevented by AM only at the dose of 100 mg/kg. AM did not prevent SUL-induced hyperprolactinemia, disruption of the vaginal cycle and a decrement in the weight of the uterus and ovaries at any dosage. This lack of efficacy of AM contrasts with that of bromocriptine, which completely prevented SUL-induced weight gain and hyperprolactinemia. The results show that despite a potent acute anorectic effect, AM displays a weak antagonistic action on SUL-induced obesity in rats, in contrast to the preliminary results obtained in humans. As AM metabolism differs in humans and rats, additional research is needed before its systematic testing in counteracting neuroleptic-induced obesity in patients with mental disorders.

Effects of the antipsychotic drug sulpiride on reproductive hormones in healthy men: relationship with body weight regulation.

Metabolic and endocrine abnormalities secondary to hyperprolactinemia, particularly hypogonadism, may be involved in the excessive body weight gain observed during treatment with antipsychotic drugs. The present study was conducted in healthy men in order to detect an endocrine imbalance secondary to antipsychotic drug administration, which, if sustained in the long term, might be involved in the development of obesity. Sulpiride (200 mg daily for 30 days) or placebo was nonblindly administered, and body weight gain was correlated with the serum levels of prolactin, luteinizing hormone, follicle-stimulating hormone, estradiol, free testosterone, thyrotropic hormone, free tetraiodothyroxine, cortisol, dehydroepiandrosterone sulphate (DHEA-S), and the ratios estradiol/testosterone and testosterone/DHEA-S; the blood lipids were also assessed. Body weight gain and the serum levels of prolactin were significantly increased by sulpiride; in addition, a significant positive correlation was observed between prolactin levels and body weight gain. Other endocrine parameters were not significantly affected by the drug. These short-term results show that in healthy men, body weight can be increased by antipsychotic drug administration; this effect may be related to hyperprolactinemia alone, since other endocrine parameters were normal at the time of treatment. A more prolonged treatment with antipsychotic agents might be required to observe the alterations in gonadal and adrenal steroids often detected in subjects with primary obesity.

Diabetes decreases limbic extracellular dopamine in rats.

Mesolimbic dopamine (DA) was measured by ventral striatum (including nucleus accumbens) microdialysis in freely moving streptozotocin (STZ)-diabetic male rats. DA and dihydroxyphenylacetic acid (DOPAC) basal levels and amphetamine-induced DA increase were lower in diabetic than in normal rats. These results are discussed in terms of decreased DA neuron activity and DA receptor hypersensitivity in the mesolimbic system of STZ-diabetic rats.